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Management of stable chronic obstructive pulmonary disease

Authors
Gary T Ferguson, MD
Barry Make, MD
Section Editor
James K Stoller, MD, MS
Deputy Editor
Helen Hollingsworth, MD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common condition with a high and continually increasing mortality, affecting men and women equally. It is estimated that approximately 7 percent of all individuals have COPD, including approximately 10 percent of individuals 65 years of age or older [1-3]. The true prevalence is likely higher because COPD is both under-recognized and under-diagnosed. COPD is the third leading cause of death among adults in the US and is expected to become the third leading cause of death worldwide by 2020 [4,5].

The management of stable COPD will be reviewed here. The diagnosis, natural history, and prognosis of COPD, risk factors for COPD, and treatment of acute exacerbations are discussed separately. (See "Chronic obstructive pulmonary disease: Definition, clinical manifestations, 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 exacerbations of chronic obstructive pulmonary disease".)

GENERAL APPROACH

We share the philosophy of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) that pharmacologic and nonpharmacologic therapies should be guided by disease severity and aim to control symptoms, decrease exacerbations, and improve patient function and quality of life [6]. Both pharmacologic and non-pharmacologic interventions are key to the management of COPD patients. Non-pharmacologic interventions include: (1) smoking cessation, (2) reduction of other risk factors, (3) vaccinations, (4) oxygen therapy, and (5) pulmonary rehabilitation. In the discussion that follows, the formal assessment of COPD severity, the various therapies for COPD, and the clinical evidence for each therapy are reviewed. Pharmacotherapy is generally added in a stepwise fashion. However, for patients who present with severe disease, a stepwise approach may not always be the best choice, as it may be necessary to initiate several medications at once to achieve symptom control. An approach to the management of patients with stable COPD is outlined below. (See 'Summary and recommendations' below.)

The mainstays of drug therapy of stable symptomatic COPD are inhaled bronchodilators (beta agonists and anticholinergics) given alone or in combination with inhaled glucocorticoids depending upon the severity and impact of disease, risk of exacerbations, and response to therapy (table 1 and table 2). These are generally administered via inhalation in the form of metered dose, soft mist, or dry powder inhalers, and some may be administered by nebulization. For maintenance therapy, long-acting agents are recommended. The oral bronchodilator theophylline, which is only modestly effective and has more side effects than inhaled bronchodilators, is occasionally used for patients with refractory COPD; it is more widely employed in developing countries with limited resources.

Education about the purpose and dosing of regularly-prescribed and as-needed medications and about proper inhaler technique is essential. (See "Delivery of inhaled medication in adults" and "The use of inhaler devices in adults" and "Patient education: Asthma inhaler techniques in adults (Beyond the Basics)".)

                                         

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