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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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 symptoms (including pharmacological and non-pharmacological strategies),
- Holistic care depending on the stage of the condition (including managing comorbidities of physical and mental health, advice on social security benefits and travel, management of complications, advice on nutrition and physical activity and palliative care).
- Education of patients and advising patients on self-management strategies.
- Identifying and monitoring patients at high risk of exacerbations of COPD.
- Prevention of exacerbations, including Influenza and pneumococcal vaccination.
For all with a confirmed diagnosis of COPD:
- Offer smoking cessation advice and support. This is the one strategy which can prevent decline in lung function. Offer nicotine replacement therapy, varenicline or bupropion to those who wish to stop smoking. It is not yet known if e-cigarettes are a safe and/or effective smoking cessation option.
- Offer vaccination for pneumonia and influenza.
- Offer pulmonary rehabilitation where indicated (see section below for indications.)
- Create an individualised self-management plan. Include management of exacerbations, including standby medication where appropriate.
- Optimise treatment/management of comorbidities.
- Review all of the above regularly.
- Only start pharmacological therapies where all the above have been offered where relevant and treatment is still needed to relieve symptoms.
Inhalers are the mainstay of treatment for COPD. Evidence is evolving rapidly at the current time. Even recent guidelines from the National Institute for Health and Care Excellence (NICE) of 2018 are due to have an update on triple therapy published in mid-2019.
- Although there is evidence that optimal use of combination inhalers can improve symptoms and lung function, there is no evidence that they halt long-term decline of the condition.
- Always educate the person in the use of a handheld inhaler, and ensure they are able to use it correctly. Consider a different device if need be. A spacer may be appropriate, in which case prescribe the one that goes with the inhaler used, and teach technique. Advise inhaling after each actuation with minimal delay. Advise washing the spacer no more often than once a month and to hand wash using warm water and washing‑up liquid, and allow the spacer to air dry.
- Nebulisers may be an alternative route of administration in some circumstances if inhalers are not effective or the person is unable to use them.
An increasingly confusing range of inhalers is now available, including bronchodilators, inhaled steroids and combinations thereof. Briefly:
- Short-acting beta2-agonists (SABA): salbutamol and terbutaline.
- Long-acting beta2-agonists (LABA): formoterol, salmeterol (twice daily) and (once daily) indacaterol, olodaterol and vilanterol.
- Short-acting antimuscarinics (SAMAs): ipratropium only in the UK.
- Long-acting antimuscarinics (LAMAs): tiotropium, aclidinium, glycopyrronium bromide and umeclidinium.
- Inhaled corticosteroids (ICS): including fluticasone, budesonide, and beclometasone. NICE guidelines advise informing patients of the risks of long-term inhaled corticosteroids, in particular the increased risk of pneumonia. Treatment with an ICS alone does not appear to improve outcomes but there is evidence that it can do in certain combination options.
- There are numerous combinations of the above including:
- SABA plus SAMA: shown to be more effective than either component alone in improving symptoms and forced expiratory volume in one second (FEV1).
- LABA plus LAMA: also more effective than either component alone, improving symptoms, FEV1 and reducing the risk of exacerbations.
- ICS plus LABA: more effective than either component alone in reducing exacerbations and improving health status in people with moderate-to-severe COPD and who are prone to exacerbations.
- Triple therapy: LABA plus LAMA plus ICS: there is evolving evidence that triple therapy improves symptoms, health status, and lung function, and reduces exacerbations in comparison to other combinations[4, 5]. Triple therapy is licensed for those with moderate- to-severe COPD not controlled with other combination options.
The Primary Care Respiratory Society has laid out all the inhaler combinations and brands available in a single document which is very helpful. However, note it has not been updated since 2014.
NICE advises using inhalers as follows:
- SABA or SAMA first-line as required to reduce breathlessness and improve exercise capacity.
- Use a combined LABA plus LAMA for those who do not have asthmatic features suggesting steroid responsiveness and who are using a short-acting bronchodilator but still have symptoms or exacerbations. For those who do have asthmatic features, use a LABA plus ICS instead. In both groups, only consider a combination inhaler if non-pharmacological options, vaccinations and smoking cessation have been addressed.
- Offer triple inhaled therapy (LAMA plus LABA plus ICS) to people with COPD with asthmatic features/features suggesting steroid responsiveness who remain breathless or have exacerbations despite taking LABA plus ICS.
- NICE defines asthmatic features suggesting steroid responsiveness in this context to include "any previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%)."
- Use combined preparations where possible to minimise the number of inhalers which have to be used.
NICE has created a visual summary/flow chart for this treatment algorithm.
- 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.
- Consider in people with a chronic productive cough and continue use if symptoms improve.
- Do not routinely use to prevent exacerbations.
- In selected people only, due to the potential adverse effects and the risk of antibiotic resistance. Usually this would be with specialist input. Check sputum culture first.
- Where appropriate, azithromycin 250 mg three times a week is usually advised. Check baseline ECG and LFT before starting.
- Only indicated where there are frequent and/or severe exacerbations.
- It is not necessary to stop the azithromycin during acute exacerbations. A standby non-macrolide should be prescribed to be on standby for exacerbations which occur despite prophylaxis.
Roflumilast is an oral phosphodiesterase‑4 inhibitor and and may be used as an option by specialists in addition to bronchodilator therapy for severe COPD in adults with chronic bronchitis, only if:
- FEV1 after a bronchodilator is less than 50% of predicted normal; and
- The person has had two or more exacerbations in the previous 12 months despite triple inhaled therapy (LAMA plus LABA plus ICS).
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 during a time when national guidance informs professionals that the influenza virus is circulating, 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.
Treatments that are not recommended include antioxidant therapy (alpha-tocopherol and beta-carotene supplements) and antitussive therapy.
- 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.
See also the separate Pulmonary Rehabilitation article.
If patients have excessive sputum, they should be taught the use of positive expiratory pressure (PEP) masks and active cycle of breathing techniques.
Assess the need for referral to occupational therapy. Regularly review the ability to undertake activities related to daily living and the effect symptoms have on this.
Consider the need for referral to social services if there is disability caused by COPD or other comorbidities.
The effect of obesity on COPD is still being explored and is currently unclear. Either being underweight or overweight may have adverse effects and the condition itself can have an effect on body weight[9, 10]. 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.
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.
Develop personalised plans in collaboration with the individual (and their family/carers where relevant). Educate and inform about COPD and risk factors for exacerbations. Develop specific exacerbation management plans with and for those at risk. Offer standby courses of an antibiotic and oral steroid if there has been an exacerbation in the previous year and the person is at risk of further exacerbation, and if they are able to use these medicines appropriately and request replacements as needed. Specific advice about medication used is covered in the separate Acute Exacerbations of COPD article.
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).
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
- Bullectomy: refer patients who are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax.
- Lung volume reduction surgery: 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 optimal medical therapy (including rehabilitation), and if they meet all of the following criteria:
- FEV1 less than 50%.
- They do not smoke.
- They can complete a six‑minute walk distance of at least 140 m (if limited by breathlessness).
- Endobronchial valve insertion to reduce lung volume in advanced emphysema is supported by NICE in the hands of specialists, provided that standard arrangements are in place for clinical governance, consent and audit.
- Evidence on use of endobronchial coils to reduce lung volume is limited, so NICE advises this only be used in the context of a clinical trial and after assessment by a lung volume reduction multidisciplinary team.
- Lung transplantation: consider referral for transplantation for those who:
- Have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment; and
- Do not smoke; and
- Have completed pulmonary rehabilitation; and
- Do not have contra-indications for transplantation (for example, comorbidities or frailty).
Palliative care in chronic obstructive pulmonary disease
See also the separate Palliative Care article.
- 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.
Further reading and references
Chronic Obstructive Pulmonary Disease; NICE CKS, May 2018 (UK access only)
Chronic Obstructive Pulmonary Disease; NICE Guidance (December 2018 - last updated 2019)
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019 Report; Global Initiative for Chronic Obstructive Lung Disease, 2019
British National Formulary (BNF); NICE Evidence Services (UK access only)
Chronic obstructive pulmonary disease: beclometasone, formoterol and glycopyrronium (Trimbow); NICE Evidence summary, May 2018
Vanfleteren L, Fabbri LM, Papi A, et al; Triple therapy (ICS/LABA/LAMA) in COPD: time for a reappraisal. Int J Chron Obstruct Pulmon Dis. 2018 Dec 1213:3971-3981. doi: 10.2147/COPD.S185975. eCollection 2018.
Roflumilast for treating chronic obstructive pulmonary disease; NICE Technology Appraisal Guidance, July 2017
Amantadine, oseltamivir and zanamivir for the treatment of influenza; NICE Technology Appraisal Guidance, February 2009
Zewari S, Vos P, van den Elshout F, et al; Obesity in COPD: Revealed and Unrevealed Issues. COPD. 2017 Dec14(6):663-673. doi: 10.1080/15412555.2017.1383978.
Spelta F, Fratta Pasini AM, Cazzoletti L, et al; Body weight and mortality in COPD: focus on the obesity paradox. Eat Weight Disord. 2018 Feb23(1):15-22. doi: 10.1007/s40519-017-0456-z. Epub 2017 Nov 6.
Eriksson B, Backman H, Bossios A, et al; Only severe COPD is associated with being underweight: results from a population survey. ERJ Open Res. 2016 Jul 72(3). pii: 00051-2015. doi: 10.1183/23120541.00051-2015. eCollection 2016 Jul.
Managing passengers with stable respiratory disease planning air travel; British Thoracic Society (2011)
Endobronchial valve insertion to reduce lung volume in emphysema; NICE Interventional Procedure Guidance, December 2017
Insertion of endobronchial nitinol coils to improve lung function in emphysema; NICE Interventional Procedure Guidance, March 2015