There are separate articles on Chronic Obstructive Pulmonary Disease, Diagnosing COPD, Acute Exacerbations of COPD and Use of Oxygen Therapy in COPD.

Following the diagnosis of chronic obstructive pulmonary disease (COPD), care should be delivered by a multidisciplinary team. The following functions should be considered when defining the activity of the multidisciplinary team:¹

• Assessing patients (e.g. spirometry, assessing need for oxygen therapy and the appropriateness of delivery systems for inhaled therapy).
• Managing patients (including pulmonary rehabilitation, palliative care, managing anxiety and depression, dietary issues, exercise, social security benefits and travel); management of pulmonary hypertension and cor pulmonale.
• Education of patients and advising patients on self-management strategies.
• Identifying and monitoring patients at high risk of exacerbations of COPD.
• Influenza and pneumococcal immunisation.
• Advising patients on nutrition and physical activity.

Management²

• Advice on how to respond promptly to symptoms of an exacerbation, including starting oral corticosteroid therapy, starting antibiotic therapy if their sputum is purulent and adjusting bronchodilator therapy to control symptoms.
• Advice on when and how to contact a healthcare professional if symptoms do not improve.
• Encouraging patients with chronic obstructive pulmonary disease (COPD) to stop smoking is one of the most important components of management. All COPD patients still smoking, regardless of age should be encouraged to stop, and offered help to do so, at every opportunity.
• Nutrition: body mass index (BMI) should be calculated. If the BMI is abnormal (high or low), or changing over time, the patient should be referred for dietetic advice. If the BMI is low, patients should also be given nutritional supplements to increase their total calorific intake, and be encouraged to take exercise to augment the effects of nutritional supplementation.
• Physiotherapy: if patients have excessive sputum, they should be taught the use of positive expiratory pressure (PEP) masks and active cycle of breathing techniques.

Promote effective inhaled therapy

Delivery systems: hand-held devices are usually best, with a spacer if appropriate. Consider a nebuliser for people with distressing or disabling breathlessness despite maximum therapy with inhalers.

• For breathlessness and/or exercise limitation: use an inhaled short-acting beta agonist (SABA), e.g. salbutamol or terbutaline or short-acting muscarinic antagonist (SAMA), e.g. ipratropium, as required.
• Short-acting beta₂ agonists can be continued with additional treatment (see below) but short-acting muscarinic antagonists must be stopped if a long-acting muscarinic antagonist (LAMA), e.g. tiotropium, is used.
• In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:
• If forced expiratory volume in one second (FEV1) is 50% or greater of predicted: either a long-acting beta agonist (LABA), e.g. formoterol or salmeterol, or LAMA.
• If FEV1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA.
• Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1.
• Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids.

Oral therapy

• Corticosteroids:
  • Maintenance use of oral corticosteroid therapy in COPD is not normally recommended.
  • Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. Keep the dose as low as possible, monitor for osteoporosis and offer prophylaxis.
• Theophylline:
  • Offer only after trials of short- and long-acting bronchodilators or to people who cannot use inhaled therapy.
  • Theophylline can be used in combination with beta₂ agonists and muscarinic antagonists.
  • Take care when prescribing to older people because of pharmacokinetics, comorbidities and interactions with other medications.
  • Reduce theophylline dose if macrolide or fluoroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
• Mucolytic therapy:
  • Consider in people with a chronic productive cough and continue use if symptoms improve.
  • Do not routinely use to prevent exacerbations.
• Treatments that are not recommended include antioxidant therapy (alpha-tocopherol and beta-carotene supplements), antitussive therapy and prophylactic antibiotic therapy.

Vaccination and antiviral therapy

• Pneumococcal vaccination and an annual influenza vaccination should be offered to all patients with COPD.
• Antivirals for influenza: zanamivir and oseltamivir are recommended for the treatment of at-risk adults who present with influenza-like illness and who can start therapy within 48 hours of the onset of symptoms.
• Zanamivir should be used with caution in people with COPD because of a risk of bronchospasm. Patients prescribed zanamivir should have a fast-acting bronchodilator available.³

Oxygen therapy

See the separate Use of Oxygen Therapy in COPD article.

Physiotherapy⁴

• Physiotherapy has an important role in the assessment and treatment of breathing dysfunction and dyspnoea, in the assessment for and the delivery of pulmonary rehabilitation and non-invasive ventilation, and in the management of impaired airway clearance.
• The British Thoracic Society (BTS) has produced a recommendation for the physiotherapy management of respiratory problems, including COPD.

Pulmonary rehabilitation

See also the separate Pulmonary Rehabilitation article.

• Outline the commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD.
• Offer to all appropriate people with COPD, including those who have had a recent hospitalisation for an exacerbation and those who consider themselves functionally disabled by COPD (usually Medical Research Council (MRC) Grade 3 and above).
• Pulmonary rehabilitation is not suitable for people who cannot walk, have unstable angina or who have had a recent myocardial infarction.
• Tailor the programme to individual needs, and include physical training, disease education, and nutritional, psychological and behavioural intervention.

Travel and leisure advice

• Passengers with COPD are potentially at risk from reduced partial pressure of oxygen and expansion of gases within closed body cavities (bullae and pneumothoraces). However the frequency of severe adverse events in patients with COPD who fly appears to be very low. A lack of correlation between predicted arterial hypoxaemia in patients with COPD undertaking air travel and outcomes suggests that they tolerate hypoxaemia fairly well as a result of physiological adaptation.⁵
• Inform people with bullous disease of the increased risk of pneumothorax during air travel.
• Scuba diving is not generally recommended for people with COPD.

Referral²

Referral for advice, specialist investigations or treatment may be appropriate at any stage of disease, not just for people who are severely disabled. Possible reasons for referral include:

• Diagnostic uncertainty.
• Suspected severe chronic obstructive pulmonary disease (COPD).
• The individual requests a second opinion.
• Onset of cor pulmonale.
• Assessment for oxygen therapy, long-term nebuliser therapy or oral corticosteroid therapy.
• Bullous lung disease.
• Rapid decline in forced expiratory volume in one second (FEV1).
• Assessment for pulmonary rehabilitation.
• Assessment for lung volume reduction surgery or lung transplantation.
• Dysfunctional breathing.
• Onset of symptoms at age under 40 years or with a family history of alpha-1-antitrypsin deficiency.
• Symptoms disproportionate to lung function deficit.
• Frequent infections.
• Haemoptysis.

Indications for surgery

• Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy.
• Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following:
  • FEV1 greater than 20% predicted.
  • PaCO₂ less than 7.3 kPa.
  • Upper lobe predominant emphysema.
  • Carbon monoxide lung transfer factor (TLCO) greater than 20% predicted.
• Bronchoscopic lung volume reduction with airway valves for advanced emphysema shows some improvement in patient-reported quality of life outcomes but there is currently inadequate evidence of improvement for the procedure to be recommended.⁶
• Lung transplantation:
  • Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy.
  • Considerations include age, FEV1, PaCO₂, homogeneously distributed emphysema on CT scan, elevated pulmonary artery pressures with progressive deterioration, comorbidities and local surgical protocols.

Palliative care²

See also the separate Palliative Care article.

• Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage chronic obstructive pulmonary disease (COPD) unresponsive to other medical therapy.
• Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness.
• Provide access to multidisciplinary palliative care teams and hospices.

Follow-up and review²

• Review people with mild or moderate chronic obstructive pulmonary disease (COPD) at least once a year and those with very severe COPD at least twice a year.
• People with stable severe COPD do not normally need regular hospital review, but there should be locally agreed mechanisms to allow rapid hospital assessment when necessary.
• People requiring interventions, such as long-term non-invasive ventilation (NIV), should be reviewed regularly by specialists.
• Mild, moderate or severe outflow obstruction:
  • Assess: smoking status and desire to quit, adequacy of symptom control (breathlessness, exercise tolerance, exacerbation frequency), presence of complications, effects of each drug treatment, inhaler technique, need for referral to specialist and therapy services, and need for pulmonary rehabilitation.
  • Measure: forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), BMI, and MRC dyspnoea scale.
• Very severe outflow obstruction:
  • Assess: smoking status and desire to quit, adequacy of symptom control (breathlessness, exercise tolerance, exacerbation frequency), presence of cor pulmonale, need for long-term oxygen therapy, nutritional state, presence of depression, effects of each drug treatment, inhaler technique, need for social services and occupational therapy input, need for referral to specialist and therapy services, and need for pulmonary rehabilitation.
  • Measure: FEV1 and FVC, BMI, MRC dyspnoea scale and oxygen saturation of arterial blood (SaO₂).

Document references

1. No authors listed; Management of exacerbations of COPD. Thorax 2004; 59:i131-i156
2. Chronic obstructive pulmonary disease, NICE Clinical Guideline (June 2010); Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). This guideline partially updates and replaces NICE clinical guideline 12
3. Influenza - zanamivir, amantadine and oseltamivir (review), NICE Technology Appraisal (February 2009); Amantadine, oseltamivir and zanamivir for the treatment of influenza (review of existing guidance No. 58)
4. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient, British Thoracic Society (May 2009)
5. Managing passengers with stable respiratory disease planning air travel, British Thoracic Society (2011)
6. Bronchoscopic lung volume reduction with airway valves for advanced emphysema, NICE Interventional Procedure Guideline (November 2009)

Internet and further reading

• Primary Care Respiratory Society UK (PRCS); formerly the General Practice Airways Group (GPIAG)
• The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
• British Thoracic Society