Chronic Lung Disease

Management Algorithm

Treatment of COPD(v)

LABA: long-acting β2-agonist
LAMA: long-acting muscarinic antagonist
ICS: inhaled corticosteroid
 
Reassess and adjust regularly according to the response to treatment in terms of dyspnea and/or acute exacerbations

Lifesaving Interventions

There are 3 lifesaving interventions in COPD:

  1. Smoking cessation 
  2. Chronic oxygen when stable (non-exacerbated) resting SpO2 ≤ 88% (or PaO2 ≤ 55 mmHg)
  3. Non-invasive ventilation (NIV) in individuals with persistent hypercapnic respiratory failure after an acute exacerbation

Footnotes

  1. Risk assessment for spirometry should be undertaken in the setting of COVID-19
  2. Based on expert opinion, also consider interstitial lung disease, CT scan may help to identify people with interstitial lung disease and lung cancer
  3. Assessment of either dyspnoea using mMRC, see https://www.verywellhealth.com/guidelines-for-the-mmrc-dyspnea-scale-914740 or symptoms using CAT™, see http://www.catestonline.org/ and history of exacerbations (including prior hospitalisations)
  4. COPD itself has significant extra-pulmonary (systemic) effects including weight loss, nutritional abnormalities and skeletal muscle dysfunction
  5. Each pharmacological treatment should be individualised and guided by the severity of symptoms, risk of exacerbations, adverse effects, co-morbidities, drug availability and cost, and the individual’s response, preference and ability to use various drug delivery devices. Inhaler technique needs to be assessed regularly. Long-term use of high dose ICS and/or use of oral glucocorticoids has no evidence of benefits in COPD and increase the risk of pneumonia. The addition of medium dose ICS to LABA or LAMA or LABA/LAMA is recommended in individuals with history of frequent exacerbations and/or asthma and/or eosinophilia (> 3%), or anyway in individuals not adequately controlled by LAMA/LABA combination. ICS should be avoided in subjects with eosinopenia (< 1%). Antibiotics should be used to treat acute exacerbation or in case of high CRP and purulent sputum (PCT is a more questionable biomarker). Azithromycin may also be considered in non-smokers, not well controlled with maximal inhaled drug dosage.
  6. LAMA/LABA/ICS are now available in a fixed dose combination. This drug combination improves clinical control of COPD and increases life expectancy.
 
With the exception of low dose beclometasone, do not use inhaled glucocorticoids with boosted ART regimens, see Drug-drug Interactions between Corticosteroids and ARVs.
Influenza, SARS-CoV-2 and pneumococcal vaccination decrease rates of lower respiratory tract infections, see Vaccination 
Pertussis vaccination is also suggested in people with COPD