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

Treatment for COPD

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 intervention besides long-term oxygen therapy proven to modify disease progression and survival. 1, 2

Smoking Cessation

• Nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions achieves higher sustained quit rates than simple advice alone, with success rates up to 30% 3, 1
• Patients typically require multiple attempts through cycles of contemplation, action, and relapse before achieving sustained cessation 3
• Abrupt cessation is more successful than gradual withdrawal, though relapse rates remain high 3

Pharmacologic Treatment by Disease Severity

Mild COPD (Group A)

• Symptomatic patients should receive short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device 1, 2
• Patients with no symptoms require no drug treatment 1
• If short-acting bronchodilators prove ineffective, they should be discontinued 3

Moderate COPD (Group B)

• Initiate long-acting bronchodilator monotherapy as first-line treatment 3, 1, 2
• Long-acting muscarinic antagonists (LAMAs) are preferred over long-acting β2-agonists (LABAs) for exacerbation prevention 3, 1
• For patients with persistent breathlessness on monotherapy, escalate to dual bronchodilator therapy (LABA/LAMA) 3, 1
• Consider a corticosteroid trial (30 mg prednisolone daily for 2 weeks) with spirometric assessment before and after; a positive response is defined as FEV1 increase of 200 ml AND 15% of baseline 1, 2

Severe COPD (Group D)

• Initiate LABA/LAMA combination therapy as first-line treatment, as it provides superior bronchodilation and exacerbation prevention compared to monotherapy or LABA/ICS combinations 3, 1, 2
• LABA/LAMA is preferred over LABA/ICS because it reduces pneumonia risk while providing better exacerbation prevention 3
• Most patients will benefit from combination of β2-agonist and anticholinergic bronchodilators 3

Escalation for Persistent Exacerbations

• Add inhaled corticosteroids (ICS) to LABA/LAMA only if: 3, 1, 2
  • FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR
  • Blood eosinophil count ≥150-200 cells/µL, OR
  • Asthma-COPD overlap syndrome is present
• For patients on LABA/LAMA/ICS with continued exacerbations and FEV1 <50% predicted with chronic bronchitis, add roflumilast, particularly if hospitalized for exacerbation in the previous year 3
• Consider adding a macrolide in former smokers with frequent exacerbations, though bacterial resistance risk must be weighed 3, 4

Inhaler Technique and Device Selection

• Inhaler technique must be demonstrated before prescribing and checked regularly, as 76% of patients make critical errors with metered-dose inhalers 1
• Select appropriate device based on patient ability; spacers and dry-powder devices can achieve good response during acute exacerbations when patients find nebulizers easier 3
• Metered-dose inhalers with or without spacers, breath-actuated inhalers, and dry-powder inhalers are all effective when technique is correct 3

Management of Acute Exacerbations

Bronchodilators

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators for acute exacerbations 3, 2
• Nebulizers may be easier for severely breathless patients, though metered-dose inhalers with spacers are equally effective 3
• Intravenous methylxanthines are not recommended due to side effects 3

Systemic Corticosteroids

• Administer 40 mg prednisone daily for 5 days (not more than 5-7 days total), as this improves FEV1, oxygenation, shortens recovery time, and reduces hospitalization duration 3, 1, 2
• Oral prednisolone is equally effective to intravenous administration 3
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 3

Antibiotics

• Prescribe antibiotics when ≥2 of the following are present: increased breathlessness, increased sputum volume, purulent sputum 1, 2
• Use 7-14 day course when sputum becomes purulent 3, 1
• First-line options include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid based on local resistance patterns 3
• Antibiotics shorten recovery time and reduce risk of early relapse and hospitalization duration 3

Non-Pharmacologic Interventions

Pulmonary Rehabilitation

• Patients with high symptom burden (Groups B, C, D) should participate in comprehensive pulmonary rehabilitation programs including physiotherapy, muscle training, nutritional support, and education 3, 1, 2
• Combination of constant load or interval training with strength training provides better outcomes than either alone 3
• Rehabilitation improves exercise tolerance and quality of life 1

Long-Term Oxygen Therapy (LTOT)

• Prescribe LTOT for patients with PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas, with goal of maintaining SpO2 ≥90% during rest, sleep, and exertion 1, 2
• LTOT improves survival in hypoxemic patients and is one of only two interventions (along with smoking cessation) proven to modify mortality 1, 5
• Oxygen concentrators are the easiest mode for home use 1

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients, as it reduces mortality by 70% in elderly patients with COPD 3, 1, 2
• Pneumococcal vaccination may be considered with revaccination every 5-10 years 1, 2

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) must be avoided in COPD patients 1, 2
• Prophylactic antibiotics given continuously or intermittently have no evidence of benefit and should not be used except in rare cases of frequently recurring infections 3, 2
• Theophyllines have limited value in routine COPD management due to side effects and should only be tried in severe disease with monitoring 3, 1, 2
• ICS should not be routinely added without meeting specific criteria, as they increase pneumonia risk without benefit in unselected patients 3, 6
• Other anti-inflammatory drugs (sodium cromoglycate, nedocromil, antihistamines) have no role in COPD management 3, 1
• Stopping ICS can be considered in patients on triple therapy without harm, particularly given pneumonia risk 3