Chronic respiratory diseases

COPD management

An effective COPD management plan includes four components: (1) assess and monitor disease; (2) reduce risk factors; (3) manage stable COPD; (4) manage exacerbations.

The goals of effective COPD management are to:

  • Prevent disease progression
  • Relieve symptoms
  • Improve exercise tolerance
  • Improve health status
  • Prevent and treat complications
  • Prevent and treat exacerbations
  • Reduce mortality

These goals should be reached with a minimum of side effects from treatment, a particular challenge in patients with COPD where comorbidities are common. The extent to which these goals can be realized varies with each individual, and some treatments will produce benefits in more than one area.

In selecting a treatment plan, the benefits and risks to the individual and the costs, direct and indirect, to the community must be considered. Patients should be identified before the end stage of the illness, when disability is substantial. However, the benefits of spirometric screening, of either the general population or smokers, are still unclear. Educating patients and physicians to recognize that cough, sputum production, and especially breathlessness are not trivial symptoms is an essential aspect of the public health care of this disease.

Reduction of therapy once symptom control has been achieved is not normally possible in COPD. Further deterioration of lung function usually requires the progressive introduction of more treatments, both pharmacologic and nonpharmacologic, to attempt to limit the impact of these changes. Acute exacerbations of signs and symptoms, a hallmark of COPD, impair patients' quality of life and decrease their health status. Appropriate treatment and measures to prevent further exacerbations should be implemented as quickly as possible.

Component 1: Assess and monitor disease

  • Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.
  • Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnoea.
  • For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation. FEV1/FVC < 70% and a postbronchodilator FEV1 < 80% predicted confirms the presence of airflow limitation that is not fully reversible.
  • Health care workers involved in the diagnosis and management of patients with COPD should have access to spirometry.
  • Measurement of arterial blood gas tensions should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure.

Component 2: Reduce risk factors

  • Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD.
  • Smoking cessation is the single most effective and cost-effective way to reduce the risk of developing COPD and stop its progression. Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to a health care provider.
  • Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment.
  • Several effective pharmacotherapies for tobacco dependence are available, and at least one of these medications should be added to counseling if necessary and in the absence of contraindications.
  • Progression of many occupationally induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases.

Component 3: Manage stable COPD

  • The overall approach to managing stable COPD should be characterized by a stepwise increase in treatment, depending on the severity of the disease.
  • For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation.
  • None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease. Therefore, pharmacotherapy for COPD is used to decrease symptoms and complications.
  • Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms.
  • The principal bronchodilator treatments are 2-agonists, anticholinergics, theophylline, and a combination of one or more of these drugs.
  • Regular treatment with inhaled glucocorticosteroids should only be prescribed for symptomatic patients with COPD with a documented spirometric response to glucocorticosteroids or for those with an FEV1 < 50% predicted and repeated exacerbations requiring treatment with antibiotics or oral glucocorticosteroids.
  • Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavourable benefit-to-risk ratio.
  • All patients with COPD benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnoea and fatigue.
  • The long-term administration of oxygen (> 15 h per day) to patients with chronic respiratory failure has been shown to increase survival.

Component 4: Manage exacerbations

  • Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD.
  • The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of approximately one-third of severe exacerbations cannot be identified.
  • Inhaled bronchodilators (particularly inhaled 2-agonists or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for treatments for acute exacerbations of COPD.
  • Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, or fever) may benefit from antibiotic treatment.
  • Noninvasive positive pressure ventilation (NIPPV) in acute exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay.