What is the recommended management for a patient with chronic obstructive pulmonary disease (COPD)?

COPD Management

Smoking Cessation: The Only Mortality-Reducing Intervention

Smoking cessation is the single most critical intervention in COPD management and, together with long-term oxygen therapy in severe hypoxemic disease, represents one of only two treatments proven to reduce mortality and slow disease progression. 1

• Combination nicotine replacement therapy (patch plus rapid-acting form such as gum or nasal spray) together with either varenicline or bupropion, plus intensive behavioral counseling, achieves sustained quit rates of up to 25% versus 3-5% with willpower alone 1, 2
• Varenicline and combination NRT are equally effective, while varenicline alone is more effective than either NRT or bupropion monotherapy 2
• All patients must be enrolled in structured smoking cessation programs at every visit, as this is the only intervention that slows the progressive decline in lung function 1, 3

Pharmacological Management: Severity-Based Algorithm

Mild COPD (FEV₁ ≥ 70-80% predicted)

• Prescribe short-acting β₂-agonist OR short-acting anticholinergic on an as-needed basis for symptom relief 1, 4
• If these drugs are ineffective after trial, they should be stopped 4
• Patients with no symptoms require no drug treatment 4

Moderate COPD (FEV₁ 50-79% predicted)

• First-line: long-acting muscarinic antagonist (LAMA) monotherapy, preferred over long-acting β₂-agonist (LABA) 1
• Most patients will be controlled on a single drug; few will need combination treatment 4
• Consider a short trial (2 weeks) of inhaled corticosteroid at 30 mg prednisolone daily to identify responders 1, 5
• Oral bronchodilators are not usually required 4

Severe COPD (FEV₁ < 50% predicted)

• First-line: fixed-dose combination of LAMA + LABA 1
• Most patients will justify combination of β₂-agonist and anticholinergic bronchodilators if they derive increased benefit 4
• Add inhaled corticosteroid only if FEV₁ < 50% predicted AND ≥2 exacerbations in the previous year 1
• Theophyllines can be tried but must be monitored for side effects and should NOT be used as first-line therapy 4, 1

Critical Inhaler Management

• Verify and optimize inhaler technique at every single clinic visit 1
• Select an appropriate delivery device based on patient ability and preference 1
• High-dose treatment including nebulized drugs should only be prescribed after formal assessment demonstrating patient response 4

Vaccinations: Proven Mortality Benefit

• Administer annual influenza vaccine to all COPD patients; it reduces COPD-related mortality by approximately 70% in older adults 1, 4
• Provide 23-valent pneumococcal vaccine as part of routine management 1

Pulmonary Rehabilitation: Mandatory for Moderate-Severe Disease

• Refer every patient with moderate-to-severe COPD and high symptom burden to comprehensive pulmonary rehabilitation 1
• Pulmonary rehabilitation improves exercise capacity, reduces dyspnea, enhances quality of life, and lowers hospitalization rates 1
• Exercise training can be performed successfully at home 4
• Exercise is both safe and desirable; breathlessness on exertion is not dangerous 4

Nutritional Management

• Weight reduction in obese patients reduces energy requirements of exercise and improves functional capacity 4
• Malnutrition is common in severe COPD and may contribute to mortality 4
• Aim for ideal body weight; avoid high-carbohydrate diets and extremely high caloric intake to reduce excess CO₂ production 4

Long-Term Oxygen Therapy: The Second Mortality-Reducing Intervention

LTOT prolongs survival and is one of only two interventions proven to reduce mortality in severe COPD (relative risk 0.61). 1

• Prescribe LTOT when arterial PaO₂ ≤ 55 mmHg (7.3 kPa) on two separate measurements at least three weeks apart 1
• Goal: maintain SpO₂ ≥ 90% during rest, sleep, and exertion 1
• Do NOT prescribe LTOT for stable COPD with only resting or exercise-induced moderate desaturation 1
• Short-burst (prn) oxygen for relief of breathlessness lacks supporting evidence and should not be used routinely 1

Management of Acute Exacerbations

• Immediately increase the dose and frequency of bronchodilators at onset 1
• Prescribe antibiotics if ≥2 of the following are present: increased breathlessness, increased sputum volume, or development of purulent sputum 1, 5
• Oral corticosteroids (40 mg prednisone daily for 5 days) improve lung function and shorten recovery time 1

Hospitalization Criteria

Hospitalize patients with any of the following: 1

• Severe dyspnea
• Markedly poor general condition
• Current LTOT use
• Markedly reduced activity level
• Adverse social circumstances

Advanced Disease Interventions

Non-Invasive Ventilation

• Offer NIV to patients with chronic severe hypercapnia who have a prior hospitalization for acute respiratory failure; NIV lowers mortality and prevents rehospitalization 1

Surgical Options

• Consider lung-volume-reduction surgery, bullectomy, or lung transplantation for selected patients with advanced emphysema refractory to optimized medical therapy 1

Palliative Care

• Use low-dose, long-acting oral or parenteral opioids to alleviate refractory dyspnea in severe COPD 1

Specialist Referral Indications

Refer to respiratory specialist for: 1, 5

• Suspected severe COPD
• Onset of cor pulmonale
• Assessment for oxygen therapy or nebulizer use
• Assessment for long-term oral corticosteroid treatment
• Complex cases requiring advanced interventions

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) must be avoided in all COPD patients 4, 1
• Theophylline has limited efficacy and should NOT be used as first-line therapy 1
• There is no role for prophylactic antibiotics, sodium cromoglycate, nedocromil sodium, antihistamines, or routine mucolytics 4
• Pulmonary vasodilators have no role in COPD with pulmonary hypertension 4

Monitoring and Psychosocial Support

• Screen for and treat depression at every visit, as it is common in severe COPD and adversely affects outcomes 1
• Psychosocial support and patient/family education improve quality of life and coping skills 4
• Discuss advance directives ("living will") with patients regarding ventilation preferences in the event of respiratory failure 4