CME credit available from Harvard Medical School through July 2020.
This module summarizes the current understanding of COPD and presents evidence-based clinical guidelines for its diagnosis and management in the primary care setting.
Chronic obstructive pulmonary disease, or COPD, is the third-leading cause of death in the U.S. following cancer and heart disease, and it is a significant global public health issue.1 Smoking is the most common contributing cause of COPD in the U.S. and other industrialized countries, although exposure to biomass smoke may be the biggest risk factor globally. A close relationship between the amount of tobacco smoked and the rate of decline in FEV1 make smoking cessation the most important intervention for preventing or delaying COPD and slowing decline in FEV1.
COPD is substantially under-diagnosed and can occur at an earlier age than is generally believed.2 A diagnosis of COPD should be considered in any patient with dyspnea, chronic cough, or chronic sputum production, and/or history of exposure to risk factors for the disease (especially tobacco smoke), especially for those over age 40. Spirometry is required for the diagnosis of COPD.
The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of COPD focuses on symptoms (e.g., dyspnea) and the frequency of exacerbations to group patients with COPD and recommend management strategies.3
Some of the goals of COPD management include relieving symptoms, improving health status and quality of life, reducing the number and severity of exacerbations, preventing and treating complications, and ensuring appropriate end-of-life planning and palliation.
Pharmacological therapy for COPD should be matched to the GOLD group.3 The table below provides recommendations for first-line therapy as well alternative therapies based on GOLD group.
Bronchodilators remain the cornerstone of therapy across all groups. It is preferable to initiate therapy with a short-acting bronchodilator (a beta-agonist or an anticholinergic/antimuscarinic) rather than a combination. For increasing symptoms, long-acting bronchodilators reduce exacerbations and provide more relief than short-acting agents. However, all patients should have short-acting bronchodilators as rescue medication.
A: SABA+SAMA, LAMA, or LABA
D: LAMA, LABA+ICS, triple therapy+roflumilast, or triple therapy+azithromycin
Prescribing a regimen of exercise, good nutrition, and immunization at all stages of COPD is essential.
Promoting smoking cessation, ensuring adherence to prescribed regimens, monitoring proper inhaler use and providing influenza immunizations, can reduce the risk of exacerbations in patients with COPD. Most exacerbations can be managed in the outpatient setting. 3 4
After each exacerbation, especially if hospitalization is required, reassess the patient’s GOLD group, optimize treatment as needed, ensure understanding of inhaler technique, and discuss adherence.
The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.
1. American Lung Association. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality. March 2013.
2. Pauwels RA, Rabe, K. F. Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet. 2004;364(9434):613-620.
3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2017 Report
4. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA: the journal of the American Medical Association. 2013;309(21):2223-2231.