What is the recommended treatment plan for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

Recommended Treatment Plan for COPD

The treatment of COPD requires a stepwise pharmacological approach based on disease severity, combined with mandatory smoking cessation, influenza vaccination, and pulmonary rehabilitation for moderate-to-severe disease. 1

Pharmacological Management by Disease Severity

Mild COPD

• Initiate short-acting bronchodilators (β2-agonist OR anticholinergic) as needed for symptomatic relief 2, 1
• Use whichever agent provides better symptomatic response 2
• Discontinue if ineffective 2

Moderate COPD

• Regular therapy with short-acting β2-agonist OR anticholinergic, or combination of both if single agent insufficient 2, 1
• Perform a corticosteroid trial (prednisolone 30 mg daily for 2 weeks) in all patients 1
• Continue corticosteroids long-term only if objective spirometric improvement documented (FEV1 increase ≥200 ml and ≥15% from baseline) 1
• Critical pitfall: Subjective improvement alone is NOT adequate justification for continuing corticosteroids 1

Severe COPD

• Combination therapy with regular β2-agonist AND anticholinergic 2, 1
• Consider corticosteroid trial as above 2, 1
• Assess for home nebulizer using formal assessment criteria 2
• Theophyllines may be added but have limited value and require monitoring for side effects 2
• Long-acting β2-agonists (e.g., salmeterol/fluticasone combination 250/50 mcg twice daily) should only be used if objective improvement documented 2, 3
• Combination inhaled corticosteroid plus long-acting β2-agonist reduces mortality (relative risk 0.82) compared to placebo 1

Device Selection and Technique

• Optimize inhaler technique and select appropriate delivery device for each patient 2, 1
• After inhalation, rinse mouth with water without swallowing to reduce oropharyngeal candidiasis risk 3

Essential Non-Pharmacological Interventions

Smoking Cessation (All Stages)

• Smoking cessation is mandatory at all disease stages 2, 1
• Active smoking cessation programs with nicotine replacement therapy achieve higher sustained quit rates 2, 1
• Smoking cessation prevents accelerated FEV1 decline but cannot restore lost lung function 2

Vaccination

• Annual influenza vaccination recommended, especially for moderate-to-severe disease 2, 1
• Influenza vaccine reduces COPD mortality by 70% in elderly patients 2

Exercise and Nutrition

• Encourage exercise within limitations of airflow obstruction 2, 1
• Weight reduction in obese patients reduces energy requirements and improves functional capacity 2, 1
• Address malnutrition in severe COPD, though optimal nutritional support protocols require further study 2

Pulmonary Rehabilitation

• Pulmonary rehabilitation improves exercise performance and reduces breathlessness in moderate-to-severe disease 2, 1
• Should be considered for all patients with moderate-to-severe COPD 2, 1

Management of Advanced Disease

Long-Term Oxygen Therapy (LTOT)

• LTOT prolongs life and is the only treatment besides smoking cessation proven to modify survival 2, 1, 4
• Prescribe LTOT if PaO2 <7.3 kPa with or without hypercapnia, and FEV1 <1.5 liters 2, 1
• Consider LTOT if PaO2 7.3-8.0 kPa with evidence of pulmonary hypertension, peripheral edema, or nocturnal hypoxemia 2
• Must be used ≥15 hours daily to achieve mortality benefit 2
• Deliver via oxygen concentrator at 2-4 L/min, titrated to achieve PaO2 >8 kPa without unacceptable PaCO2 rise 2
• Patients must have stopped smoking before LTOT prescription 2
• Requires six-monthly follow-up and reassessment 2

Surgical Interventions

• Surgery indicated for recurrent pneumothoraces and isolated bullous disease 2, 1
• Lung volume reduction surgery may benefit highly selected patients with severe air trapping and markedly increased functional residual capacity 2, 1

Psychosocial Management

• Screen for and treat depression, which is very common in advanced disease 2, 1
• Assess social circumstances and available support 2, 1

Management of Acute Exacerbations

Outpatient Treatment

• Increase or add bronchodilators (β2-agonist and/or anticholinergic) 2, 1
• Prescribe antibiotics if ≥2 of the following present: increased breathlessness, increased sputum volume, purulent sputum 2, 1
• First-line antibiotics: amoxicillin or tetracycline 2
• Oral corticosteroids (prednisolone 30 mg daily for 7-14 days) if patient already on steroids, documented previous response, or inadequate response to increased bronchodilators 2

Hospital Admission Criteria

Consider admission if multiple negative answers to: mild breathlessness, good general condition, not on LTOT, good activity level, good social circumstances 2, 1

Inpatient Management

• Controlled oxygen therapy: Start with 28% FiO2 or 2 L/min nasal cannulae, targeting PaO2 ≥6.6 kPa without pH <7.26 2
• Check arterial blood gases within 60 minutes of starting oxygen and after any FiO2 change 2
• Nebulized bronchodilators (salbutamol 2.5-5 mg or ipratropium 0.25-0.5 mg) every 4-6 hours 2, 5
• Systemic corticosteroids (prednisolone 30 mg daily or hydrocortisone 100 mg IV) for 7-14 days 2, 5
• Antibiotics as per outpatient criteria 2
• Consider non-invasive positive pressure ventilation (NIPPV) if pH <7.26 with rising PaCO2 despite optimal therapy 2, 5

Follow-Up and Monitoring

Primary Care Follow-Up

• Document COPD diagnosis and baseline spirometry in medical record 2
• Monitor for rapid FEV1 decline (>500 ml over 5 years warrants specialist referral) 2
• Reassess medication effectiveness objectively 2

Indications for Specialist Referral

• Age <40 years or <10 pack-year smoking history 1
• Uncertain diagnosis or symptoms disproportionate to lung function 2, 1
• Rapid FEV1 decline 1
• Assessment for LTOT, nebulizers, or oral corticosteroids 1
• Frequent infections (exclude bronchiectasis) 2, 1
• Suspected severe COPD or cor pulmonale 1

Critical Pitfalls to Avoid

• Do not use short-burst oxygen for breathlessness—evidence is lacking 2, 1
• Do not continue corticosteroids without objective spirometric improvement 1
• Do not prescribe LTOT without documented hypoxemia (PaO2 <7.3 kPa) 2, 1
• Avoid excessive oxygen in acute exacerbations—may worsen respiratory acidosis 5
• Do not use prophylactic antibiotics—no evidence of benefit 2
• No role for mucolytics, antihistamines, or other anti-inflammatory drugs (cromoglycate, nedocromil) 2