Management of Chronic Obstructive Pulmonary Disease (COPD)

Introduction

COPD is a chronic, progressive disorder that usually affects smokers. It is defined as airflow obstruction with little reversibility, with symptoms of breathlessness and cough.

The pharmacological treatment of stable COPD is based upon examination of symptoms and future risk of exacerbations with a shift towards a more personalised approach to treatment with strategies for escalation and de-escalation of pharmacological therapy.

The aim is to reduce symptoms, reduce the severity and frequency of exacerbations and to improve exercise tolerance and health status. Each time a patient attends for a consultation with a healthcare professional it is important to address dosages and effectiveness of current drug regimen, adherence to regimen, inhaler technique and any adverse effects. 

Diagnosis

COPD is diagnosed using spirometry as airflow obstruction (FEV1/FVC <0.7) with little or no reversibility. The severity is defined by impairment of FEV1 (mild >80%, moderate 50-80%, severe <50%). Degree of breathlessness (see MRC Dyspnoea Scale), symptoms (see COPD Assessment Test (CAT)) and exacerbation history should also be assessed. Always consider alternative or co-existing diagnoses (e.g. asthma, heart failure). 

General management

• Smoking cessation has the greatest capacity to influence mortality in COPD and improve symptoms. All patients with COPD should receive education and support relating to this (see Appendix 1) where appropriate.
• The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present. 
• Pulmonary rehabilitation should be considered in those who have had a recent hospital admission for an exacerbation and those who consider themselves functionally disabled by COPD. Pulmonary rehabilitation improves symptoms, quality of life and physical and emotional participation in everyday activities.
• Patients should be encouraged to maintain or improve physical activity levels.
• Education and self-management improves health status and ability to cope with COPD (i.e. breathlessness, exacerbations). 
• Pharmacological therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations and improve health status and exercise tolerance. 
• Pneumococcal vaccination (once only) and influenza vaccination (annually) should be offered to all patients with COPD. It decreases the incidence of lower respiratory tract infections. Vaccination appears to be more effective in older patients and those with more severe disease or cardiac co-morbidity.