How should I diagnose and manage a patient with chronic obstructive pulmonary disease, including spirometry confirmation, smoking cessation, vaccinations, bronchodilator therapy, inhaled corticosteroids, acute exacerbation treatment, supplemental oxygen, pulmonary rehabilitation, and second‑line options?

COPD Diagnosis and Management

Diagnosis and Confirmation

Diagnose COPD using post-bronchodilator spirometry showing FEV₁/FVC < 0.70, which must be obtained before initiating any pharmacotherapy. 1

• Suspect COPD in patients over 40 years with smoking history (especially >40 pack-years), chronic dyspnea, cough with or without sputum, or wheezing 2
• The combination of peak flow <350 L/min, diminished breath sounds, and ≥30 pack-year smoking history strongly predicts airflow obstruction 2
• Post-bronchodilator spirometry is mandatory; pre-bronchodilator testing alone leads to misdiagnosis 3
• If only pre-bronchodilator spirometry is available, use FEV₁/FVC <0.66 (not 0.70) to improve diagnostic accuracy by 15% 3

Smoking Cessation: The Foundation

Smoking cessation is mandatory at every visit and is the only intervention proven to slow disease progression. 1

• Enroll patients in structured cessation programs combining behavioral support with nicotine replacement therapy (gum, patch, nasal spray, or inhaler), bupropion SR, or varenicline 1, 4
• These programs achieve 10-30% sustained quit rates versus <5% with brief advice alone 1
• Cessation prevents accelerated FEV₁ decline but does not restore lost lung function 1, 4

Pharmacological Management by Disease Severity

Mild COPD (FEV₁ ≥60% predicted)

• Use short-acting β₂-agonist (SABA) or short-acting anticholinergic (SAMA) as needed for symptom relief 1, 4
• No maintenance therapy is required if the patient is asymptomatic 1

Moderate COPD (FEV₁ 40-59% predicted)

• Initiate long-acting muscarinic antagonist (LAMA) monotherapy as first-line maintenance (tiotropium 18 µg once daily, umeclidinium 62.5 µg once daily, or aclidinium 400 µg twice daily) 1
• If LAMA is not tolerated, substitute long-acting β₂-agonist (LABA) monotherapy (salmeterol 50 µg twice daily or formoterol 12 µg twice daily) 1
• Perform a corticosteroid trial in all moderate COPD patients: give 30 mg prednisolone daily for 2 weeks with pre- and post-spirometry 1, 4
• A positive response requires both FEV₁ increase ≥200 mL and ≥15% of baseline; only 10-20% of patients meet this objective criterion 1, 4
• If objective improvement is not achieved, do not continue corticosteroids even if the patient reports subjective benefit 1

Severe COPD (FEV₁ <40% predicted)

• Start with fixed-dose LAMA/LABA combination therapy; dual bronchodilation reduces exacerbations by 13-17% compared to monotherapy 1
• Add inhaled corticosteroid (ICS) to LAMA/LABA only when:
  • FEV₁ <50% predicted and ≥2 moderate exacerbations or ≥1 hospitalization in the prior year, or
  • Blood eosinophil count ≥150-200 cells/µL, or
  • Documented asthma-COPD overlap 1, 5
• Recommended ICS doses: fluticasone 250-500 µg twice daily or budesonide 320-400 µg twice daily 1
• If no recent exacerbations and normal eosinophil count, withdraw ICS as cessation has not shown significant harm 1

Rescue Medication for All Severities

• Prescribe albuterol (salbutamol) 2 puffs every 4-6 hours as needed for acute symptoms 1
• If rescue use exceeds 2-3 times per week, escalate maintenance therapy 1

Inhaler Device Selection and Technique

Assess and optimize inhaler technique at every visit, as 76% of patients make critical errors with metered-dose inhalers and 10-40% with dry-powder inhalers. 1

• Use metered-dose inhaler (MDI) with spacer; this provides outcomes equivalent to nebulizer therapy 1
• If the patient cannot use an MDI correctly after demonstration, prescribe an alternative device regardless of cost 1

Non-Pharmacological Interventions

Pulmonary Rehabilitation

Refer all patients with CAT score ≥10 or moderate-to-severe COPD to comprehensive pulmonary rehabilitation. 1

• Programs must include exercise training, physiotherapy, muscle conditioning, nutritional support, and patient education 1, 4
• Rehabilitation improves exercise capacity, reduces dyspnea, and enhances quality of life 1

Vaccinations

• Administer annual influenza vaccination to all COPD patients 1, 4
• Give pneumococcal vaccination: PCV13 + PPSV23 for patients ≥65 years; PPSV23 alone for younger patients with significant comorbidities 1

Nutritional Management

• Treat both obesity and malnutrition actively, as malnutrition causes respiratory-muscle weakness and higher mortality 1, 4

Long-Term Oxygen Therapy (LTOT)

Prescribe LTOT when arterial PaO₂ ≤55 mmHg (7.3 kPa) or SpO₂ ≤88% confirmed on two separate measurements ≥3 weeks apart. 1, 4

• Target SpO₂ ≥90% at rest, during sleep, and with exertion 1, 4
• LTOT reduces mortality (relative risk 0.61) in chronically hypoxemic patients 1
• Oxygen concentrators are the preferred mode for home use 1
• Do not prescribe short-burst (prn) oxygen for breathlessness alone; supporting evidence is lacking 1, 4

Management of Acute Exacerbations

Home-Based Treatment

Treat exacerbations at home when the patient has mild breathlessness, good general condition, is not on LTOT, maintains good activity level, and has adequate social support. 4

• Increase bronchodilator dose/frequency and verify proper inhaler technique 4, 6
• Prescribe antibiotics when at least two of the following are present: increased dyspnea, increased sputum volume, or purulent sputum 4, 6
• Give oral prednisone 30-40 mg daily for 5-7 days; this improves lung function, shortens recovery, and reduces early relapse 1, 6
• Do not extend corticosteroids beyond 7 days; longer courses provide no additional benefit 1

Hospitalization Criteria

• Admit patients with severe dyspnea, markedly poor general condition, current LTOT use, markedly reduced activity level, or adverse social circumstances 1, 4

Follow-Up After Exacerbation

• Re-evaluate 4-6 weeks after exacerbation or hospital discharge 4
• Measure FEV₁, reassess inhaler technique, review medication adherence, and emphasize lifestyle management (smoking, weight, exercise) 4

Second-Line and Advanced Therapies

For Persistent Exacerbations Despite Optimal Therapy

• Consider roflumilast 500 µg once daily for patients with FEV₁ <50% predicted, chronic bronchitis, and ≥1 hospitalization for exacerbation in the prior year 1
• Consider azithromycin 250 mg daily or 500 mg three times weekly in former smokers with frequent exacerbations, acknowledging antimicrobial resistance risk 1

Surgical Options

• Refer for lung-volume-reduction surgery, bullectomy, or lung transplantation in advanced emphysema refractory to optimized medical therapy 1, 4
• Surgery is specifically indicated for recurrent pneumothoraces and isolated bullous disease 1, 4

Specialist Referral Indications

Refer to pulmonology when: 4

• Suspected severe COPD requiring confirmation and treatment optimization
• Onset of cor pulmonale
• Assessment for oxygen therapy (arterial blood gas measurement needed)
• COPD in patient <40 years (to identify α₁-antitrypsin deficiency and screen family)
• Rapid FEV₁ decline
• Uncertain diagnosis
• Symptoms disproportionate to lung function deficit
• Frequent infections (to exclude bronchiectasis)
• Bullous disease assessment for surgery

Critical Pitfalls to Avoid

• Do not use theophyllines as first-line therapy; they have limited efficacy and toxicity risk 1, 4
• Do not prescribe ICS without clear indications (eosinophilia, asthma-COPD overlap, or frequent exacerbations despite dual bronchodilation) 1
• Do not use prophylactic or continuous antibiotics; evidence is lacking 1
• Do not judge corticosteroid trial response by subjective improvement alone; require objective spirometric improvement (≥200 mL and ≥15% FEV₁ increase) 1, 4
• Avoid beta-blocking agents (including ophthalmic formulations) in all COPD patients 1
• Do not continue long-acting β₂-agonists without documented objective benefit 1

Comorbidity Management

• Screen for and treat depression, which is common in severe COPD and adversely affects outcomes 1, 4
• Assess social circumstances and available support, as these are valuable in management 4
• Evaluate and manage cardiac comorbidities, as many COPD patients die of heart disease 7