COPD Presentation and Management
COPD typically presents with chronic dyspnea, cough, and sputum production in patients with tobacco or harmful particle exposure, requiring spirometry for diagnosis and a stepwise treatment approach prioritizing bronchodilators, with management intensity determined by symptom burden and exacerbation frequency. 1, 2
Clinical Presentation
Stable COPD Symptoms
- Progressive dyspnea that worsens with exertion 1
- Chronic cough with or without sputum production 3
- Wheeze and chest tightness 1
- Exercise intolerance and limitation in daily activities 4
Acute Exacerbation Presentation
An exacerbation represents acute worsening superimposed on stable disease, characterized by:
- Increased sputum purulence 1
- Increased sputum volume 1
- Increased dyspnea 1
- Increased wheeze and chest tightness 1
- Fluid retention 1
Critical Red Flags Requiring Hospital Evaluation
- Drowsiness or altered mental status (indicates hypercapnic respiratory failure) 5
- Severe dyspnea at rest 2
- Significant clinical deterioration 2
- Uncertain severity of exacerbation 2, 5
Diagnostic Approach
Essential Diagnostic Criteria
- Spirometry is mandatory for diagnosis—look for post-bronchodilator FEV1/FVC ratio <0.70 3, 6
- Assess severity based on FEV1 percentage predicted 2, 6
- Evaluate exposure history: tobacco smoking, biomass fuel, occupational dusts 3, 6
Differential Diagnoses to Exclude During Exacerbations
- Pneumonia 1
- Pneumothorax 1
- Left ventricular failure/pulmonary edema 1
- Pulmonary embolism 1
- Lung cancer 1
- Upper airway obstruction 1
Management of Stable COPD
Mild COPD (FEV1 ≥60% predicted)
- Initiate short-acting bronchodilators (β2-agonists or anticholinergics) as needed for symptom relief 2
- Smoking cessation is the single most effective intervention to modify disease progression and reduce mortality 4, 6
Moderate to Severe COPD (FEV1 <60% predicted)
- Combine β2-agonists and anticholinergics to maximize bronchodilation 2
- For COPD maintenance, use combination inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) such as fluticasone/salmeterol 250/50 mcg twice daily 7
- Consider adding ICS if FEV1 decline exceeds 50 mL/year or frequent exacerbations occur (≥2 per year) 2, 4
Non-Pharmacological Interventions
- Pulmonary rehabilitation reduces exacerbations, hospitalizations, and improves quality of life—offer to all patients with dyspnea or exercise intolerance despite optimal pharmacotherapy 4, 6
- Long-term oxygen therapy (LTOT) for patients with chronic hypoxemia (PaO2 ≤7.3 kPa or 55 mmHg) reduces mortality 1, 6
Management of Acute Exacerbations
Mild Exacerbations (Home Management)
Treat at home if patient has no red flags and can manage symptoms:
- Increase bronchodilator dose or frequency, or add combination β2-agonist plus anticholinergic 1, 2
- Prescribe antibiotics if two or more of the following are present: increased breathlessness, increased sputum volume, purulent sputum 1
- Use amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid for 7-14 days 1
- Add oral corticosteroids (prednisolone 30 mg daily for 7 days) if marked wheeze present or patient already on steroids 1
- Encourage sputum clearance by coughing and adequate fluid intake 1, 2
- Reassess within 48 hours—if worsening, refer to hospital 1
Severe Exacerbations (Hospital Management)
Immediate Interventions
- Obtain arterial blood gases immediately to assess for hypercapnic respiratory failure (pH <7.26, elevated PaCO2) 1, 5
- Initiate controlled oxygen therapy at 28% via Venturi mask or 2 L/min nasal cannulae, targeting SpO2 88-92% to prevent worsening hypercapnia 2, 5
- Administer nebulized bronchodilators (β2-agonist plus anticholinergic) every 4-6 hours 2, 5
Systemic Therapy
- Give prednisolone 30 mg orally daily (or hydrocortisone 100 mg IV if unable to take oral) for 7-14 days 2, 5
- Prescribe broad-spectrum antibiotics (oral or IV)—consider cephalosporins or newer macrolides for severe presentations rather than first-line amoxicillin 1, 5
Respiratory Support
- Initiate non-invasive positive pressure ventilation (NIPPV) if pH <7.26 with rising PaCO2 after 30 minutes of standard therapy 5
- NIPPV reduces intubation rates and hospital length of stay 5
Monitoring Parameters
- Continuous pulse oximetry 5
- Repeat arterial blood gases if clinical deterioration 5
- Check FEV1 before discharge 1
- Recheck arterial blood gases on room air before discharge in patients with hypercapnic respiratory failure to assess need for LTOT 1
Surgical Considerations for Advanced Disease
Bullectomy
- Consider for patients with large unilateral or bilateral air cysts with collapsed parenchyma visible on CT scan 1, 2
- Predictors of success: preserved transfer factor, PaCO2 not severely elevated, zones of non-emphysematous lung present 1
Lung Transplantation
- Refer patients <65 years with FEV1 <25% predicted, PaO2 <7.5 kPa (56 mmHg), and PaCO2 >6.5 kPa (49 mmHg) 1, 2
- Five-year survival approximately 50% 1, 2
Critical Pitfalls to Avoid
Common Errors
- Do not assume drowsiness is due to other causes (e.g., alcohol)—hypercapnic respiratory failure is the most likely etiology and requires immediate intervention 5
- Do not provide excessive oxygen (>92% saturation) as this worsens hypercapnia and respiratory acidosis 5
- Do not use ICS/LABA combinations for acute symptom relief—these are maintenance medications only 7
- Do not continue antibiotics beyond 7 days unless clinically indicated 1, 5
- Do not delay hospital evaluation when exacerbation severity is uncertain 2
Air Travel Precautions
- Patients with PaCO2 ≥6.7 kPa (50 mmHg) or PaO2 ≤6.7 kPa (50 mmHg) should avoid air travel without supplemental oxygen 1, 2
- Simulate cabin pressure conditions in laboratory before long flights for borderline patients 1