management of COPD

Management of Chronic Obstructive Pulmonary Disease (COPD) involves adjusting treatment based on symptoms and exacerbations ¹. A diagnosis of COPD is suspected in individuals over 35 with a risk factor (typically smoking) and symptoms such as exertional breathlessness, chronic cough, regular sputum production, frequent winter 'bronchitis', or wheeze ². The Medical Research Council (MRC) dyspnoea scale should be used to grade breathlessness ². Spirometry is performed at diagnosis, to reconsider the diagnosis if there is a good response to treatment, and to monitor disease progression ². Post-bronchodilator spirometry is used to confirm the diagnosis ².

Self-management plans should be developed collaboratively, covering COPD and its symptoms, non-pharmacological measures (diet, physical activity, pulmonary rehabilitation, smoking cessation, avoiding passive smoking), vaccinations, appropriate use of inhaled therapies, and early recognition and management of exacerbations ¹. This includes advice on adjusting short-acting bronchodilator therapy and when to use prescribed oral corticosteroids and antibiotics for exacerbations ¹. People with COPD should be advised that continued smoking, passive smoke exposure, infections, air pollution, lack of physical activity, and seasonal variations increase their risk of exacerbations ².

Pulmonary rehabilitation should be made available to all appropriate individuals with COPD, including those recently hospitalised for an exacerbation, and offered to those who feel functionally disabled by the condition (MRC grade 3 and above) ². Rehabilitation programmes should be tailored, multidisciplinary, and include physical training, disease education, and nutritional, psychological, and behavioural interventions ².

Pneumococcal and annual flu vaccinations should be offered to all individuals with COPD ². Azithromycin may be indicated for symptomatic individuals with frequent severe exacerbations and sputum production, after non-pharmacological and inhaled therapies have been optimised, with further assessment including sputum culture and CT thorax prior to initiation ¹. Roflumilast is an option for severe COPD (FEV1 < 50% predicted) with two or more exacerbations in the previous 12 months despite triple inhaled therapy, and should be initiated by a respiratory specialist ¹.

Referral to a respiratory specialist is indicated if lung cancer is suspected, there is diagnostic uncertainty (e.g., difficulty distinguishing from asthma, disproportionate symptoms to spirometry, very severe or rapidly worsening COPD, suspected cor pulmonale), or if the individual is under 40 with a family history of alpha-1-antitrypsin deficiency ¹. Referral may also be required for oxygen therapy, long-term non-invasive ventilation, nebulizer therapy, long-term oral corticosteroids, or lung surgery ¹. Optimal COPD treatment, including smoking cessation advice, should be provided for cor pulmonale caused by COPD ². Oedema associated with cor pulmonale can usually be managed with diuretic therapy ².