Chronic Obstructive Pulmonary Disease

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a heterogenous lung condition characterized by chronic respiratory symptoms (dyspnoea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.

  • The main environmental exposures leading to COPD are tobacco smoking and the inhalation of toxic particles and gases from household and outdoor air pollution, but other environmental and host factors (including genetic factors, abnormal lung development and accelerated lung aging) can also contribute.

Forced spirometry that demonstrates the presence of a non-fully reversible airflow obstruction (i.e. FEV1/FVC <0.7 post-bronchodilator) is mandatory to establish the diagnosis of COPD.

GOLD ABE Assessment Tool

Modified MRC Dyspnea Scale
CAAT Assessment



Management

Management of COPD

Apart from smoking cessation and vaccination (e.g. COVID-19, influenza, pneumococcal, RSV and dTaP vaccines, and zoster vaccine to protect against shingles for people with COPD aged >50 years), initial pharmacological therapy for COPD should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient's preference, and ability to use various drug delivery devices.

  • Importantly, inhaler technique (and adherence to therapy) should be assessed before concluding that the current therapy is insufficient.

The goals for treatment of stable COPD

  • Reduce symptoms
    • Relieve symptoms
    • Improve exercise tolerance
    • Improve health status
  • Reduce risk
    • Prevent disease progression
    • Prevent and treat exacerbations
    • Reduce mortality
Initial Pharmacological Treatment of COPD
Follow-up Pharmacological Treatment of COPD



Pharmacological Therapies

Inhaled bronchodilators in COPD are central to symptom management and commonly given on a regular basis to prevent or reduce symptoms.

Acute exacerbations

  • Regular and as-needed use of SABA or SAMA improves FEV1 and symptoms.
  • Combinations of SABA and SAMA are superior compared to either medication alone in improving FEV1 and symptoms.
  • LAMAs have a greater effect on exacerbation reduction compared with LABAs and decrease hospitalizations.
Stable COPD
  • LABAs and LAMAs are preferred over short-acting agents except for patients with only occasional dyspnoea.
  • LABAs and LAMAs significantly improve lung function, dyspnoea, health status and reduce exacerbation rates.
  • When initiating treatment with long-acting bronchodilators, the preferred choice is a combination of LABA and LAMA. In patients with persistent dyspnoea on a single long-acting bronchodilator treatment should be escalated to two.
    • Combination treatment with a LABA and LAMA increases FEV1, reduce symptoms and reduce exacerbations compared to monotherapy.
    • Combination can be given as single inhaler or multiple inhaler treatment. Single inhaler therapy may be more convenient and effective than multiple inhalers.
  • While having a narrow therapeutic index, theophylline exerts a small bronchodilator effect in stable COPD and that is associated with modest symptomatic benefits.
Anti-inflammatory maintenance therapy
  • If patients with COPD have features of asthma, treatment should always contain an ICS.
  • Regular treatment with ICS increases the risk of pneumonia especially in those with severe disease.
    • There is high quality evidence from RCTs that ICS use modifies the airway microbiome and is associated with higher prevalence of oral candidiasis, hoarse voice, skin bruising and pneumonia.
    • Since year 2017, GOLD guideline started advocating the use of LAMA or/and LABA instead of corticosteroid inhalers in initial management.
  • If a patient with COPD and no features of asthma has been treated - for whatever reason - with LABA+ICS and is well controlled in terms of symptoms and exacerbations, continuation with LABA+ICS is an option. However, if the patient has:
    • Further exacerbations: treatment should be escalated to LABA+LAMA+ICS if the blood eosinophil count is ≥ 100 cells/µL or switched to LABA+LAMA if it is < 100 cells/µL.
    • Major symptoms: change to LABA+LAMA or LABA+LAMA+ICS depending on previous treatment response to ICS.
COPD Patients Currently on LABA + ICS
  • Triple inhaled therapy with LAMA+LABA+ICS improves lung function, symptoms and health status and reduces exacerbations compared to LABA+ICS, LABA+LAMA, or LAMA monotherapy.
    • Recent data suggest beneficial effect of triple inhaled therapy versus fixed-dose LABA + LAMA combinations on mortality in symptomatic COPD patients with a history of frequent and/or severe exacerbations.
    • Patients treated with LABA+LAMA+ICS should not have the ICS component withdrawn unless the ICS was started inappropriately, there has been no response to ICS or they experience significant side-effects or severe or recurrent pneumonia. The risks and benefits of discontinuing ICS should be considered.
Factors to Consider When Initiating ICS Treatment
  • Long-term use of oral glucocorticoids has numerous side effects with no evidence of benefits.
  • Regular treatment with mucolytics such as erdosteine, carbocisteine and N-acetylcysteine reduces the risk of exacerbation in select populations.
  • In patients with moderate to severe COPD with a history of exacerbations despite triple therapy and higher eosinophils (≥300 cells/µl):
    • Dupilumab reduces exacerbations, improves lung function and quality of life in patients with chronic bronchitis.
    • Mepolizumab reduces exacerbations in patients with and without chronic bronchitis.



Summary

COPD is a common, preventable and treatable disease, but extensive under-diagnosis and misdiagnosis lead to patients receiving no treatment or incorrect treatment.

COPD Underdiagnosis



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