Management of COPD

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1. DIAGNOSIS AND ASSESSMENT

• Consider diagnosis of COPD if: age >35 years, smoker/ex-smoker, no asthma symptoms and presenting with any of the below:
  – exertional breathlessness
  – chronic cough
  – regular sputum production
  – frequent winter 'bronchitis'
  – wheeze
• Confirm presence and degree of airflow obstruction with post-bronchodilator spirometry (see Table 1)
• Perform chest X-ray, FBC and calculate BMI
• Also consider:
  – Level of disability (eg, breathlessness [use MRC dyspnoea scale], exercise limitation, frequency of exacerbations)
  – Other prognostic factors (eg, BMI, health status, PaO₂, cor pulmonale)
• Calculate BODE Index** if information available
• Consider CT scan or T_LCO* testing if symptoms disproportionate to spirometric impairment

KEY: * TLCO = carbon monoxide lung transfer factor ** BODE Index comprises measures of BMI, airflow obstruction, dyspnoea and exercise tolerance

Table 1: Severity of airflow obstruction where post-bronchodilator FEV1/FVC <0.7
Severity of airflow obsctruction	Stage 1: Mild	Stage 2: Moderate	Stage 3: Severe	Stage 4: Very severe
FEV1 (% predicted)	≥80 + symptoms	50–79	39–49	<50 + respiratory failure or <30

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2. MANAGEMENT OF STABLE DISEASE

INHALED TREATMENT

Refer to the treatment algorithm at the top of this page.

• Choose a drug based on patient's symptomatic response and preference, side-effects of drug and potential to reduce exacerbations and cost
• Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids
• Be aware of potential side-effects (including non-fatal pneumonia) of inhaled corticosteroids and be prepared to discuss with patients
• Assess effectiveness in terms of: lung function, symptoms, daily activities, exercise capacity, speed of symptom relief (short-acting bronchodilators only)
• Consider nebuliser if distressing or disabling breathlessness despite maximal inhaled therapy; continue use only if condition improves

ORAL TREATMENT

• Long-term oral corticosteroid treatment – consider only if no other practical way of managing frequent exacerbations and/or severe breathlessness; keep dose as low as possible. Monitor patients for osteoporosis and prescribe appropriate prophylaxis; if >65 years, start prophylaxis without monitoring
• Theophylline – consider if inhaled therapy cannot be used or if patient still symptomatic after trials of short-acting and long-acting bronchodilators (can be added to these). Assess effectiveness as for inhaled therapy; monitor plasma levels and interactions
• Mucolytics – consider if chronic productive cough; continue use only if symptoms improve (do not use routinely to prevent exacerbations)

OXYGEN THERAPY

• Assess need for long-term oxygen therapy (LTOT) in patients with FEV₁ <30% predicted, cyanosis, polycythaemia, peripheral oedema, raised JVP or O₂ saturations ≤92% breathing air
• Offer LTOT to patients with PaO₂ <7.3kPa when stable, or >7.3kPa and <8kPa when stable plus a secondary condition (eg, peripheral oedema, pulmonary hypertension, secondary polycythaemia, nocturnal hypoxaemia)
• Following specialist assessment, offer ambulatory oxygen to patients on LTOT who are motivated to use it, have PaO₂ ≤7.3kPa and exercise desaturation, and oxygen improves exercise capacity and/or breathlessness
• Advise patient to use for ≥15 hours/day and warn of fire/explosion risk
• Consider short-burst oxygen therapy only for episodes of severe breathlessness not relieved by other treatments; continue only if effective

Note:

• Exclude clinically significant COPD if FEV₁ and FEV₁/FVC normalise on drug therapy
• Consider asthma if >400ml FEV₁ response to bronchodilators/oral corticosteroids and significant daily fluctuations in peak flow

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3. INITIAL MANAGEMENT OF EXACERBATIONS

• Increase frequency of bronchodilator use and consider use of a nebuliser
• Prescribe oral antibiotics if sputum is purulent or clinical signs of pneumonia
• Offer prednisolone 30mg daily for 7–14 days
• Decide whether to manage at home or in hospital, taking into account clinical and social factors

SELF MANAGEMENT

Provide patients at risk of exacerbation with a course of antibiotics and corticosteroids to keep at home and encourage patients to respond to an exacerbation by:

• starting oral corticosteroid if breathlessness increases sufficiently to interfere with daily activities
• starting antibiotics if sputum is purulent
• adjusting bronchodilator therapy to control symptoms

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4. FOLLOW-UP

• Review patients with mild or moderate COPD at least yearly and those with very severe COPD at least twice yearly

Additional supportive measures

Smoking cessation: – Provide encouragement and assistance to all patients at every opportunity – Offer nicotine replacement therapy, varenicline or bupropion Offer pulmonary rehabilitation to all appropriate patients, including those with a recent hospitalisation for an acute exacerbation, and to those who consider themselves to be functionally disabled by COPD Use non-invasive ventilation for persistent hypercapnic ventilatory failure during exacerbations unresponsive to drug therapy Offer annual influenza and pneumococcal vaccinations to all patients Identify and treat anxiety and depression Address obesity or poor nutrition Consider referral for physiotherapy, dietetic advice, occupational therapy, social services and multidisciplinary palliative care as appropriate

Specialist referral

Diagnostic uncertainty Suspected severe COPD Onset of cor pulmonale Assessment for O2 therapy, long-term nebuliser therapy or oral corticosteroid therapy Rapid decline in FEV1 Assessment for pulmonary rehabilitation Assessment for surgical options Dysfunctional breathing Onset of symptoms <40 years or a family history of alpha-1 antitrypsin deficiency Symptoms disproportionate to lung function deficit Frequent infections Haemoptysis Bullous lung disease

Full NICE guideline

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KEYWORDS: LABA | LAMA | ICS | Beta2 agonist | Anticholinergic | Antimuscarinic | Muscarinic | Antagonist | Bronchodilator | Corticosteroid | Inhaled COPD therapy

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