Therapy goals
- Nicotine restriction (abstinence from tobacco use including passive smoking) [only causal therapeutic approach!]
- Symptom relief
- Improvement of the resilience
- Prevention of disease progression (progression of the disease) and exacerbations (significant worsening of symptoms).
Therapy recommendations
Chronic obstructive pulmonary disease (COPD) is treated according to the following staged regimen, depending on severity:
| Inhaled bronchodilators (drugs that dilate the bronchial tubes) if needed | Inhaled bronchodilators as continuous therapy. | Inhaled glucocorticoids (synonym: inhaled steroids, ICS). | Oxygen therapy up to 16-24 h/d | |
| Grade 1 (light) | + | – | – | – |
| Grade 2 (moderate) | + | + | – | – |
| Grade 3 (heavy) | + | + | + | – |
| Grade 4 (very difficult) | + | + | + | + |
None of the drugs shown can prevent disease progression. Note: FLAME study: LAMA/LABA combination (indacaterol and glycopyrronium) protects against exacerbations better than ICS/LABA combination (indacaterol and glycopyrronium) in severe COPD. Treatment of stable COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2019) [modified from guideline: 3]. Initial pharmacological treatment
| Group | Agents | |
| 0 or 1 moderate exacerbation (without hospitalization. | A |
Bronchodilator
|
| B |
|
|
| ≥ 2 moderate exacerbations or ≥ 1 with hospitalization. | C |
|
|
||
| D |
|
|
|
Legend
- LABA: long-acting beta-2-agonists) or long-acting muscarinic antagonists.
- LAMA: long-acting muscarinic antagonist.
- ICS (Inhaled Corticosteroids): inhaled steroids.
Dyspnea (shortness of breath).
* Consider de-escalation of ICS or switch if: Pneumonia, inapplicable original indication, or lack of response to ICS.
Exacerbation (worsening, temporary increase, resurgence of disease).
Legend
- Eos = eosinophil granulocytes (absolute number/µl).
- * Consider if Eos ≥ 300 or ≥ 100 AND ≥ 2 moderate exacerbations/1 hospitalization.
- * * Consider de-escalation of ICS or switch if: Pneumonia, inapplicable original indication, or lack of response to ICS.
Further notes
- Maximum bronchodilation (dilation of the bronchi) is possible only by means of combination of LAMA (long-acting muscarinic antagonist)) and LABA (long-acting beta-2-agonists).FLAME study: LAMA/LABA combination protects better against exacerbations than the combination ICS/LABA in severe COPD.
- Patients who complain of palpitations (heart palpitations) while taking a beta-2 mimetic are better served by an anticholinergic.
- Inhaled glucocorticoids (synonym: inhaled steroids, ICS):
- The dose-response curve of steroids is very flat, i.e. high-dose therapy is usually not required!
- One study demonstrated LABA plus LAMA in patients with severe chronic obstructive pulmonary disease who discontinued inhaled steroid therapy without an increase in exacerbations. However, there was also a greater decrease in FEV1 (43 mL) than with continued steroid therapy. There was no difference for dyspnea (shortness of breath) in either group.
- Additional facts about ICS:
- In COPD significantly weaker effect than in bronchial asthma.
- ICS decreases COPD exacerbation rate (worsening of clinical picture); effectiveness is increased with increasing percentage of eosinophils in blood
- According to the first table, ICS are used inferior to bronchodilators.
- ICS effect on reduction of annual FEV1 loss is not clinically meaningful
- ICS can be gradually reduced in stable COPD patients
- Notice: Inhaled corticosteroids (ICS) increase the risk of non-tuberculous mycobacterial infection in COPD patients.
- COPD patients with gold stages 3 and 4 benefit from the bronchoconstrictive effects of beta-blockers (beta-blockade), i.e., exacerbations decreased when beta-blockers were taken.
- Inhaled glucocorticoids (synonym: inhaled steroids, ICS) increase risk of severe pneumonia (pneumonia): fluticasone increased the number of severe pneumonias (requiring hospitalization) by 78% (odds ratio1.78, 95% confidence interval: 1.50-2.12).
- The fixed combination of two bronchodilators (LAMA + LABA) will become combination of first choice for all COPD patients; also regarding the primary endpoint “annual exacerbation rate”, this fixed combination was superior to the previous standard of care.
- Inhalable corticosteroid (ICS): blood eosinophils (= predictor of response to ICS) and exacerbation rate determine whether or not to take an inhalable corticosteroid (ICS) in COPD.ICS should not be discontinued in patients with an eosinophil count greater than 300/μl [guidelines: ERS].
- See also information on typical comorbidities of COPD at the end of this article.
Oxygen administration in severe exacerbations of COPD
- Oxygen administration to provide adequate oxygenation and respiratory muscle relief. Note: Noninvasive oxygen administration (NIV) was associated with lower mortality (death rate), lower risk of nosocomial pneumonia (pneumonia as a hospital-acquired infection), and shorter hospital stay compared with invasive oxygen administration (invasive mechanical ventilation, IMV).
Cardiovascular disease and COPD
Hypertension (high blood pressure), coronary artery disease (CAD, coronary artery disease), heart failure (heart failure) and atrial fibrillation (AF) are the most common comorbidities (concomitant diseases) of COPD. This may necessitate the use of opposing therapeutic principles in COPD patients with CHD and heart failure. The GOLD guideline recommends treating these cases as if they did not have COPD. However, cardioselective (“cardioactive”) agents such as bisoprolol should be given preference. See also below under the title “Postmyocardial Therapy for CPO in COPD.”
Postmyocardial Infarction Therapy in COPD
Reluctance to use beta-blockers in COPD patients with acute myocardial infarction (heart attack) should be abandoned: The mortality risk of patients with newly initiated beta blockade is 50% lower than that of patients without beta blockers during nearly 3 years of follow-up, according to one study.
