5th January 2024

Management of chronic COPD

General Principles 

1. Support to stop smoking should be offered.
2. Pneumococcal and influenza vaccinations.
3. Pulmonary rehabilitation if required.
4. Co-develop personalised self-management care.
5. Optimise management of comorbidities.

Pharmacological treatment

Pharmacological treatment should only be offered after consideration of the above principles and when inhaled therapies are required to relieve symptoms and improve exercise tolerance.

Determine whether the patient has asthmatic features or features of steroid responsiveness such as previous diagnosis of asthma or atopy, elevated eosinophil count, significant FEV1 variation over time (>=400 ml) or PEF diurnal variation.

• Start short-acting beta2 agonists (SABA) or short-acting muscarinic antagonist (SAMA) as required. Additional treatment should be offered in case of ongoing symptoms or exacerbations despite treatment.
• COPD  with asthmatic features:
  1. Offer LABA + ICS
  2. Offer LABA +LAMA + ICS if symptoms impacting quality of life or in case of 1 severe or 2 moderate exacerbations in a year.
• COPD without asthmatic features
  1. Offer LABA + LAMA
  2. Offer LABA + LAMA + LCS

Oral theophylline

Oral theophylline is reserved for people who are unable to use inhaled therapy or after trial of SABA and LABA, as it requires regular monitoring of plasma levels and interactions.

Oral mucolytic therapy

Mucolytic drugs may be considered for people with chronic productive cough and only continued if there is symptomatic improvement.

Prophylactic antibiotics

Azithromycin 250 mg 3 times a week should be considered in people with COPD if they continue to have frequent (4 or more per year) exacerbations, prolonged exacerbations and exacerbations resulting in hospitalisation. Non- pharmacological management, including smoking cessation, relevant vaccinations, referral to pulmonary rehabilitation, and inhaled therapies, should be optimised before offering prophylactic antibiotics.

The following investigations are prerequisites of starting prophylactic Azithromycin:

• Sputum culture and sensitivity, including tuberculosis, to identify causes of recurrent infection that may need specific treatment.
• CT scan of chest to exclude bronchiectasis.
• ECG as Azithromycin can prolong QT interval.
• Liver function tests.

Prophylactic Azithromycin should be reviewed 3 months after initiation and then every 6 months.

A non-macrolide antibiotic should be provided to patients who are at risk of exacerbations as part of exacerbation action plan.

Long-term oxygen therapy

The need for long-term oxygen should be evaluated in people with:

• FEV1 less than 30% predicted
• Cyanosis
• Polycythemia
• Peripheral oedema
• Raised JVP
• Oxygen saturation of 92% or less

Arterial blood gas should be measured on two occasions at least 3 weeks apart. Long-term oxygen should be considered in people with:

• PaO2 of 7.3kPa and below when stable.
• PaO2 of between 7.3 and 8 kPa with secondary polycythemia, peripheral oedema, or pulmonary hypertension.

Oxygen therapy should be offered to patients who do not smoke. Risk of falls from tripping over equipment and risk of burns should be evaluated and documented prior to commencing oxygen.

Patients should breathe supplemental oxygen for minimum of 15 hours per day.

Non-invasive ventilation (NIV)

The following patients should be referred to specialist centre for consideration of NIV:

• Who are on optimum treatment but have chronic type 2 respiratory failure and have required either invasive or non-invasive ventilation during an exacerbation.
• Who are acidotic or hypercapnic on long-term oxygen therapy.

Lung surgery and lung reduction procedures

Respiratory and surgical review can be offered to patients who meet the following criteria:

• Patients with severe COPD with FEV1 less than 50% and breathlessness despite optimum medical treatment.
• Non-smokers
• Patients who can complete 6 minutes of at least 140 meters of distance.