Management of Chronic Obstructive Pulmonary Disease (COPD)
Introduction
COPD is a chronic, progressive disorder that usually affects smokers. It is defined as airflow obstruction with little reversibility, with symptoms of breathlessness and cough. Referral for a respiratory opinion is indicated in those with no or minimal smoking history, recurrent admissions, requiring non-invasive ventilation (NIV) during admission or age <40 years. Treatment for COPD is used to improve symptoms during admission and reduce exacerbations.
Diagnosis
COPD is diagnosed using spirometry as airflow obstruction (FEV1/FVC <0.7) with little or no reversibility. The severity is defined by impairment of FEV1 (mild >80%, moderate 50-80%, severe <50%). Exacerbation frequency, symptoms and degree of breathlessness (see MRC Dyspnoea Scale) should also be assessed. Always consider alternative or co-existing diagnoses (e.g. asthma, heart failure).
General management
- Smoking cessation has the greatest capacity to influence mortality in COPD and improve symptoms. All patients with COPD should receive education and support relating to this (see Appendix 1).
- The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present.
- Patients with exertional dyspnoea (MRC grade 3/5 or more) should be considered for pulmonary rehabilitation. Pulmonary rehabilitation is also associated with improved survival.
- Pharmacological therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations and improve health status and exercise tolerance.
- Pneumococcal vaccination (once only) and influenza vaccination (annually) should be offered to all patients with COPD.
- Peripheral oedema may indicate the development of cor pulmonale and the need for long-term oxygen therapy. If oxygen saturation <92% when stable, check arterial blood gases. If PaO2 <8kPa, refer to chest clinic to assess for long-term oxygen therapy if stopped smoking.
- 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 device choice
- Should be determined by the device which patients find most straightforward to use. Your clinical pharmacist or respiratory nurse specialist can assess the patient and advise on alternative inhaler devices if appropriate.
- Spacer devices can improve lung deposition with metered dose inhalers (MDIs). Specific drug choice at each step may be determined by the appropriate inhaler device for the patient.
- Drug choice can also be determined by a number of other factors e.g. disease severity, frequency of exacerbations, degree of reversibility on lung function testing, peripheral eosinophilia. Liaise with respiratory nurse specialists / physicians to help select appropriate inhaled therapy.
- The 'COPD inhaler device guide' can be found on the NHSGGC Clinical Guidelines Platform.
Oral Therapy
- Mucolytic therapy, oral theophylline and long-term antibiotics may be appropriate in selected patients. Discuss with a specialist.
Guideline last reviewed: February 2021
Page last updated: September 2022
