GGC Medicines


Adult Therapeutics Handbook

Management of Chronic Obstructive Pulmonary Disease (COPD)

Management of Chronic Obstructive Pulmonary Disease (COPD)

Introduction

COPD is a chronic, usually progressive disorder, characterised by airflow obstruction with little reversibility and usually >20 pack years of smoking. Referral for a chest opinion is indicated in those with no or minimal smoking history, or age <40 years. Treatment for COPD is used to decrease symptoms and/or complications. Dyspnoea is the reason most patients seek medical attention and is a major cause of disability and anxiety associated with the disease.

Assessment / Monitoring

  • Dyspnoea / exercise tolerance
  • Spirometry
  • Oximetry
  • Weight

General management

  • Smoking cessation has the greatest capacity to influence mortality in COPD and all patients with COPD should receive education and support relating to this (see Appendix 1).
  • Pneumococcal vaccination (once only) and influenza vaccination (annually) should be offered to all patients with COPD.
  • A stepped approach with increases in treatment according to severity of disease is taken in the pharmacological management of chronic COPD. (The step down approach used in asthma is not applicable as COPD is a progressive disease).
  • Patients with exertional dyspnoea (MRC grade 3/5 or more) should be considered for pulmonary rehabilitation.
  • Peripheral oedema may indicate the development of cor pulmonale and the need for long-term oxygen therapy. If oxygen saturation <92% check ABG. If PaO2 <8kPa refer to chest clinic to assess for long-term oxygen therapy.
  • Patients with a BMI <20 or significant (>3kg) unintended weight loss should be assessed for causes of weight loss, in particular the development of lung cancer, and referred for dietary advice.

Drug therapy / treatment options

Inhaler devices

Metered dose inhalers (MDIs) are first-line, however, not all patients can use them. Spacer devices can improve lung deposition with MDIs. Some examples of inhalers which may be used are detailed below, however the drug choice at each step may be determined by the appropriate inhaler device for the patient. Your clinical pharmacist or respiratory nurse specialist can assess the patient and advise on alternative inhaler devices if appropriate.

Table 1 – Inhaled treatment options for COPD

* Patient has had ≥2 exacerbations in 12 consecutive months.

  FEV1 >50% FEV1 ≤50%
First-line inhaled treatment SABA SABA
Second-line inhaled treatment LAMA or LABA LAMA or LCCI*
Third-line inhaled treatment LAMA + LABA LAMA + LCCI*
Notes:
  • SABA = short-acting Beta2 agonist e.g. Salbutamol inhaler 2 puffs (200 microgram) as required.
  • LAMA = long-acting muscarinic antagonist e.g. Tiotropium Handihaler® (dry powder) 18 microgram once daily
  • LABA = long-acting Beta2 agonist e.g. Formoterol 12 microgram twice daily.

    If this preferred option is not suitable or tolerated, other LABAs and LAMAs are available. See Formulary (www.ggcmedicines.org.uk) or BNF for choices.

  • LCCI = LABA + corticosteroid combination inhaler – choice can vary, see BNF / NHSGGC Adult Formulary.
  • If still symptomatic despite maximal inhaled therapy, consider adding oral theophylline and mucolytic therapy. Prescribe theophylline by brand name as the pharmacokinetic profiles of controlled-release preparations differ. Theophylline dose will need to be reduced if patient is treated with a macrolide or fluoroquinolone. Theophylline monitoring advice can be found here.
  • Consider long-term oxygen therapy (LTOT) in patients with PaO2 ≤7.3kPa when stable, or >7.3kPa and <8kPa when stable and: secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, if they have stopped smoking.