Following the diagnosis of chronic obstructive pulmonary disease (COPD), care should be delivered by a multidisciplinary team. The following functions should be considered when defining the activity of the multidisciplinary team:
- Assessing patients (eg, spirometry, assessing need for oxygen therapy and the appropriateness of delivery systems for inhaled therapy).
- Managing patients (including pulmonary rehabilitation, palliative care, managing anxiety and depression, dietary issues, exercise, social security benefits and travel); management of pulmonary hypertension and cor pulmonale.
- Education of patients and advising patients on self-management strategies.
- Identifying and monitoring patients at high risk of exacerbations of COPD.
- Influenza and pneumococcal immunisation.
- Advising patients on nutrition and physical activity.
Clinical Editor's note
May 2018 - Dr Hayley Willacy recommends the latest edition of the report from GOLD. New research showed combination LABA/LAMA treatment had the greatest improvement in quality of life compared to placebo or its individual bronchodilator components, in patients with the highest baseline symptom burden. For this reason GOLD recommends starting patients who fall into Group D on a LABA/LAMA combination. Also dealing with management, a double-blind, parallel group RCT reported that treatment with extrafine fixed triple therapy had clinical benefits compared with tiotropium in patients with symptomatic COPD, FEV1 <50%, and a history of exacerbations. Another double-blind RCT reported benefits of single-inhaler triple therapy compared with ICS/LABA therapy in patients with advanced COPD. Their treatment algorithm clearly shows when triple therapy should be considered.
- Advice on how to respond promptly to symptoms of an exacerbation, including starting oral corticosteroid therapy, starting antibiotic therapy if their sputum is purulent and adjusting bronchodilator therapy to control symptoms.
- Advice on when and how to contact a healthcare professional if symptoms do not improve.
- Encouraging patients with COPD to stop smoking is one of the most important components of management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.
- Nutrition: body mass index (BMI) should be calculated. If the BMI is abnormal (high or low) or changing over time, the patient should be referred for dietetic advice. If the BMI is low, patients should also be given nutritional supplements to increase their total calorific intake, and be encouraged to take exercise to augment the effects of nutritional supplementation.
- Physiotherapy: if patients have excessive sputum, they should be taught the use of positive expiratory pressure (PEP) masks and active cycle of breathing techniques.
Promote effective inhaled therapy
Delivery systems: handheld devices are usually best, with a spacer if appropriate. Consider a nebuliser for people with distressing or disabling breathlessness despite maximum therapy with inhalers.
- For breathlessness and/or exercise limitation: use, as required, an inhaled short-acting beta agonist (SABA) - eg, salbutamol or terbutaline; or use, as required, a short-acting muscarinic antagonist (SAMA) - eg, ipratropium.
- Short-acting beta2 agonists can be continued with additional treatment (see below) but short-acting muscarinic antagonists must be stopped if a long-acting muscarinic antagonist (LAMA) - eg, tiotropium - is used.
- There is evidence that inhaled long-acting beta-agonists (LABAs) are effective over the medium and long term for patients with moderate-to-severe COPD. Their use is associated with improved quality of life and reduced exacerbations, but they have not been shown to reduce mortality or serious adverse events significantly.
- In people with COPD, the evidence is equivocal as to whether or not tiotropium offers greater benefit than LABAs in improving quality of life.
- In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:
- If forced expiratory volume in one second (FEV1) is 50% or greater of predicted: either a LABA (eg, formoterol or salmeterol) or a long-acting muscarinic antagonist (LAMA).
- If FEV1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA.
- Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1.
- Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids.
- The role of inhaled steroids in COPD is controversial:
- They are not recommended as monotherapy for most patients. Current guidelines advocate LABAs as frontline therapy for COPD, with regular inhaled corticosteroid therapy as an adjunct in patients experiencing frequent exacerbations.
- Inhaled steroids used as monotherapy have only a modest effect in relieving dyspnoea and improving lung function and less effect than long-acting bronchodilators.
- Inhaled corticosteroids reduce the risk of exacerbations without affecting mortality or the rate of decline in lung function.
- Inhaled corticosteroid use by patients with COPD increases the risk of serious pneumonia. The risk is particularly increased and dose-related with fluticasone.
- Maintenance use of oral corticosteroid therapy in COPD is not normally recommended.
- Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. Keep the dose as low as possible, monitor for osteoporosis and offer prophylaxis.
- Offer only after trials of short- and long-acting bronchodilators or to people who cannot use inhaled therapy.
- Theophylline can be used in combination with beta2 agonists and muscarinic antagonists.
- Take care when prescribing to older people because of pharmacokinetics, comorbidities and interactions with other medications.
- Reduce the theophylline dose if macrolide or fluoroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
- Mucolytic therapy:
- Consider in people with a chronic productive cough and continue use if symptoms improve.
- Do not routinely use to prevent exacerbations.
- Treatments that are not recommended include antioxidant therapy (alpha-tocopherol and beta-carotene supplements), antitussive therapy and prophylactic antibiotic therapy.
- The use of continuous prophylactic antibiotics, however, results in a clinically significant benefit in reducing exacerbations in COPD.
Vaccination and antiviral therapy
- Pneumococcal vaccination and an annual influenza vaccination should be offered to all patients with COPD.
- Antivirals for influenza: zanamivir and oseltamivir are recommended for the treatment of at-risk adults who present with influenza-like illness and who can start therapy within 48 hours of the onset of symptoms.
- Zanamivir should be used with caution in people with COPD because of a risk of bronchospasm. Patients prescribed zanamivir should have a fast-acting bronchodilator available.
See the separate article on Use of Oxygen Therapy in COPD.
- Physiotherapy has an important role in the assessment and treatment of breathing dysfunction and dyspnoea, in the assessment for and the delivery of pulmonary rehabilitation and non-invasive ventilation, and in the management of impaired airway clearance.
- The British Thoracic Society (BTS) has produced a recommendation for the physiotherapy management of respiratory problems, including COPD.
See also the separate article on Pulmonary Rehabilitation.
- Outline the commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD.
- Offer to all appropriate people with COPD, including those who have had a recent hospitalisation for an exacerbation and those who consider themselves functionally disabled by COPD (usually Medical Research Council (MRC) Grade 3 and above).
- Pulmonary rehabilitation is not suitable for people who cannot walk, have unstable angina or who have had a recent myocardial infarction.
- Tailor the programme to individual needs, and include physical training, disease education, and nutritional, psychological and behavioural intervention.
Travel and leisure advice
- Passengers with COPD are potentially at risk from reduced partial pressure of oxygen and expansion of gases within closed body cavities (bullae and pneumothoraces). However the frequency of severe adverse events in patients with COPD who fly appears to be very low. A lack of correlation between predicted arterial hypoxaemia in patients with COPD undertaking air travel and outcomes suggests that they tolerate hypoxaemia fairly well as a result of physiological adaptation.
- Inform people with bullous disease of the increased risk of pneumothorax during air travel.
- Scuba diving is not generally recommended for people with COPD.
Referral for advice, specialist investigations or treatment may be appropriate at any stage of disease, not just for people who are severely disabled. Possible reasons for referral include:
- Diagnostic uncertainty.
- Suspected severe COPD.
- The individual requests a second opinion.
- Onset of cor pulmonale.
- Assessment for oxygen therapy, long-term nebuliser therapy or oral corticosteroid therapy.
- Bullous lung disease.
- Rapid decline in FEV1.
- Assessment for pulmonary rehabilitation.
- Assessment for lung volume reduction surgery or lung transplantation.
- Dysfunctional breathing.
- Onset of symptoms at age under 40 years or with a family history of alpha-1-antitrypsin deficiency.
- Symptoms disproportionate to lung function deficit.
- Frequent infections.
Indications for surgery
- Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy.
- Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following:
- FEV1 greater than 20% predicted.
- PaCO2 less than 7.3 kPa.
- Upper lobe predominant emphysema.
- Carbon monoxide lung transfer factor greater than 20% predicted.
- Bronchoscopic lung volume reduction with airway valves for advanced emphysema shows some improvement in patient-reported quality of life outcomes but there is currently inadequate evidence of improvement for the procedure to be recommended.
- Lung transplantation:
- Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy.
- Considerations include age, FEV1, PaCO2, homogeneously distributed emphysema on CT scan, elevated pulmonary artery pressures with progressive deterioration, comorbidities and local surgical protocols.
See also the separate article on Palliative Care.
- Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other medical therapy.
- Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness.
- Provide access to multidisciplinary palliative care teams and hospices.
Follow-up and review
- Review people with mild or moderate COPD at least once a year and those with very severe COPD at least twice a year.
- People with stable severe COPD do not normally need regular hospital review, but there should be locally agreed mechanisms to allow rapid hospital assessment when necessary.
- People requiring interventions, such as long-term non-invasive ventilation (NIV), should be reviewed regularly by specialists.
- Mild, moderate or severe outflow obstruction:
- Assess: smoking status and desire to quit, adequacy of symptom control (breathlessness, exercise tolerance, exacerbation frequency), presence of complications, effects of each drug treatment, inhaler technique, need for referral to specialist and therapy services, and need for pulmonary rehabilitation.
- Measure: FEV1 and forced vital capacity (FVC), BMI, and MRC dyspnoea scale.
- Very severe outflow obstruction:
- Assess: smoking status and desire to quit, adequacy of symptom control (breathlessness, exercise tolerance, exacerbation frequency), presence of cor pulmonale, need for long-term oxygen therapy, nutritional state, presence of depression, effects of each drug treatment, inhaler technique, need for social services and occupational therapy input, need for referral to specialist and therapy services, and need for pulmonary rehabilitation.
- Measure: FEV1 and FVC, BMI, MRC dyspnoea scale and oxygen saturation of arterial blood (SaO2).
Further reading and references
Chronic obstructive pulmonary disease; NICE CKS, November 2010 (UK access only)
Chronic obstructive pulmonary disease - roflumilast; NICE Technology Appraisal Guideline, January 2012
Corticosteroids - inhaled; NICE CKS, August 2010 (UK access only)
No authors listed; Management of exacerbations of COPD. Thorax 2004 59:i131-i156
GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE; Global initiative for obstructive lung disease (2018)
Chronic obstructive pulmonary disease; NICE Clinical Guideline (June 2010)
Broekhuizen BD, Sachs AP, Verheij TJ; COPD in primary care: from episodic to continual management. Br J Gen Pract. 2012 Feb62(595):60-1. doi: 10.3399/bjgp12X625003.
Kew KM, Mavergames C, Walters JA; Long-acting beta2-agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2013 Oct 1510:CD010177. doi: 10.1002/14651858.CD010177.pub2.
Chong J, Karner C, Poole P; Tiotropium versus long-acting beta-agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Sep 129:CD009157. doi: 10.1002/14651858.CD009157.pub2.
Park HY, Man SF, Sin DD; Inhaled corticosteroids for chronic obstructive pulmonary disease. BMJ. 2012 Oct 25345:e6843. doi: 10.1136/bmj.e6843.
Spencer S, Karner C, Cates CJ, et al; Inhaled corticosteroids versus long-acting beta(2)-agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Dec 7(12):CD007033. doi: 10.1002/14651858.CD007033.pub3.
Suissa S, Patenaude V, Lapi F, et al; Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013 Nov68(11):1029-36. doi: 10.1136/thoraxjnl-2012-202872.
Amantadine, oseltamivir and zanamivir for the treatment of influenza; NICE Technology Appraisal Guidance, February 2009
Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient; British Thoracic Society (May 2009)
Managing passengers with stable respiratory disease planning air travel; British Thoracic Society (2011)
Bronchoscopic lung volume reduction with airway valves for advanced emphysema; NICE Interventional Procedure Guideline (November 2009)
I'm a 53 year old non smoker who has suffered with supposedly 'mild' asthma since the 1990s. Various inhalers have not helped and symptoms gradually worsened (severe breathlessness when walking up...sherylbceroc
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