Chronic obstructive pulmonary disease (COPD)

COPD is a largely preventable lung condition. The main risk factor for development and exacerbation of COPD is tobacco smoking, but environmental and/or occupational exposure to pollutants is also implicated in the pathology of COPD. A very small number of cases are caused by genetic defects or impaired lung development. Smoking cessation is the most effective way to prevent COPD, or to reduce symptoms and exacerbations from established disease.

The lung damage in COPD is progressive and becomes incurable, with persistent airflow limitation and other respiratory complications (infections, wheeze, chronic cough, sputum production) being the most prevalent symptoms. Small airways disease (obstructive bronchiolitis), parenchymal destruction (emphysema), and fibrotic processes underlie the chronic tissue damage and airflow limitation in COPD.

The aims of COPD management and treatments are to reduce symptoms, exacerbations and improve patients’ quality of life.

Management of stable COPD:

Inhalation short-acting bronchodilators are the initial therapeutic option, to relieve breathlessness and exercise limitation. They can be in the form of a short-acting beta₂ receptor agonist (SABA; salbutamol) or a short-acting muscarinic receptor antagonist (SAMA; ipratropium).

Step-up treatment options, for patients who continue to be breathless or have exacerbations, include long-acting beta₂ agonists (LABA; salmeterol and formoterol) and long-acting muscarinic antagonist (LAMA; tiotropium; in place of the SAMA). Use of SABAs can continue as required.

Inhaled corticosteroid (ICS) agents (budesonide, beclometasone, fluticasone) can be tried, if the bronchodilator drugs alone are failing to prevent moderate-severe exacerbations, and symptoms are adversely impacting quality of life. A large range of combination formoterol (LABA)/ICS medications is available.

Prophylactic use of antibacterials (e.g., azithromycin) can be considered in cases where other lung pathologies, QT prolongation, sputum culture and sensitivity testing have been carried out to justify antibacterial use.

Respiratory specialists can initiate treatment with roflumilast (a phosphodiesterase-4 inhibitor) as an add-on option for patients with severe COPD with chronic bronchitis.

Mucolytic treatment for productive cough (carbocysteine, acetylcysteine), and antitussives should be used when appropriate.

Management of COPD exacerbations:

Higher dose short-acting inhaled bronchodilators can be administered through a nebuliser or hand-held device to reduce breathlessness.

A short course of prednisolone can be considered for hospitalised patients (in the absence of contraindications). If oral corticosteroids are considered as an appropriate option, the dose and length of treatment depend on the severity of the exacerbation. Potential adverse effects of systemic glucocorticoids that may require mitigation, include hyperglycemia (in patients with diabetes mellitus), fluid retention, hypertension, and pneumonia.