What is the management of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Chronic Obstructive Pulmonary Disease (COPD)

Smoking cessation is the single most critical intervention at all disease stages, as it is the only measure proven to modify long-term lung function decline and reduce mortality, and should be aggressively pursued with nicotine replacement therapy and behavioral support. 1

Initial Assessment and Diagnosis

Confirm diagnosis with post-bronchodilator spirometry showing FEV1/FVC < 0.7, which is the gold standard over peak expiratory flow measurements. 1 A positive bronchodilator response (FEV1 increase ≥200 ml and ≥15% from baseline) suggests possible asthma component. 1

Essential baseline investigations include:

• Chest radiography to exclude alternative diagnoses (though it cannot positively diagnose COPD). 1
• Arterial blood gas measurement in severe disease to identify hypoxemia with or without hypercapnia. 1
• Trial of oral corticosteroids (30 mg prednisolone daily for 2 weeks) in moderate-to-severe disease, with objective spirometric improvement expected in only 10-20% of cases. 1

Critical pitfall: Subjective improvement alone is insufficient for corticosteroid trials; objective spirometric documentation is mandatory. 1

Pharmacological Management by Disease Severity

Mild COPD

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed for symptomatic relief. 1

Moderate COPD

• Regular short-acting bronchodilators or combination of both classes. 1
• Consider corticosteroid trial with objective measurement of response. 1

Severe COPD

• Combination therapy with regular β2-agonist and anticholinergic agents. 1
• Long-acting bronchodilators reduce exacerbations by 13-25% compared to placebo and should be the maintenance treatment backbone. 2, 1
• Combination inhaled corticosteroid plus long-acting β2-agonist (ICS/LABA) reduces mortality with relative risk 0.82 versus placebo (absolute reduction ~1%) and relative risk 0.79 versus ICS alone. 2, 3

The combination ICS/LABA is specifically indicated for patients with severe COPD and history of repeated exacerbations who remain symptomatic despite bronchodilators alone. 1 The FDA-approved dosing for COPD is fluticasone/salmeterol 250/50 mcg twice daily. 3

Important limitation: Theophyllines have limited value in routine COPD management. 1 Long-acting β2-agonists should only be used if objective evidence of improvement exists. 1

Non-Pharmacological Interventions

Smoking Cessation (Priority #1)

• Active participation in cessation programs with nicotine replacement therapy significantly increases quit rates. 1
• Approximately one-third of patients successfully quit with support, requiring repeated attempts through cycles of contemplation, action, and relapse. 2

Pulmonary Rehabilitation

Pulmonary rehabilitation improves exercise performance, reduces breathlessness, and improves health status and dyspnea, though effects on walking distance are variable. 2, 1 This multidisciplinary intervention should be offered to all patients with dyspnea, exercise intolerance, or activity limitations despite optimal pharmacotherapy. 4

Rehabilitation reduces exacerbation rates, urgent visits, and hospitalization duration, making it cost-effective beyond just exercise capacity improvement. 4

Vaccination

• Annual influenza vaccination, especially for moderate-to-severe disease. 1
• Pneumococcal vaccination is recommended. 5

Nutritional and Psychosocial Support

• Address obesity and poor nutrition. 1
• Assess for depression and provide appropriate treatment, as this significantly impacts outcomes. 1
• Evaluate social circumstances and available support systems. 1

Management of Advanced Disease

Long-Term Oxygen Therapy (LTOT)

LTOT prolongs life in hypoxemic patients (mortality relative risk 0.61) and should be prescribed if PaO2 < 7.3 kPa or with high oxygen cylinder use (>2 per week). 2, 1 This is one of only two interventions (along with smoking cessation) proven to modify survival in severe COPD. 6

Important caveat: Short-burst oxygen for breathlessness lacks supporting evidence despite common prescription. 1

Surgical Interventions

• Surgery indicated for recurrent pneumothoraces and isolated bullous disease. 1
• Lung volume reduction surgery may benefit selected patients. 1

Air Travel Considerations

Air travel is hazardous if PaO2 breathing room air is < 6.7 kPa; verify oxygen availability on flights. 1

Management of Exacerbations

Home Treatment

Increase bronchodilators and consider antibiotics if ≥2 of the following are present: increased breathlessness, increased sputum volume, or purulent sputum. 1

Hospital Admission Criteria

Consider admission based on:

• Severity of symptoms
• General condition
• Oxygen requirements
• Activity level
• Social circumstances 1

Critical issue: Poor discharge medication reconciliation contributes to 30-day readmission rates as high as 22%. 1 Ensure comprehensive discharge planning with medication review, inhaler technique verification, and follow-up arrangements.

Indications for Specialist Referral

Refer patients with:

• Suspected severe COPD or onset of cor pulmonale 1
• Assessment needs for oxygen therapy or nebulizer use 1
• COPD in patients <40 years or with <10 pack-years smoking history 1
• Rapid decline in FEV1 1
• Uncertain diagnosis or symptoms disproportionate to lung function 1
• Frequent infections to exclude bronchiectasis 1
• Bullous lung disease or surgical consideration 1

Optimizing Inhaler Therapy

Optimize inhaler technique and select appropriate device to ensure efficient delivery, as poor technique undermines even the best pharmacological regimen. 1 After inhalation, patients should rinse mouth with water without swallowing to reduce oropharyngeal candidiasis risk. 3

Patients using ICS/LABA should not use additional LABA for any reason. 3