What are the treatment options for Chronic Obstructive Pulmonary Disease (COPD)?

COPD Treatment

Smoking cessation is the single most important intervention for all COPD patients and must be addressed at every clinical encounter, as it is the only treatment besides long-term oxygen therapy proven to modify disease progression and survival. 1, 2

Smoking Cessation

• Smoking cessation should be strongly encouraged at every visit regardless of disease severity, as it prevents the accelerated decline in lung function characteristic of COPD 1, 2
• Active smoking cessation programs with nicotine replacement therapy (gum or transdermal patches) achieve higher sustained quit rates, with reported success rates of 10-30% 3, 1
• Repeated advice and encouragement is often needed, and success can be monitored by breath carbon monoxide levels, blood carboxyhaemoglobin estimation, or urinary cotinine levels 3

Bronchodilator Therapy: Staged Approach by Disease Severity

Mild COPD

• Patients with no symptoms require no drug treatment 1, 2
• Symptomatic patients should receive a trial of short-acting bronchodilators (β2-agonist or anticholinergic) taken as needed via appropriate inhaler device 1, 2
• If these drugs are ineffective, they should be stopped 3

Moderate COPD

• Regular use of long-acting bronchodilator monotherapy is recommended, with long-acting muscarinic antagonists (LAMAs) preferred for exacerbation prevention 1, 2
• Most patients will be controlled on a single drug; a few will need combination treatment 3
• The choice between LAMA and LABA should be based on symptom relief 1
• Oral bronchodilators are not usually required 3

Severe COPD

• Combination of long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) is recommended as first-line treatment 1, 2
• Regular β2-agonist and anticholinergic combination therapy should be used 2
• For patients with persistent breathlessness on monotherapy, escalate to dual bronchodilator therapy (LABA/LAMA) 1

Inhaled Corticosteroids (ICS)

• ICS should be added to bronchodilator therapy only for specific indications, not routinely 1
• Add ICS to LABA + LAMA combination therapy if: FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR blood eosinophil count ≥150-200 cells/µL, OR asthma-COPD overlap syndrome 1
• For moderate COPD, perform a corticosteroid trial (30 mg prednisolone daily for 2 weeks with spirometric assessment before and after) 1
• A positive response is defined as FEV1 increase of 200 ml AND 15% of baseline 1, 2
• Subjective improvement alone is not satisfactory; objective spirometric improvement is required 1
• LABA/ICS combinations may be first-choice initial therapy for patients with asthma-COPD overlap or high blood eosinophil counts 1

Inhaler Technique and Delivery Devices

• Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked before changing or modifying inhaled treatments 3, 1, 2
• 76% of COPD patients make important errors when using metered-dose inhalers, while 10-40% make errors with dry powder inhalers 3, 1
• Metered dose inhalers are the cheapest delivery device, but if the patient cannot use one correctly, a more expensive device is justifiable 3
• Most patients can be treated with bronchodilators delivered by metered dose inhalers and spacers or by dry powder devices 3

Home Nebulizer Therapy

• Most patients can be managed without nebulizers; only a few with severe disease may benefit from high dose bronchodilator treatment more conveniently given by nebulizer 3
• Nebulizers should only be supplied to patients who have been assessed fully by a respiratory physician 3
• Assessment should include: ensuring correct diagnosis, optimal use of metered dose and dry powder inhalers has been made, patients respond to the nebulizer, and a home trial with peak expiratory flow measurements should precede prescription 3, 1

Long-Term Oxygen Therapy (LTOT)

• LTOT is recommended for patients with PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas, with the goal of maintaining SpO2 ≥90% during rest, sleep, and exertion 1
• LTOT improves survival in hypoxemic patients and is the only treatment besides smoking cessation shown to modify survival rates in severe cases 1, 2
• Oxygen concentrators are the easiest mode of treatment for home use 1
• In end-stage COPD, short bursts of oxygen may help intractable dyspnea 1
• LTOT should only be prescribed with objectively demonstrated low oxygen levels 2

Pulmonary Rehabilitation

• Rehabilitation programs should include physiotherapy, muscle training, nutritional support, and education 1
• Programs have been shown to increase exercise tolerance and improve quality of life in patients with moderate to severe COPD 1, 2
• Both obesity and poor nutrition require treatment in COPD patients 1
• Exercise should be encouraged where possible 2

Management of Acute Exacerbations

• Antibiotics should be used when ≥2 of the following symptoms are present: increased breathlessness, increased sputum volume, purulent sputum 1
• Use a 7-14 day course when sputum becomes purulent 1
• Systemic corticosteroids (30-40 mg prednisone daily for 5-7 days) improve lung function and shorten recovery time 1
• Increase bronchodilator therapy and consider nebulizers if inhaler technique is inadequate during an acute exacerbation 1

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients, especially those with moderate to severe disease 1, 2
• Pneumococcal vaccination may be considered, with revaccination every 5-10 years 1

Surgical Interventions

• Surgery may be indicated for recurrent lung collapses and isolated bullous disease 2
• Lung volume reduction surgery may be useful in selected patients 2

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) should be avoided in all COPD patients 3, 1, 2
• There is no evidence supporting the use of prophylactic antibiotics given continuously or intermittently 3, 1, 2
• There is no role for other anti-inflammatory drugs such as sodium cromoglycate, nedocromil sodium, antihistamines, or mucolytics in COPD 3, 1
• Theophyllines are only modest bronchodilators with variable effect and are of limited value in routine COPD management 3, 1
• Patients using LABA/LAMA combinations should not use additional LABA for any reason 4
• More frequent administration or a greater number of inhalations than prescribed is not recommended, as some patients are more likely to experience adverse effects with higher doses 4