ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Stable COPD: Overview of management

Stable COPD: Overview of management
Literature review current through: Jan 2024.
This topic last updated: Nov 06, 2023.

INTRODUCTION — Chronic obstructive pulmonary disease (COPD) is a common condition with high morbidity and mortality [1]. It is estimated that approximately 10 percent of individuals aged 40 years or older have COPD, although the prevalence varies between countries and increases with age [1-3]. COPD affects males and females equally.

An overview of the management of COPD will be provided here. The clinical manifestations, evaluation, diagnosis, natural history, risk factors, comorbidities, prognosis, management of refractory disease, and treatment of acute exacerbations are discussed separately. (See "Chronic obstructive pulmonary disease: Diagnosis and staging" and "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions" and "Chronic obstructive pulmonary disease: Risk factors and risk reduction" and "Management of refractory chronic obstructive pulmonary disease" and "COPD exacerbations: Management" and "Stable COPD: Initial pharmacologic management".) (Related Pathway(s): Chronic obstructive pulmonary disease: Severity assessment and selection of initial therapy in adults and Chronic obstructive pulmonary disease: Identifying patients with an acute exacerbation who warrant hospitalization.)

ADVICE RELATED TO COVID-19 — COPD is associated with a greater likelihood of intensive care unit admission, invasive ventilation, or death among patients with coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [4,5]. We agree with expert recommendations that individuals with COPD should make every effort to reduce the risk of COVID-19 through vaccinations and to avoid exposure by using face masks, hand hygiene, and social distancing.

All maintenance medications necessary to treat COPD should be continued during the COVID-19 pandemic, including bronchodilators, inhaled glucocorticoids, and, when indicated, roflumilast and azithromycin [6,7]. These medications help to minimize risk of a COPD exacerbation and optimize lung function. There is no good evidence that inhaled glucocorticoids have an adverse effect on the course of COVID-19 [8,9]. Furthermore, the usual guidelines for prompt initiation of systemic glucocorticoids for a COPD exacerbation should be followed, as delaying therapy can increase the risk of a life-threatening exacerbation. For patients hospitalized with COVID-19, nebulized medications should be delivered in a controlled environment such as a negative pressure room because of the risk of aerosolizing SARS-CoV-2 and enhancing disease spread. For patients who use nebulizers at home, caution is advisable to avoid spread of the virus to other members of the household.

Additional information about COVID-19 is provided separately. (See "COVID-19: Management in hospitalized adults" and "COVID-19: Management of the intubated adult".)

ASSESSMENT OF DISEASE SEVERITY — The Global Initiative for Chronic Obstructive Lung Disease (GOLD) advises a combined multidimensional assessment of disease severity to guide therapy, and we concur with this approach [1]. The combined multidimensional assessment of COPD includes spirometry after inhaled bronchodilator for staging the severity of airflow obstruction (spirometry grades 1 to 4, corresponding to postbronchodilator FEV1 >80 percent predicted, 50 to 80 percent predicted, 30 to 50 percent predicted, and <30 percent predicted, respectively) and assessment of patient symptoms and exacerbation risk using the GOLD "ABE" grades to guide initial COPD management (algorithm 1). The details of COPD assessment are described separately. (See "Stable COPD: Initial pharmacologic management", section on 'Assessing disease pattern and severity'.) (Related Pathway(s): Chronic obstructive pulmonary disease: Severity assessment and selection of initial therapy in adults.)

Comorbidities, such as coronary heart disease, heart failure, arrhythmias, obstructive sleep apnea, lung cancer, bronchiectasis, interstitial lung disease, and gastroesophageal reflux, are common in COPD. When assessing disease symptoms, severity, and exacerbations, it is important to consider whether a portion are attributable to another disease process [10]. (See "Chronic obstructive pulmonary disease: Diagnosis and staging", section on 'Differential diagnosis' and "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions", section on 'Comorbid diseases'.)

GENERAL MEASURES FOR ALL PATIENTS — Several important general measures are appropriate for all patients with COPD, including smoking cessation, avoidance of other inhalational particulate and gaseous exposures, vaccination against respiratory infections, and education about medication usage, inhaler technique, exacerbation identification, and exacerbation management.

Patient education and counselling — Education and counselling for patients with COPD are important in the office, during hospitalization, and as part of pulmonary rehabilitation. Education about COPD, medications, exacerbations, and coping strategies help to create a partnership between the patient and clinician. Such a partnership can help improve patient adherence to the medical regimen by incorporating the patient's symptoms, comorbidities, concerns, and goals into medication and device selection, and can help improve outcomes.

Appropriate patient education topics include reducing risk factors (eg, cigarette smoke, other irritant exposures, and respiratory infections), appropriate administration and use of medications (including treatment of current symptoms and preventive maintenance therapy), recognizing and treating exacerbations and complications, minimizing dyspnea, using long-term supplemental oxygen, and making end-of-life decisions. The benefits of patient education include enhanced health, better adherence to the treatment plan, fewer hospitalizations, and fewer emergency visits [11-13]. (See "Pulmonary rehabilitation", section on 'Education' and 'Information for patients' below.)

Smoking cessation — Encouraging smoking cessation is an essential step in COPD management for all individuals who are currently smoking, vaping, or using other inhaled agents (table 1 and table 2) [1]. Smoking cessation can substantially reduce the rate of decline in lung function (forced expiratory volume in one second [FEV1]) that occurs in smokers with COPD. As an example, the Lung Health Study reported a decline in postbronchodilator FEV1 of 54 and 66 mL/year in females and males, respectively, who continued to smoke over an 11 year period [14]. Females and males who were sustained quitters of smoking had significantly lower declines in FEV1 of 22 and 30 mL per year, respectively.

Interventions that assist smoking cessation include clinician advice and encouragement, nicotine replacement therapy, bupropion, varenicline, and behavioral counseling [15]. The best cessation rates are achieved when counseling is combined with medication therapy [16]. (See "Patient education: Quitting smoking (Beyond the Basics)" and "Overview of smoking cessation management in adults".)

Inhaler technique — Education about proper inhaler technique is an essential component of COPD management [17]. Guidelines recommend that a short-acting bronchodilator be prescribed for relief of intermittent symptoms in all patients with COPD [1]. This initial prescription is an excellent time to focus on correct inhaler technique whether a metered-dose, soft mist, or dry powder inhaler is ultimately prescribed for maintenance therapy (table 3 and table 4 and table 5 and table 6). It is often helpful for patients to watch a video demonstrating use of the particular type of inhaler (eg, metered-dose inhaler with spacer, Diskus, Ellipta, HandiHaler, Respimat). The clinician should demonstrate correct technique, observe the patient practice the technique, and provide correction, if needed. Difficulties with actuation-inhalation coordination with metered-dose inhalers may be reduced by use of a valved holding chamber or breath-actuated device (figure 1). (See "The use of inhaler devices in adults", section on 'pMDI technique' and "The use of inhaler devices in adults", section on 'Soft mist inhaler technique' and "The use of inhaler devices in adults", section on 'DPI technique' and 'Information for patients' below.)

At follow-up visits, inhaler technique should be reviewed and correct technique reinforced. When different types of inhalers are prescribed, education should be provided about any differences in technique and dosing (table 6). Cognitive function, hand arthritis, and inspiratory flow rate should be considered when selecting the type of device. Some patients may benefit from nebulizers. (See "The use of inhaler devices in adults".)

Self-management — The optimal use of self-management strategies that aim to enable patients with COPD to become active participants in their care remains unclear. In a systematic review of 23 studies (3189 participants), COPD self-management improved quality of life, reduced respiratory-related hospital admissions (odds ratio [OR] 0.69, 95% CI 0.51-0.94), and ameliorated dyspnea [18]. However, several prior studies did not support a role for self-management in COPD, and a randomized trial with 426 participants found an unexplained increase in mortality in the self-management group [19].

We establish a partnership with our patients and use collaborative self-management, working with patients to establish goals of importance to them and assisting them in achieving these goals. For example, the patient goal of avoiding hospitalizations requires the patient to recognize exacerbations and work with the physician to quickly and effectively treat such episodes.

Pulmonary rehabilitation — Comprehensive pulmonary rehabilitation that includes exercise, promotion of healthy behaviors, education, adherence to medication, and psychological support has been shown to improve exercise capacity, improve quality of life, decrease dyspnea, and decrease health care utilization. In addition, it may be helpful following hospitalizations to reduce mortality [20]. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy suggests participation in pulmonary rehabilitation as part of a comprehensive COPD management strategy, particularly for patients with persistent dyspnea (algorithm 1) [1]. (See "Pulmonary rehabilitation".)

Exercise training improves levels of physical activity in COPD patients [21]. A combination of strength and endurance training may reduce dyspnea more than either modality alone [22].

Vaccination — Infection is a common cause of COPD exacerbations. Vaccination can help reduce infections and exacerbations:

Pneumococcal – Vaccination against pneumococcus reduces exacerbations and community-acquired pneumonia in COPD patients [23]. Appropriate pneumococcal vaccination should be recommended to all patients with COPD. (See "Pneumococcal vaccination in adults".)

Influenza – An annual influenza vaccine should be given to all patients, particularly those with COPD [24-26]. Influenza vaccination reduces the number of exacerbations and influenza-related hospitalization [25,26]. The influenza vaccination itself does not increase the risk of acute exacerbation in the days following vaccination [27]. (See "Seasonal influenza vaccination in adults".)

Pertussis – Vaccination against pertussis (Tdap: tetanus, diphtheria, acellular pertussis) is recommended as a one-time dose as an adult (≥19 years) (figure 2). If the patient has not had a dose of Tdap as an adult, it should be administered. (See "Tetanus-diphtheria toxoid vaccination in adults", section on 'Routine adult immunization'.)

COVID-19 – Vaccination against COVID-19 reduces risk of hospitalizations and severe infections. COVID-19 vaccination with appropriate boosters should be recommended to all patients with COPD. (See "COVID-19: Vaccines".)

Respiratory syncytial virus (RSV) – Two recombinant vaccines are available as single-dose vaccinations for the prevention of RSV lower respiratory tract infections among adults aged ≥60 years. In unvaccinated patients with COPD, RSV is associated with approximately 10 percent of COPD exacerbations [28]. (See "Overview of preventive care in adults", section on 'Immunization'.)

Nutrition — While there is no ideal COPD diet, it is reasonable to advise patients to follow a generally healthy diet and aim to achieve a normal body mass index (BMI). (See "Healthy diet in adults".)

For overweight patients and patients with obesity, excess weight can contribute to dyspnea, and weight loss can help improve exercise tolerance and reduce dyspnea [1]. (See "Obesity in adults: Overview of management".)

Some patients with advanced COPD develop pulmonary cachexia (eg, weight loss of >5 percent within 12 months, associated with decreased muscle strength, fatigue, anorexia, low fat free mass index, and/or evidence of inflammatory markers), which is associated with reduced survival. The effect of low BMI on survival is also reflected in the inclusion of a BMI ≤21 as a marker of more severe disease in the BODE index, which assesses mortality risk (calculator 1). Patients with low body weight and pulmonary cachexia may benefit from strategies to enhance caloric intake. (See "Malnutrition in advanced lung disease".)

Vitamin D deficiency is associated with reduced lung function and increased hospitalizations for COPD exacerbation [29-32]. Studies are underway to determine whether vitamin D and other nutritional supplements can reduce exacerbations and improve lung function [33,34], although at least one study did not identify a benefit to vitamin D [35].

PHARMACOLOGIC THERAPY — We share the philosophy of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) that pharmacologic and nonpharmacologic therapies should be guided, in part, by disease severity, but the aim of therapy should be to improve patient symptoms, decrease exacerbations, and improve patient function and quality of life [1]. The details of pharmacologic therapy in the following clinical settings are discussed separately:

Pharmacotherapy is generally initiated based on an assessment of the level of symptoms and risk of exacerbations (algorithm 1). Therapy is adjusted at subsequent visits based on the response to therapy. (See 'Assessment of disease severity' above and "Stable COPD: Initial pharmacologic management".) (Related Pathway(s): Chronic obstructive pulmonary disease: Severity assessment and selection of initial therapy in adults.)

A portion of patients with COPD have persistent symptoms and/or exacerbations despite initial and subsequent adjustments to therapy; these patients may benefit from additional medication or nonpharmacologic therapies. (See "Management of refractory chronic obstructive pulmonary disease".)

In general, therapy for COPD does not need to be adjusted in the presence of concomitant cardiac disease. (See "Management of the patient with COPD and cardiovascular disease" and "Arrhythmias in COPD".)

NONPHARMACOLOGIC THERAPY

Supplemental oxygen — Many patients with stable severe COPD (especially Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stage IV disease) have chronic hypoxemia. The decision to prescribe supplemental oxygen is based on the severity of hypoxemia at rest and whether exertional hypoxemia limits activity. The logistics of prescribing supplemental oxygen, titration of flow rate, and modes of delivery are discussed separately. (See "Long-term supplemental oxygen therapy" and "Portable oxygen delivery and oxygen conserving devices".)

Chronic hypoxemia — We recommend long-term, continuous oxygen (O2) therapy for patients with chronic, severe persistent hypoxemia at rest manifest by an arterial oxygen tension (PaO2) ≤55 mmHg (7.33 kPa) or pulse oxygen saturation (SpO2) ≤88 percent, as supplemental oxygen therapy has been shown to improve survival and quality of life for these patients [1,36,37]. Supplemental oxygen should be titrated to a target oxygen saturation of 92 to 95 percent. The lower value of 92 percent ensures that the actual saturation is not below 90 percent, given that pulse oximeters are accurate to about 2 percentage points. (See "Long-term supplemental oxygen therapy" and "Pulse oximetry".)

Two randomized trials, the Nocturnal Oxygen Therapy Trial (NOTT) and the Medical Research Council (MRC) trial demonstrated improved survival among patients who received continuous O2, compared with nocturnal O2 alone [37,38]. NOTT (203 patients with COPD) found that mortality was 1.94 times higher (p = 0.01) with nocturnal O2 compared with continuous O2 (figure 3) [37]. A correlation was noted between survival and the average daily duration of oxygen use [37]. The MRC trial (87 patients with COPD) found that supplemental O2 was associated with 45 percent mortality, while no O2 was associated with 85 percent mortality over 5 years (figure 4) [38].  

Exertional hypoxemia — For patients with COPD and moderate hypoxemia at rest (eg, SpO2 89 to 93 percent) or hypoxemia only with exertion (eg, SpO2 <90 percent), a clear benefit of supplemental O2 on survival or quality of life has not been demonstrated. It remains unclear whether supplemental oxygen during exertion might have other benefits, such as improved exercise tolerance, in selected patients with normoxia or mild hypoxemia at rest and exercise-related desaturation. Further study is needed to determine whether individualized testing would identify patients in whom supplemental oxygen might be of benefit.

The long-term oxygen treatment trial (LOTT) enrolled 738 adults with COPD who had either an SpO2 89 to 93 percent at rest, or oxygen desaturation during a six-minute walk test to <90 percent for ≥10 seconds and ≥80 percent for ≥5 minutes [39]. Participants in the first group were randomly assigned to receive supplemental oxygen at 2 L/min continuously or no supplemental oxygen (open label); participants with walking hypoxemia were randomly assigned to receive oxygen 2 L/min during exercise and sleep or no supplemental oxygen. The trial monitored participants for 1 to 6 years. No difference was found in time to death or first hospitalization, rate of COPD exacerbations, or rate of COPD-related hospitalizations. No between group differences were noted in quality of life, lung function, or distance walked in six minutes.

The possibility that some patients with exertional hypoxemia may experience improved exercise tolerance with supplemental oxygen was examined in a trial of 124 patients with COPD that assessed the effect of supplemental oxygen during a six-minute walk test [40]. Oxygen was associated with an increase in the distance walked among those with mild hypoxemia and exercise-induced hypoxemia, but not those with normoxia, although less than 50 percent of participants experienced a clinically significant improvement.

Nocturnal hypoxemia — The evaluation and management of nocturnal hypoxemia in patients with COPD is discussed separately. (See "Sleep-related breathing disorders in COPD".)

Hypoxemia during air travel — Some patients with COPD who are not hypoxemic at sea level can become hypoxemic during air travel since the pressure in commercial aircraft is adjusted to approximate an altitude of 8000 feet above sea level. Supplemental oxygen is advised for individuals whose in-flight PaO2 is expected to fall below 50 mmHg (6.7 kPa). The evaluation of patients for air travel is discussed separately. (See "Evaluation of patients for supplemental oxygen during air travel", section on 'Screening for in-flight hypoxemia' and "Patient education: Supplemental oxygen on commercial airlines (Beyond the Basics)".)

Additional considerations for advanced disease — Selected patients with advanced COPD or emphysema may benefit from nocturnal noninvasive ventilation, bronchoscopic or surgical lung volume reduction, or lung transplantation. Periodic discussions about goals of care are appropriate as COPD progresses and can improve quality of life and clarify the patient’s desires surrounding end-of-life care. (See "Management of refractory chronic obstructive pulmonary disease" and "Palliative care for adults with nonmalignant chronic lung disease".)

Nocturnal noninvasive ventilation for hypercapnia — Nocturnal noninvasive ventilation (NIV) is reserved for a small portion of patients with COPD, who have chronic hypercapnia. Patients who require continuous NIV during an acute exacerbation may benefit from nocturnal NIV after discharge to home. For stable outpatients with chronic hypercapnia, it is reasonable to consider in-laboratory polysomnography to exclude obstructive sleep apnea and initiate NIV in the sleep laboratory, rather than at home. (See "Nocturnal ventilatory support in COPD" and "Sleep-related breathing disorders in COPD".)

Bronchoscopic and surgical interventions — Carefully selected patients with advanced COPD and refractory dyspnea may benefit from an intervention, such as bronchoscopic lung volume reduction (LVR) using endobronchial valves, lung volume reduction surgery (LVRS), or lung transplantation (See "Bronchoscopic treatment of emphysema" and "Lung volume reduction surgery in COPD" and "Management of refractory chronic obstructive pulmonary disease", section on 'Lung Volume Reduction, in select patients with dyspnea'.)

Goals of care and advance directives — Discussions about goals of care, advance directives, and end-of-life care are an important component of management of COPD, particularly for patients who have advanced disease. It can be helpful to introduce palliative care as "supportive care" at the time of a transition, such as increasing dyspnea, deterioration in pulmonary function tests, initiation of supplemental oxygen, or an exacerbation, particularly one requiring hospitalization (table 7). (See "Palliative care for adults with nonmalignant chronic lung disease" and "Advance care planning and advance directives" and "Management of refractory chronic obstructive pulmonary disease", section on 'Palliative care measures'.)

MONITORING — Routine monitoring of symptoms (eg, breathlessness, cough, sputum, activity limitations, sleep disturbance), medication use, exacerbations, airflow limitation, and oxygenation is needed to ascertain whether an adequate response to therapy has been achieved and whether complications or comorbidities have developed [1]. Optimal intervals for assessment have not been determined.

Office visits — In our practice, we see most patients with advanced disease at three to six month intervals to assess symptoms and oximetry. When monitoring symptoms, it is helpful to record and follow specific parameters, such as the modified Medical Research Council (mMRC) dyspnea scale (calculator 2) or COPD Assessment Test (CAT) (calculator 3) [41] for breathlessness, frequency of cough, amount of daily sputum production, and frequency of rescue inhaler use.

Current smoking status and smoke exposure should be assessed at each visit; smoking cessation should be recommended for those who continue to smoke. (See "Overview of smoking cessation management in adults".)

Nonadherence is common and contributes to poor outcomes. We ask patients about which medications they are taking regularly (or not), how they are taking their medications, their beliefs about the risks and benefits of therapy, and barriers to implementation (eg, lack of perceived benefit, adverse effects, difficulty remembering, complexity of regimen, expense, logistics).

Monitoring lung function and gas exchange — Consistent with current guidelines, we obtain spirometry annually, or sooner if symptoms worsen [1]. Worsening airflow limitation is associated with increasing exacerbations, hospitalizations, and risk of death [1,42,43].

Arterial blood gases (ABGs) and pulse oximetry are the only reliable methods of detecting hypoxemia in patients with COPD because most patients have few if any symptoms that can specifically be related to decreased oxygenation. As pulse oximetry can overestimate oxygen saturation in COPD, ABGs are appropriate when the pulse oxygen saturation (SpO2) is <92 percent [1,44]. ABG analysis is also helpful in assessing the presence and severity of hypercapnia, which can complicate oxygen therapy and, when severe, be an indication for noninvasive ventilation. (See "Mechanisms, causes, and effects of hypercapnia".)

Lung cancer screening — COPD and lung cancer share a common risk factor in cigarette smoking. Among current smokers, smoking cessation is likely to have a far greater impact on lung cancer mortality than screening. Nonetheless, lung cancer screening with low-dose computed tomography (LDCT) has the potential to significantly reduce the burden of lung cancer for current and former smokers. High-risk criteria include age 50 to 80 years, a history of smoking at least 20 pack-years and, if a former smoker, having quit within the previous 15 years [45]. (See "Screening for lung cancer", section on 'Low-dose chest CT' and "Screening for lung cancer", section on 'Recommendations by expert groups'.)

Depending on overall health, screening may be appropriate up to 80 years old. The National Cancer Institute has developed a guide for patients and clinicians to review the data from the National Lung Screening Trial (NLST) and facilitate communication about the benefits and harms of screening. (See "Screening for lung cancer", section on 'Our approach to counseling for screening'.)

Comorbid disease — As comorbid diseases are common in COPD and can contribute to symptoms, we regularly assess for comorbidities such as coronary heart disease, heart failure, arrhythmias, bronchiectasis, or interstitial lung disease. This evaluation may entail such tests as a chest radiograph, high resolution computed tomography (for bronchiectasis, interstitial lung disease, or severity and location of emphysema), electrocardiogram (ECG), transthoracic echocardiography, cardiac stress testing, and N-terminal pro-brain natriuretic peptide (NT pro-BNP). Other comorbidities, including depression and osteoporosis, should also be considered in COPD patients. (See "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions" and "Management of the patient with COPD and cardiovascular disease", section on 'Evaluation and diagnosis of CHD in patients with COPD'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic obstructive pulmonary disease" and "Society guideline links: Pulmonary rehabilitation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Chronic obstructive pulmonary disease (COPD) (The Basics)" and "Patient education: Shortness of breath (The Basics)" and "Patient education: How to use your metered dose inhaler (adults) (The Basics)" and "Patient education: How to use your dry powder inhaler (adults) (The Basics)" and "Patient education: How to use your soft mist inhaler (adults) (The Basics)" and "Patient education: Coping with high drug prices (The Basics)" and "Patient education: Medicines for COPD (The Basics)" and "Patient education: Inhaled corticosteroid medicines (The Basics)" and "Patient education: Pulmonary rehabilitation (The Basics)")

Beyond the Basics topics (see "Patient education: Chronic obstructive pulmonary disease (COPD) (Beyond the Basics)" and "Patient education: Chronic obstructive pulmonary disease (COPD) treatments (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Management of chronic obstructive pulmonary disease (COPD) is guided by a combined multidimensional assessment of COPD, which includes spirometric measurement of airflow limitation (after inhaled bronchodilator) and use of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) “ABE” tool for formal assessment of symptoms and exacerbation risk. Follow-up visits adjust therapy based on control of symptoms and exacerbations. (See 'Assessment of disease severity' above and 'Monitoring' above.) (Related Pathway(s): Chronic obstructive pulmonary disease: Severity assessment and selection of initial therapy in adults.)

All patients with COPD should be advised to quit smoking (if still smoking) and educated about COPD and inhaler techniques. Seasonal influenza vaccination and COVID-19 vaccination (with appropriate boosters) should be recommended to all patients with COPD. Our view is that pneumococcal vaccination should be given to patients with moderate or greater COPD severity. (See 'Smoking cessation' above and 'Vaccination' above and 'Patient education and counselling' above and "Pneumococcal vaccination in adults", section on 'Approach to healthy older adults and those with predisposing medical conditions'.)

For current smokers, smoking cessation is likely to have a far greater impact on lung cancer mortality than screening. Nonetheless, lung cancer screening of high-risk patients with low-dose computed tomography (LDCT) has the potential to significantly reduce the burden of lung cancer for current and former smokers. (See 'Monitoring' above.)

For patients with symptomatic COPD, we suggest pulmonary rehabilitation (Grade 2B). The purpose of pulmonary rehabilitation is to improve symptoms, exercise capacity, and quality of life. Pulmonary rehabilitation also reduces COPD exacerbations. (See 'Pulmonary rehabilitation' above and "Pulmonary rehabilitation".)

While there is no ideal COPD diet, excess weight can contribute to dyspnea. It is reasonable to advise patients to follow a generally healthy diet and aim to achieve a normal body mass index (BMI). Patients with pulmonary cachexia and low body weight (BMI ≤20) may benefit from strategies to enhance caloric intake. (See 'Nutrition' above.)

Pharmacotherapy is generally initiated in a stepwise fashion, depending upon assessment of the level of symptoms and risk of exacerbations (algorithm 1). However, for patients who present with more severe disease, it may be necessary to initiate several medications at once to achieve appropriate symptom and exacerbation control. (See 'Pharmacologic therapy' above.)

We recommend long-term, continuous oxygen therapy in all patients with COPD who have chronic hypoxemia, defined as a resting arterial oxygen tension (PaO2) ≤55 mmHg (7.33 kPa) or pulse oxygen saturation (SpO2) ≤88 percent (Grade 1A). (See 'Supplemental oxygen' above.)

A clear benefit of long-term oxygen therapy has not been demonstrated for patients with moderate hypoxemia at rest (eg, SpO2 89 to 93 percent) or with exertion (eg, SpO2 <90 percent). (See 'Exertional hypoxemia' above.)

  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2024 Report. www.goldcopd.org www.goldcopd.org (Accessed on November 16, 2023).
  2. Sullivan J, Pravosud V, Mannino DM, et al. National and State Estimates of COPD Morbidity and Mortality - United States, 2014-2015. Chronic Obstr Pulm Dis 2018; 5:324.
  3. World Health Organization. Global Health Observatory (GHO) Data. https://www.who.int/gho/ncd/mortality_morbidity/en/ (Accessed on February 11, 2019).
  4. Gerayeli FV, Milne S, Cheung C, et al. COPD and the risk of poor outcomes in COVID-19: A systematic review and meta-analysis. EClinicalMedicine 2021; 33:100789.
  5. Puebla Neira DA, Watts A, Seashore J, et al. Outcomes of Patients with COPD Hospitalized for Coronavirus Disease 2019. Chronic Obstr Pulm Dis 2021; 8:517.
  6. https://goldcopd.org/gold-covid-19-guidance/ (Accessed on April 03, 2020).
  7. https://www.copdfoundation.org/Downloads/COVID19_Webinar_Q_&_A_FINAL.pdf (Accessed on April 03, 2020).
  8. Schultze A, Walker AJ, MacKenna B, et al. Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform. Lancet Respir Med 2020; 8:1106.
  9. Halpin DMG, Singh D, Hadfield RM. Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective. Eur Respir J 2020; 55.
  10. Martinez CH, Mannino DM, Divo MJ. Defining COPD-Related Comorbidities, 2004-2014. Chronic Obstr Pulm Dis 2014; 1:51.
  11. Make B. Collaborative self-management strategies for patients with respiratory disease. Respir Care 1994; 39:566.
  12. Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003; 163:585.
  13. Bourbeau J, Bartlett SJ. Patient adherence in COPD. Thorax 2008; 63:831.
  14. Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002; 166:675.
  15. van Eerd EA, van der Meer RM, van Schayck OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016; :CD010744.
  16. Warnier MJ, van Riet EE, Rutten FH, et al. Smoking cessation strategies in patients with COPD. Eur Respir J 2013; 41:727.
  17. National Jewish Health Video Library. Devices to inhale medication (Asthma inhalers, COPD inhalers). https://www.nationaljewish.org/health-insights/multimedia/devices-to-inhale-medication (Accessed on May 10, 2018).
  18. Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 8:CD011682.
  19. Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med 2012; 156:673.
  20. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015; :CD003793.
  21. Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis 2016; 11:3121.
  22. Ortega F, Toral J, Cejudo P, et al. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002; 166:669.
  23. Walters JA, Tang JN, Poole P, Wood-Baker R. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 1:CD001390.
  24. Calderón-Larrañaga A, Carney L, Soljak M, et al. Association of population and primary healthcare factors with hospital admission rates for chronic obstructive pulmonary disease in England: national cross-sectional study. Thorax 2011; 66:191.
  25. Bekkat-Berkani R, Wilkinson T, Buchy P, et al. Seasonal influenza vaccination in patients with COPD: a systematic literature review. BMC Pulm Med 2017; 17:79.
  26. Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2018; 6:CD002733.
  27. Tata LJ, West J, Harrison T, et al. Does influenza vaccination increase consultations, corticosteroid prescriptions, or exacerbations in subjects with asthma or chronic obstructive pulmonary disease? Thorax 2003; 58:835.
  28. Zwaans WA, Mallia P, van Winden ME, Rohde GG. The relevance of respiratory viral infections in the exacerbations of chronic obstructive pulmonary disease—a systematic review. J Clin Virol 2014; 61:181.
  29. Mekov E, Slavova Y, Tsakova A, et al. Vitamin D Deficiency and Insufficiency in Hospitalized COPD Patients. PLoS One 2015; 10:e0129080.
  30. Malinovschi A, Masoero M, Bellocchia M, et al. Severe vitamin D deficiency is associated with frequent exacerbations and hospitalization in COPD patients. Respir Res 2014; 15:131.
  31. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017; 356:i6583.
  32. Burkes RM, Ceppe AS, Doerschuk CM, et al. Associations Among 25-Hydroxyvitamin D Levels, Lung Function, and Exacerbation Outcomes in COPD: An Analysis of the SPIROMICS Cohort. Chest 2020; 157:856.
  33. Rafiq R, Aleva FE, Schrumpf JA, et al. Prevention of exacerbations in patients with COPD and vitamin D deficiency through vitamin D supplementation (PRECOVID): a study protocol. BMC Pulm Med 2015; 15:106.
  34. Gold DR, Litonjua AA, Carey VJ, et al. Lung VITAL: Rationale, design, and baseline characteristics of an ancillary study evaluating the effects of vitamin D and/or marine omega-3 fatty acid supplements on acute exacerbations of chronic respiratory disease, asthma control, pneumonia and lung function in adults. Contemp Clin Trials 2016; 47:185.
  35. Lehouck A, Mathieu C, Carremans C, et al. High doses of vitamin D to reduce exacerbations in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med 2012; 156:105.
  36. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011; 155:179.
  37. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93:391.
  38. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet 1981; 1:681.
  39. Long-Term Oxygen Treatment Trial Research Group, Albert RK, Au DH, et al. A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation. N Engl J Med 2016; 375:1617.
  40. Jarosch I, Gloeckl R, Damm E, et al. Short-term Effects of Supplemental Oxygen on 6-Min Walk Test Outcomes in Patients With COPD: A Randomized, Placebo-Controlled, Single-blind, Crossover Trial. Chest 2017; 151:795.
  41. COPD Assessment Test (CAT). http://www.catestonline.org (Accessed on October 23, 2012).
  42. Soriano JB, Lamprecht B, Ramírez AS, et al. Mortality prediction in chronic obstructive pulmonary disease comparing the GOLD 2007 and 2011 staging systems: a pooled analysis of individual patient data. Lancet Respir Med 2015; 3:443.
  43. Müllerova H, Maselli DJ, Locantore N, et al. Hospitalized exacerbations of COPD: risk factors and outcomes in the ECLIPSE cohort. Chest 2015; 147:999.
  44. Amalakanti S, Pentakota MR. Pulse Oximetry Overestimates Oxygen Saturation in COPD. Respir Care 2016; 61:423.
  45. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2021; 325:962.
Topic 120326 Version 29.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟