Management of Chronic Obstructive Pulmonary Disease (COPD)

Initial Assessment and Diagnosis

The European Respiratory Society suggests that patients over 50 years of age who are long-term smokers with chronic breathlessness on minor exertion should be treated as having suspected COPD 4
Spirometry is essential to confirm the diagnosis of COPD, with post-bronchodilator FEV1/FVC ratio <0.70 being diagnostic, as recommended by the European Respiratory Society 3
Physical examination should focus on identifying indicators of airflow limitation such as wheezing during tidal breathing, prolonged forced expiratory time (>5 seconds), and use of accessory respiratory muscles, according to the European Respiratory Society 3

The European Respiratory Society recommends providing a clear explanation of smoking's effects and the benefits of stopping, with strong encouragement to quit abruptly rather than gradually 1, 2
Offer nicotine replacement therapy (gum or transdermal patches) combined with behavioral intervention, which has been shown to increase success rates, as suggested by the European Respiratory Society 1, 2
Approximately one-third of patients are able to quit smoking with support; multiple attempts are often needed, according to the European Respiratory Society 1

The European Respiratory Society recommends starting with inhaled bronchodilator therapy to relieve symptoms, even if spirometric changes are not seen in all patients 5
Consider using one of three groups of bronchodilators: β2-agonists, anticholinergic drugs (such as tiotropium), or methylxanthines, as suggested by the European Respiratory Society 5
For patients with purulent sputum, prescribe a 7-14 day course of antibiotics, with common choices including amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid, according to the European Respiratory Society 1
Knowledge of local resistance patterns is helpful in directing empirical antibiotic therapy, as recommended by the European Respiratory Society 1

The Thorax journal recommends that if the patient has respiratory acidosis due to excessive oxygen therapy, do not discontinue oxygen immediately but step down to 28% or 35% oxygen from a Venturi mask, or 1-2 L/min from nasal cannulae 4
A saturation target of 88-92% is recommended for acidotic patients, according to the Thorax journal 4
Consider oxygen alert cards for patients who have had an episode of hypercapnic respiratory failure, as suggested by the Thorax journal 4

The Chest journal recommends considering centrally acting cough suppressants such as dihydrocodeine and hydrocodone for persistent cough 6
Treatment of cough caused by radiation pneumonitis (if applicable) consists of symptomatic treatment (inhaled β2-mimetics, oxygen supplementation), anti-inflammatory drugs, and treatment of comorbid diseases, according to the Annals of Oncology 7

The European Respiratory Society recommends not relying solely on physical signs to assess severity of airflow limitation, as they are poor guides 3
Remember that absence of wheezing or other physical signs does not exclude COPD, as suggested by the European Respiratory Society 3
Avoid confusing COPD with chronic asthma in older subjects; history of heavy smoking, evidence of emphysema on imaging, decreased diffusing capacity, and chronic hypoxemia favor the diagnosis of COPD, according to the European Respiratory Society 3