How exactly is COPD treated and monitored?

Once the diagnosis has been confirmed and the stage of the disease determined, the focus turns to:

•    Patient education to help him/her understand the disease
•    Modification of risk factors with smoking cessation of the utmost importance to slow the progression of the disease
•    Medications like inhaled bronchodilators, oral and inhaled corticosteroids, antibiotics and others.

These pharmacological and non-pharmacological therapies should be added in a step-wise fashion as outlined below to control symptoms, prevent exacerbations and improve quality of life.

Treatment of Stable COPD

1) Smoking cessation

All of us, whether we smoke or not, or whether we have COPD or not, will experience a decline in our lung function over time. This is a function of ageing, and results from the loss of elasticity within the lung. This is a normal process, and can be compared to the development of wrinkles in the skin, also a function of the loss of elastic tissue. However, this loss of lung function is rarely symptomatic as it never deteriorates to the threshold at which shortness of breath is experienced. In patients with COPD, inflammation within the lung leads to accelerated loss of lung function, with more rapid deterioration to the point of respiratory disability.

So while no curative treatment for COPD exists, cessation of smoking is the only significant therapeutic intervention that can retard the accelerated decline in lung function experienced by smokers with COPD. Patients must be informed that secondary cigarette smoke, as well as exposure to noxious fumes, gases and dust at work, needs to be addressed to preserve respiratory function.

Any extra treatment of COPD will depend on the severity of the patient’s COPD. COPD can be classified as mild, moderate, severe or very severe. This classification is based on staging systems for COPD, using the value of FEV1 ("forced expiratory volume in one second") as a percentage of the normal value for an individual of the same age, height, gender and ethnicity. The degree of airflow (FEV1) reduction has implications for the prognosis and relates with the mortality and morbidity.

2) Vaccinations

Patients with COPD have vulnerable lungs with reduced respiratory reserve and need to be protected from preventable respiratory infections. These individuals should be vaccinated against the predominant viral strains every year – in particular seasonal and pandemic influenza serotypes, where available. All patients with chronic respiratory disease should also receive a pneumococcal vaccination every 5 - 10 years with the 23-polyvalent vaccine to protect against Streptococcus pneumonia.

3) Bronchodilators

These include inhaled anticholinergics and beta-agonists, both of which are available in short or long-acting preparations, and oral theophylline.

The use of short-acting bronchodilator therapy (medications to dilate the bronchial airways), on an as-needed basis during episodes of wheezing is very effective. Inhaled bronchodilators in combination have been shown to have the most benefit on lung function, and usually include an anticholinergic like iprapropium bromide and a beta2-antagonist like salbutamol.

In patients in whom short-acting bronchodilaotrs alone or in combination are insufficient to control symptoms, or in patients with more advanced disease, long-acting inhaled bronchodilators can be added. Both long-acting anticholinergic drugs (like tiotropium) or long-acting beta-2-agonists (called LABAs, like salmeterol or formoterol) can be used. Tiotropium has been conclusively shown in the recent large UPLIFT trial to improve airflow, hyperinflation, exercise tolerance, exacerbation frequency, and health-related quality of life with a convenient once-daily dosing, A combination of both classes of drugs is the most effective strategy, and provides an additive effect on lung function throughout a 24-hour period.

The benefits of oral theophylline are modest, and this therapy is least preferred because of its potential toxicity and interactions with other medications.

4) Inhaled corticosteroids

For patients who continue to have symptoms or have advanced disease (GOLD Stage III), or those who continue to have repeated exacerbations despite an optimal long-acting bronchodilator regimen, it is recommended that inhaled corticosteroids (ICS) are added. If the existing regimen contains a long-acting beta-2-agonist (called LABA, like salmeterol), the ICS can be added alone; if the regimen does not already contain a LABA, the combination of ICS and a LABA can be added.

Many patients with severe COPD will therefore qualify for long-acting anticholinergics, long-acting beta-agonists, and inhaled corticosteroids – so-called “triple-inhaler therapy”.

5) Other treatments

Long-term antibiotic prophylaxis

Chronic antibiotic therapy is without benefit in most patients with COPD, except in those who have a chronic bronchial infection called bronchiectasis.


Thick, tenacious secretions can be a major problem in COPD – however, there is little evidence that thinning these secretions with mucolytics confers any clinical benefit. Thus the use of agents like n-acetylcysteine is not recommended.


More than 30% of patients with COPD have protein-calorie malnutrition, and loss of weight is an important symptom in late-stage COPD. Low body-mass index is associated with increased mortality impaired respiratory muscle function and diminished immune competence. High calorie diets and appetite stimulants have been used in an effort to combat malnutrition, but there is no evidence that these treatments confer a long-term benefit.

Pulmonary rehabilitation

Rehabilitation is an important component of treatment of patients with severe COPD. The aim is to improve the fitness of exercising muscle to better cope with the low oxygen tension in the blood: this involves strengthening the arm and leg muscles as well as the muscles of respiration, and enables patients to cope with moderate exercise and to carry on with their daily routine in spite of considerable loss of lung function and low blood oxygen concentrations. This state of “fitness” is only achieved after an intensive rehabilitation programme, which has to be conducted under supervision of doctors and physiotherapists.

Long-term oxygen therapy

All patients with severe COPD feel better on oxygen, however this therapy has only been shown to decrease mortality in the sub-set of patients with chronically low blood oxygen concentrations. However, the provision of home oxygen is expensive, and it is imperative that patients who are prescribed this therapy have stopped smoking. Oxygen devices that operate through home power sources generate enough oxygen to support patients for an essential 16 hours per day.

Lung volume reduction surgery

Surgery known as lung volume reduction surgery (LVRS) has been shown to be of benefit in a small subset of carefully selected patients who have predominantly upper lobe emphysema, low exercise capacity and no other serious co-morbid disease.  The surgery works by excising parts of the lung with the extensive thin-walled cysts called bullae, allowing the adjacent non-involved lung to inflate better, resulting in less gas-trapping.

6) Future directions in COPD treatment

Several novel treatments are being investigated for COPD which target inflammatory pathways. Roflumilast is a highly-specific, oral, second-generation PDE-4 inhibitor being investigated for patients with COPD. Its treatment benefits are, however, small compared to standard bronchodilators.

Treatment of exacerbations

Acute exacerbations are characterised by acute worsening of the symptoms of COPD, including:

•    increased shortness of breath
•    increased wheezing
•    increased sputum production
•    change in sputum colour (often becoming yellow or green).

The mainstays of therapy include

•    Oxygen therapy to correct the hypoxia
•    Bronchodilators to improve airflow to and from the lungs. A combination of nebulised or inhaled anticholinergic and beta-adrenergic agonists (fast-acting) are often used as first-line therapy.
•    Antibiotics such as penicillins, quinolones or tetracyclines for 7 - 14 days to reduce the infection and phlegm production.
•    Oral or injected corticosteroids for 5 - 10 days to reduce inflammation in the airways. Inhaled corticosteroids have not been proven effective in treating COPD exacerbations.
•    Non-invasive ventilation, if available, in the case of respiratory failure
•    Mechanical ventilation in ICU if unresponsive to above measures. The decision to intubate and ventilate is dependant on multiple factors, including the relative reversibility of the precipitating insult, the patient’s baseline level of functioning and quality of life, and the wishes of the patient and their family.


The battle for prevention of COPD will be won or lost depending on the education those health authorities, doctors and the media provide to the public about COPD. Preventing smoking at school level is a much more cost-effective method of combating the disease than trying to convert smokers or treating symptoms when they occur.

The management and treatment of patients with COPD has frequently been met with a very nihilistic attitude by health providers. The argument that it is a self-induced, progressive disease, to which treatment does not make a difference, needs to be replaced with a new and more enthusiastic approach to the problem.

Much has changed during recent years in terms of understanding and preventing the disease, and its rational treatment, which may alleviate the suffering of a large number of patients. Clearly, education of health authorities, health workers and the public will contribute to a decreasing prevalence of this much neglected condition.

(Written by Prof J.R. Joubert, MSc, MBChB (Stell), FCP (SA), MMed (Int. Med), MD (Stell.))

(Reviewed by Dr Greg Calligaro, physician at the Lung Unit, Groote Schuur Hospital and University of Cape Town, August 2010)
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