17th February 2025

Management of COPD

Acute exacerbation of COPD

An acute exacerbation of COPD can be infective or non-infective. Key pathogens include:

• Bacterial: Haemophilus influenzae (most common bacterial pathogen in COPD), Streptococcus pneumoniae
• Viral: rhinovirus is the most common

Management is as follows:

• ABG to determine target SaO2: normally aim for 88-92%, but increase to 94-98% if normal pCO2
• Keep saturations 88-92% with a history of T2RF (type 2 respiratory failure), chronic hypercapnia or if baseline saturations are known to be <94%
• Bronchodilators: nebulised delivery and increased frequency are often required during an exacerbation
• Steroids: 30 mg prednisolone for 5 days
• Antibiotics are indicated only with signs of infection, e.g. purulent sputum, raised inflammatory markers or chest X-ray changes

Non-invasive ventilation (NIV) is typically indicated in the presence of T2RF with acidosis:

• Recommended with pH 7.25-7.35
• If pH <7.25, ITU involvement and possible intubation should be considered
• NIV delivers different air pressures for inspiration and expiration. The inspiratory positive airway pressure (IPAP) is set higher to improve ventilation and aid the patient’s own respiratory effort. The expiratory positive airway pressure (EPAP) recruits collapsed alveoli to increase gas exchange and allow removal of exhaled gases. Typical initial settings for NIV are IPAP 10-15 cmH₂O and EPAP 4-5 cmH₂O

Long-term management of COPD

The most important intervention is smoking cessation. Other facets to long-term management include vaccinations (once-off pneumococcal and annual influenza), pulmonary rehabilitation and inhaler therapy as per NICE guidelines:

• Step 1 (new diagnosis): SABA or short-acting muscarinic antagonist (SAMA) as needed
  Beyond this stage, it is important to check for features of asthma or steroid responsiveness, e.g. history of asthma, high eosinophils, diurnal variation in PEF or FEV1
• Step 2a (no features of steroid responsiveness): SABA (PRN) + LABA + LAMA
• Step 2b (features of steroid responsiveness): SABA or SAMA (PRN) + LABA + ICS
• Step 3: SABA (PRN) + LABA + LAMA + ICS

Box 3 Common medications used in COPD

Other treatments may include:

• Theophylline if symptomatic with maximal inhaler therapy
• Mucolytic, e.g. carbocisteine, in cases of ongoing productive cough
• Prophylactic antibiotics in selected cases, e.g. azithromycin (usually 3 times a week) can be considered for non-smokers already receiving optimal medical management with frequent (>4 per year) or severe (prolonged or resulting in hospitalisation) exacerbations of COPD
• Surgical input (for selected patients), e.g. lung reduction surgery or bullectomy
• Diuretics if evidence of cor pulmonale (right-sided heart failure due to chronic raised pulmonary pressures)

Long-term oxygen therapy is indicated for non-smokers in selected cases:

• pO2 on room air <7.3 kPa OR
• pO2 on room air 7.3-8.0 kPa and one of secondary polycythaemia, pulmonary hypertension or fluid overload

End-stage COPD

COPD is a chronic progressive illness and the end stage of the disease will typically feature a progressive decline with increasing frequency and severity of acute exacerbations. 

Factors that may indicate a patient is approaching end-stage COPD and end of life care are: 

• Increasing frequency of hospitalisation and worsening severity of acute exacerbations
• Low body mass index
• Poor lung function on spirometry testing 
• Other comorbidities such as cardiac disease or malignancy 

Management of end-stage COPD should involve advance care planning and ensuring optimal medical management. MDT approach should involve respiratory specialist nurses, district nurses, palliative care team and social services/occupational therapy as appropriate.

It is important to ensure management of symptoms associated with COPD in conjunction with palliative care specialists: 

• Breathlessness: simple breathing exercises, home oxygen, opiates and benzodiazepines
• Cough and secretions
• Pain
• Anxiety and depression