Management of stable COPD

There are related separate articles: Chronic Obstructive Pulmonary Disease, Diagnosing COPD, Acute Exacerbations of COPD and Use of Oxygen Therapy in COPD.

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:¹

• 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.

COPD treatment and management: general points¹

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.

Inhaler options¹

Inhalers are the mainstay of treatment for COPD.

General points:

• 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 large 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.^{2 3} Triple therapy is licensed for those with moderate- to-severe COPD not controlled with other combination options.

Inhaler choice⁴

There is a useful NHS document summarising recommended prescribing and available treatment options.⁵ There are differences in CO₂ emission for different devices to consider also.

GOLD advises grouping patients by symptom burden and risk of future exacerbations.⁴

High risk of future exacerbations

High risk of exacerbation is given by past history of > 2 moderate exacerbations, or one or more severe exacerbations, leading to hospitalisation.

• This group are called Group E and are treated the same, regardless of symptom burden.

• Their initial treatment is a long-acting beta₂ agonist (LABA) + long-acting muscarinic agent (LAMA). A combination device may be more convenient and cost-effective.

• Consider adding in an inhaled corticosteroid (ICS) where the blood eosinophil count is > 300 cells per microlitre, or where the count is between 100-300 but with a history of a moderate exacerbation in the last year.

• Consider removing ICS component of there is an episode of pneumonia.

Low risk of future exacerbations

Those at low risk and divided into those with low symptom burden (Group A) and those with high symptom burden (Group B). Group A have a COPD Assessment Test score of <10, and Group B have a score >10.⁶

• Group A are treated with a bronchodilator (short-acting beta₂ agonist or short-acting muscarinic agent).

• Group B are treated with a long-acting beta₂ agonist (LABA) + long-acting muscarinic agent (LAMA).

There is no initial role for inhaled corticosteroids in this group with low risk of exacerbations in the latest GOLD report.

This rationale differs from NICE 2019 guidance that prioritises asthmatic symptoms as the key treatable trait.¹

COPD and asthmatic features

For patients with features suggestive of an asthmatic component (secure diagnosis of asthma or atopy, higher blood eosinophil count, substantial variation in FEV1 over time or substantial diurnal variation in peak expiratory flow), a combination LABA + LAMA can be considered, with the addition of an ICS if there is an exacerbation requiring hospitalisation, or 2 moderate exacerbations.

COPD without asthmatic features

Initial treatment is with a combined LABA + LAMA, only adding ICS for a 3 month trial IF the symptom burden remains high.

Other medication¹

Oral corticosteroids

• 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.

Theophylline

• 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.

• A 2022 systematic review showed carbocisteine reduced the number of exacerbations.⁷

• Guidelines recommend not routinely using mucoactive agents to prevent exacerbations.

Prophylactic antibiotics

• 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

Roflumilast is an oral phosphodiesterase‑4 inhibitor and may be used as an option by specialists in addition to bronchodilator therapy for severe COPD in adults with chronic bronchitis, only if:⁸

• 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).

Oxygen

This may be needed in people with severe COPD. Assessment for oxygen therapy and prescribing oxygen are covered in the separate Use of Oxygen Therapy in COPD and Prescribing Oxygen articles.

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.⁹

• 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.¹⁰

Treatments that are not recommended include antioxidant therapy (alpha-tocopherol and beta-carotene supplements) and antitussive therapy.

Non-pharmacological treatment and management¹

Pulmonary rehabilitation

• Outline the commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD.¹¹

• 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.

Physiotherapy

If patients have excessive sputum, they should be taught the use of positive expiratory pressure (PEP) masks and active cycle of breathing techniques.

Occupational therapy

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.

Social services

Consider the need for referral to social services if there is disability caused by COPD or other comorbidities.

Nutrition

The effect of obesity on COPD is still being explored and is currently unclear.¹² Either being underweight or overweight may have adverse effects and the condition itself can have an effect on body weight.^{13 14} 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). A hypoxic challenge test is recommended for those with resting oxygen saturations below 95%, or those who desaturate to below 84% on six minute walking test, or are at risk of hypercapnia.¹⁵

• Inform people with bullous disease of the increased risk of pneumothorax during air travel.

• Scuba diving is not generally recommended for people with COPD.

Self-management plans

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 review¹

• 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).

Referral¹

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.

• Haemoptysis.

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.¹⁶

  • 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.¹⁷

• 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 disease¹

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.