Mount Carmel Health Partners Clinical Guidelines Chronic Obstructive Pulmonary Disease | Page 4

Management of Stable COPD
Patients with severe COPD should have a visit with their PCP at least once every six months.
Reduce risk factors by:
• Influenza and pneumococcal vaccines
• Reducing and/or eliminating occupational exposures and other pollutants
• Smoking cessation, which is the most effective and co-effective intervention to reduce the risk of developing COPD and slow its progression
• Treatment of anxiety and depression, as both are major comorbidities.
• Assessing inhaler techniques
• Establish Advanced Directives
Management of Exacerbations
The American Thoracic Society defines an exacerbation of COPD as an acute change in a patient’s baseline dyspnea, cough, and/or sputum
beyond day to day variability that is sufficient to warrant a change in therapy. Common causes include exposure to air pollution or other
irritants, ambient temperature, medical noncompliance, and respiratory infection.
Tests needed to assess an exacerbation:
• Arterial blood gas
• Chest x-ray to identify other diagnoses that produce symptoms similar to a COPD exacerbation
• ECG
• Sputum culture
• Biochemical tests to detect electrolyte disturbances
• Whole blood count to identify polycythemia, bleeding, or infection
Pulmonary Rehabilitation
Pulmonary rehabilitation should be considered for patients who have:
•GOLD B,C,D
•FEV1<50%
•persistent symptoms
•limited functional capacity
•difficulty adjusting to the illness
Supply the patient with a pulmonary rehabilitation booklet if the patient is unable to attend pulmonary rehabilitation.
Benefits of a pulmonary rehabilitation program include:
•improved quality of life
•decreased dyspnea
•decreased hospitalization and emergency room utilization
Pharmacological Treatment
Bronchodilators
• Beta-2 agonists: short-acting include albuterol and levalbuterol;
long-acting beta agonists (LABAs) include salmeterol, formoterol,
arformoterol, indacaterol, olodaterol
• Anticholinergics: short-acting include ipratropium, formoterol;
long-acting muscarinic agents (LAMAs) include, aclidinium,
tiotropium, umeclidinium, glycopyrronium
• Combination therapy: short-acting beta-2 agonist plus
anticholinergic include albuterol/ipratroium; long-acting beta-2
agonist plus anticholinergic include vilanterol/umeclidium,
olodaterol.tiotropium, formoterol.glycopyrronium, indacaterol/
glycopyrronium
• Methylxanthines: Theophylline
Inhaled Corticosteroids (ICS)
• Combination of long-acting beta-2agonist plus corticosteroids
include formoterol/budesonide, formoterol/mometasone,
salmeterol/fluticasone, vilanterol/fluticasone Preferred Therapy
Inhaled. Regular treatment with
long-acting bronchodilators is more
effective than short- acting
bronchodilators Combination Therapy
Combining bronchodilators of
different classes may decrease side
effects and improve efficacy
Preferred Therapy
An ICS combined with a LABA is more
effective than monotherapy in
improving lung function and reducing
exacerbations in patients with
exacerbations and moderate-severe
COPD. Triple inhaled therapy of ICS/
LAMA/LABA improves lung function,
symptoms, and health status
compared to ICS/LABA or LAMA alone Long-Term Therapy
Regular treatment with ICS increases
risk of pneumonia especially in those
with severe COPD and does not
reduce mortality
Glucocorticosteroids (prednisone, methylprednisolone)
Reduce frequency of exacerbations and improve health status for
patients with an FEV1 less than 60%. No effect on the long-term
decline in FEV1 Preferred Therapy
For the acute management of
exacerbations to reduce rate of
treatment failure, rate of relapse, and
improve lung function and
breathlessness
Preferred Therapy Long-Term Therapy
Numerous side effects including
steroid myopathy
Phosphodiesterase-4 Inhibitors (roflumilast), daliresp)
Reduce inflammation by inhibiting the breakdown of intracellular
cyclic AMP
Once daily oral medication shown to
decrease FEV in patients treated with
salmeterol or tiotropium in patients
with chronic bronchitis type of COPD
Combination Therapy
Should always be combined with at
least one long-acting
bronchodilator and in patients who are
controlled on fixed-dose LABA/ICS
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