COPD Management

Aka: COPD Management, Chronic Obstructive Pulmonary Disease Management, Emphysema Management, Chronic Bronchitis Management

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II. Monitoring

  1. Symptoms: Dyspnea
    1. mMRC Dyspnea Index
    2. COPD Assessment Test (CAT Tool)
  2. Exam
    1. Pulse Oximetry
    2. Timed walking of specific distances
  3. Spirometry
    1. Serial FEV1 Measurements are most significant value
    2. FEV1 <1 Liter indicates severe disease
    3. Poor prognosis if FEV1 <750 cc (<50% predicted)
  4. Goals
    1. Decrease Dyspnea
    2. Improve quality of life
    3. Prevent exacerbations
    4. Decrease hospitalizations
    5. Slow disease progression and decrease mortality

III. Prevention

  1. See COPD Exacerbation Prevention
  2. Immunizations
    1. Influenza Vaccine yearly
    2. Pneumococcal Vaccine (PCV20 or PCV15 and PPSV23)
    3. Covid Vaccine
  3. Tobacco Cessation! (and Vaping cessation)
    1. Single most important intervention
    2. Decreases FEV1 decline and mortality
    3. Make use of Smoking Cessation adjuncts (Bupropion, Varenicline, Nicotine Replacement)
    4. Educating patients about their lung age (estimated via Spirometry) is effective motivation
      1. Parkes (2008) BMJ 336(7644): 598-600 [PubMed]
  4. Pulmonary Rehabilitation
    1. Indicated in moderate to severe COPD with Dyspnea-limited activities or impaired quality of life
    2. Includes Pulmonary Rehabilitation Exercise, nutritional counseling, education and behavioral modification
    3. Reduces Dyspnea, improves Exercise ability and improves quality of life if continued for at least 6 months
      1. Salman (2003) J Gen Intern Med 18(3): 213-21 [PubMed]

IV. Management: Approach

  1. GOLD Treatment protocols focus on 2 criteria
    1. Dyspnea (mMRC Dyspnea Scale, COPD Assessment Test)
    2. Exacerbations (based on presence of high risk criteria)
      1. Hospitalizations
      2. Two or more moderate exacerbations
  2. Exacerbations
    1. Moderate Exacerbations 0 to 1 (not leading to hospitalization)
      1. Gold A: Fewer Symptoms (mMRC Dyspnea Scale 0 to 1, COPD Assessment Test <10)
        1. Maintain single long-acting Bronchodilator (LABA or LAMA)
      2. Gold B: More Symptoms (mMRC Dyspnea Scale >=2, COPD Assessment Test <10)
        1. Maintain dual therapy (LABA and LAMA)
    2. Moderate Exacerbations >=2 (at least one hospitalization): GOLD Group E
      1. Maintain dual therapy (LABA and LAMA)
      2. Use Triple Therapy (add Inhaled Corticosteroid) if indicated as below
      3. Background
        1. GOLD Group E as of 2023 combines prior Groups C and D
        2. Group C included patients with fewer symptoms (mMRC 0-1, CAT<10)
        3. Group D included patients with more symptoms (mMRC >=2, CAT>=10)
  3. Inhaled Corticosteroid
    1. Inhaled Corticosteroid examples: Fluticasone (Flovent)
    2. Indications (Eosinophilic Inflammation)
      1. Blood Eosinophil Count >300 cells/uL (may consider if count 100 to 300 cells/uL) OR
      2. Comorbid Asthma OR
      3. Two or more COPD exacerbations per year
    3. Contraindications
      1. Multiple Pneumonia events
      2. Blood Eosinophil Count <100 cells/uL
      3. Mycobacterial infections
    4. Precautions
      1. See Medications in COPD Management for Inhaled Corticosteroid precautions
      2. Corticosteroids increase risk of Pneumonia (NNH 64 for triple therapy compared with dual therapy)
      3. Corticosteroids are not uniformly effective in COPD
        1. Overall, NNT 16 to reduce one exacerbation in 12 months with triple therapy (compared with dual therapy)
        2. Eosinophil Count >300 cells/ul (>4% of total WBC) predicts steroid responsiveness
        3. Unlikely to be steroid responsive if Eosinophil Count <100 cells/ul
        4. Eosinophil Count is only has predictive value when OFF inhaled and Systemic Corticosteroids
        5. COPD may still respond to Systemic Corticosteroids despite low Eosinophil Count
      4. References
        1. Pascoe (2019) Lancet Respir Med 7(9):745-56 [PubMed]

V. Management: GOLD Criteria - Low Risk (Groups A and B)

  1. See GOLD Combined Assessment
  2. See Medications in COPD Management
  3. Low risk criteria
    1. Exacerbations 0 to 1 moderate (not leading to hospitalization)
    2. Other typical findings
      1. Spirometry Mild to Moderate Severity (FEV1 >50% of predicted)
  4. Less Symptoms (GOLD A): mMRC Dyspnea Scale <2 or COPD Assessment Test <10
    1. First-choice (intermittent symptom management)
      1. Single Bronchodilator (LABA or LAMA) is recommended by GOLD 2023 Guidelines
      2. Long-acting muscarinic (LAMA, e.g. Tiotropium) may be preferred over LABA
        1. Consider as first-line agent (decreases exacerbations even in mild disease, NNT 10)
        2. (2017) Presc Lett 24(12): 67-8
    2. Second-choice (options from GOLD 2017)
      1. Long-Acting Beta Agonist (LABA, e.g. Salmeterol)
      2. Short-acting Beta Agonist (e.g. Albuterol) 2 puffs as needed up to every 6 hours OR
      3. Short-acting Anticholinergic (e.g. Ipratropium) as needed up to every 6 hours OR
      4. Combined Short-acting Beta Agonist with short-acting Anticholinergic (e.g. Combivent)
  5. More Symptoms (GOLD B): mMRC Dyspnea Scale 2 or COPD Assessment Test 10 or higher
    1. First-choice (long-acting symptom management)
      1. Long-Acting Beta Agonist (LABA) AND Long-acting Anticholinergic (LAMA)
      2. Combination LABA and LAMA examples
        1. Salmeterol and TiotropiumInhalers
        2. Anoro Ellipta (Umeclidinium and Vilanterol) OR
        3. Stiolto Respimat (Tiotropium and olodaterol)
    2. Second-choice (options from GOLD 2017)
      1. Long-acting Anticholinergic (e.g. Tiotropium) OR
      2. Long-Acting Beta Agonist (e.g. Salmeterol)
    3. Third-choice (options from GOLD 2017)
      1. Combined Short-acting Beta Agonist with short-acting Anticholinergic (e.g. Combivent) OR
      2. Short-acting Beta Agonist (e.g. Albuterol) 2 puffs as needed up to every 6 hours AND/OR
      3. Short-acting Anticholinergic (e.g. Ipratropium) as needed up to every 6 hours

VI. Management: GOLD Criteria - High Risk (Group E, previously C and D)

  1. See GOLD Combined Assessment
  2. See Medications in COPD Management
  3. High risk criteria
    1. Two or more COPD exacerbation per year (including one or more hospitalizations)
    2. Other typical findings
      1. Spirometry Severe to Very Severe (FEV1 <50% of predicted)
  4. Combined Exacerbation Criiteria (GOLD E)
    1. As of GOLD 2023 Criteria, Gold C and Gold D are combined in Gold E
      1. GOLD C (fewer symptoms): mMRC Dyspnea Scale <2 or COPD Assessment Test <10
      2. GOLD D (more symptoms): mMRC Dyspnea Scale 2 or COPD Assessment Test 10 or higher
    2. First-line Dual Therapy
      1. Long-Acting Beta Agonist (LABA) AND Long-acting Anticholinergic (LAMA)
      2. Combination LABA and LAMA examples
        1. Salmeterol and TiotropiumInhalers
        2. Anoro Ellipta (Umeclidinium and Vilanterol) OR
        3. Stiolto Respimat (Tiotropium and olodaterol)
    3. Adjunctive: Triple Therapy with Inhaled Corticosteroid (added to Dual Therapy)
      1. See Inhaled Corticosteroid indications (and contraindications) as above
    4. Adjunctive: Other options
      1. Phosphodiesterase-4 Inhibitor (e.g. Roflumilast or Daliresp)
      2. Theophylline

VII. Management: Stepped Care of Dyspnea (Older Protocol Replaced by GOLD Guidelines)

  1. Medication protocols here are replaced by GOLD Guidelines
    1. However, kept for other adjunctive measures to consider
  2. See Medications in COPD Management
  3. At risk: Stage 0 (Normal Pulmonary Function Tests)
    1. Chronic intermittent symptoms
    2. Eliminate exposures (e.g. Tobacco)
  4. Mild: Stage I (FEV1/FVC <0.7, FEV1>80%) - Intermittent symptoms management
    1. Short-acting Beta Agonist (e.g. Albuterol) 2 puffs as needed up to every 6 hours OR
    2. Short-acting Anticholinergic (e.g. Ipratropium) as needed up to every 6 hours
  5. Moderate: Stage II (FEV1/FVC <0.7, FEV1 50-80%)
    1. Add to Stage I management
    2. Long acting beta Agonist (e.g. Salmeterol or Serevent) or Long acting Anticholinergic (e.g. Tiotropium or Spiriva)
    3. Patients benefit most during daytime active hours
      1. Consider dosing only in morning to save cost
      2. However, sleep is improved
  6. Severe: Stage III (FEV1/FVC <0.7, FEV1 30-50%)
    1. Add to Stage I and II management (short acting beta Agonist and long acting beta Agonist)
    2. Inhaled Corticosteroid (e.g. fluticasone or Flovent)
      1. See above for Inhaled Corticosteroid indications
      2. See Medications in COPD Management for Inhaled Corticosteroid precautions
    3. Consider using both a long acting beta Agonist and a long acting Anticholinergic
      1. Long-Acting Beta Agonist (e.g. Salmeterol) AND Long-acting Anticholinergic (e.g. Tiotropium) OR
      2. Anoro Ellipta (Umeclidinium and Vilanterol) OR
      3. Stiolto Respimat (Tiotropium and olodaterol)
    4. Low-flow oxygen at night and with exertion
    5. Pulmonary Rehabilitation
    6. Consider Systemic Bronchodilator
      1. Leukotriene Receptor Antagonist (e.g. Accolate)
      2. Theophylline (see efficacy below)
  7. Very severe: Stage IV (FEV1/FVC <0.7, FEV1 <30%)
    1. Add to Stage I, II and III management (short acting beta Agonist, long acting beta Agonist, Inhaled Corticosteroid)
    2. Continuous Low-flow oxygen
    3. Consider adding Phosphodiesterase-4 Inhibitor (e.g. Roflumilast or Daliresp)
    4. Consider using both a long acting beta Agonist and a long acting Anticholinergic
      1. Long-Acting Beta Agonist (e.g. Salmeterol) AND Long-acting Anticholinergic (e.g. Tiotropium) OR
      2. Anoro Ellipta (Umeclidinium and Vilanterol) OR
      3. Stiolto Respimat (Tiotropium and olodaterol)
    5. Consider less efficacious methods for Dyspnea
      1. Buspirone as Anxiolytic agent
      2. Sustained release oral Morphine 20 mg daily
        1. Use with caution, studies are preliminary
        2. Abernethy (2003) BMJ 327:523-6 [PubMed]
  8. Crisis Management
    1. See Acute Exacerbation of Chronic Bronchitis
    2. Beta Agonist up to 6 to 8 puffs q1-2 hours
    3. Ipratropium Bromide up to 6 to 8 puffs q3-4 hours
    4. Systemic Corticosteroids for 5-10 days (see below)
    5. Theophylline
      1. Rarely if ever used in U.S.
      2. See Medications in COPD Management for efficacy and safety
    6. Oxygen therapy: Do not limit FIO2 in CO2 retainers
      1. Set O2 Sat goal of 88-91%
      2. Anticipate CO2 rise of 12 points
      3. Consider BiPap for pH < 7.25

VIII. Management: Protocols

  1. Exacerbation Guidelines
    1. See Stepped Management as above
    2. See Antibiotic Use in COPD Exacerbation
    3. Do not define exacerbation severity by Spirometry
    4. Consider Chest XRay in hospitalized patients
    5. Prednisone 40 mg orally daily (5 day course is typical)
      1. Five day course of 40 mg daily is sufficient for most COPD exacerbations
        1. Leuppi (2013) JAMA 309(21):2223-31 [PubMed]
      2. Ten day course reduces relapse rate after COPD evaluation in ER
        1. Aaron (2003) N Engl J Med 348:2618-25 [PubMed]
    6. Avoid low efficacy therapies
      1. Mucolytic medications are not shown helpful
      2. Chest physiotherapy is not efficacious
      3. Theophylline not helpful in exacerbations
    7. References
      1. Snow (2001) Chest 119:1185-9 [PubMed]
  2. Maintenance Guidelines
    1. Before Intervention
      1. Test Spirometry
      2. Review Patient's symptoms
    2. Initiate Trial of Intervention
    3. After Intervention
      1. Recheck Spirometry
      2. Were Patient's symptoms improved?

IX. Management: Surgical Interventions

  1. Lung Transplantation
  2. Lung Volume reduction surgery
    1. High Risk Surgery (high mortality)
    2. Indicated in severe upper lobe predominant Emphysema and low post-Pulmonary Rehabilitation Exercise capacity
    3. Improves 5 year survival in severe COPD with heterogeneous distribution of Emphysema and upper lobe predominance
      1. Improved quality of life if BODE Index >5
      2. Sanchez (2010) J Thorac Cardiovasc Surg 140(3): 564-72 [PubMed]
    4. Worse prognosis (increased 30 day mortality) if FEV1 <20% predicted, low DLCO or homogenous Emphysema
      1. (2001) N Engl J Med 345(15): 1075-83 [PubMed]

X. Management: Other Interventions

  1. Phosphodiesterase-4 Inhibitor
    1. Reduces pulmonary inflammation by inhibiting breakdown of intracellular cAMP
    2. Indicated in severe, refractory COPD with frequent exacerbations
    3. Roflumilast (Daliresp) 500 mcg daily
      1. NNT: 24 severe COPD patients to prevent 1 hospitalization per year
      2. Field (2011) Circ Respir Pulm Med 5: 57–70 [PubMed]
    4. Ensifentrine (Ohtuvayre)
      1. Combined PED3 and PDE4 Inhibitor nebulized twice daily
      2. Very expensive and efficacy unclear at release in 2024
  2. Longterm Oxygen Therapy
    1. Indications
      1. Severe resting Hypoxemia (after breathing room air for 30 minutes)
        1. Partial Pressure of oxygen <=55 mmHg OR
        2. Oxygen Saturation <=88%
      2. Tissue Hypoxia findings (alternative criteria)
        1. Hematocrit >55%
        2. Cor Pulmonale
        3. Pulmonary Hypertension
    2. Efficacy
      1. Decreases mortality in severe resting Hypoxemia
      2. Does not improve outcomes or quality of life in exertional Dyspnea
    3. Target
      1. Use for >=15 hours/day
      2. Target Oxygen Saturations 88 to 92%
  3. Beta Blockers (Cardioselective)
    1. Recommended in COPD (despite prior relative contraindication in COPD)
    2. Cardioselective Beta Blockers (e.g. Metoprolol, Bisoprolol) improve cardiopulmonary status
    3. Associated with decreased COPD exacerbations and increased survival
    4. Decrease Bronchodilator induced Tachycardia
    5. Do not reduce Bronchodilator (beta Agonist) effectiveness
    6. References
      1. Farland (2013) Ann Pharmacother 47(5):651-6 [PubMed]
      2. Yang (2020) Eur Heart J 41:4415-22 +33211823 [PubMed]
  4. Prophylactic Antibiotics
    1. Not routinely recommended
      1. Risk of resistance
      2. Risk of medication adverse effects (e.g. QTc Prolongation with Macrolides)
    2. Macrolide Antibiotics reduce COPD exacerbations (NNT 8 to prevent 1 exacerbation in 50 weeks)
      1. Erythromycin 500 mg orally twice daily OR Azithromycin 250 mg daily (or 500 mg three times per week)
      2. No benefit with Tetracycline or fluroquinolone prophylaxis
      3. Janjua (2021) Cochrane Database Syst Rev (1): CD013198 [PubMed]

XI. Management: Excessive upper airway secretions

  1. Mucolytics (e.g. Guaifenesin)
    1. Reduces days of illness per month by 1/2 day
    2. Doubles chance of being free of exacerbations
    3. Poole (2001) BMJ 322:1-6 [PubMed]
  2. N-Acetylcysteine (for thick secretions)
    1. Dose: 600-1200 mg/day in divided dosing
    2. Decramer (2005) Lancet 365(9470):1552-60 [PubMed]
  3. Intranasal Steroid
    1. Consider if considerable airway phlegm

XII. Resources

  1. Global Initiative for Chronic Obstructive Lung Disease
    1. http://www.goldcopd.com

XIII. Prognosis

  1. See BODE Index

XIV. References

  1. (1995) Am J Respir Crit Care Med 152(5 pt 2):S77-121 [PubMed]
  2. Agusti (2023) NPJ Prim Care Respir Med 33(1):28 +PMID: 37524724 [PubMed]
  3. Cagle (2023) Am Fam Physician 107(6): 604-12 [PubMed]
  4. Celli (1998) Postgrad Med 103(4):159-76 [PubMed]
  5. Cooper (1997) Ann Thorac Surg 63:312-9 [PubMed]
  6. Donohue (2002) Chest 122:47-55 [PubMed]
  7. Fein (2000) Curr Opin Pulm Med 6:122-6 [PubMed]
  8. Gentry (2017) Am Fam Physician 95(7): 433-41 [PubMed]
  9. Hunter (2001) Am Fam Physician 64(4):603-12 [PubMed]
  10. Lee (2013) Am Fam Physician 88(10): 655-63 [PubMed]
  11. Obrien (1998) Postgrad Med 103(4):179-202 [PubMed]
  12. Qaseem (2011) Ann Intern Med 155(3): 179-91 [PubMed]
  13. Runo (2001) West J Med 175:197-201 [PubMed]
  14. Sayiner (2001) Chest 119:726-30 [PubMed]
  15. Voelkel (2000) Chest 117(5 suppl 2):S376-9 [PubMed]
  16. Weg (1998) Postgrad Med 103(4):143-55 [PubMed]

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