![]() ![]() Initial inhaled therapy: Initial pharmacological management of COPD should be carried out according to the individualised assessment of symptoms and exacerbation risk and subsequent categorisation to one of four groups A, B, C, or D: Non-inhaled prevention and maintenance strategies: including smoking cessation, vaccinations and pulmonary rehabilitation play a vital role in the management of COPD – see slider below for further details. MRC = Medical Research Council breathlessness / dyspnoea scale CAT = COPD Assessment Test.SABA = Short-acting beta 2 agonist SAMA = Short-acting muscarinic antagonist LABA = Long-acting beta 2 agonist LAMA = Long-acting muscarinic antagonist ICS = Inhaled corticosteroid.DPI = Dry powder inhaler SMI = Soft mist inhaler pMDI = Pressurised metered dose inhaler BAI = Breath actuated inhaler. ![]() Local and national resources which support patient training can be accessed via links at the bottom of the page. When discussing inhaled treatment options, consideration should also be given to the environmental impact of inhalers. Adherence to treatment regimens should also be checked. It is essential that patients can demonstrate the proper inhaler technique when prescribing an inhaler device recheck patient technique at each visit to ensure continued correct use of the inhaler. Patient preference should be considered when prescribing treatments. Treatment regimens should be patient-specific, and individualised. Therapy should be reviewed annually and following an exacerbation. Non inhaled prevention and maintenance strategies are essential in the management of COPD (see slider below) It is important to establish that patients meet the diagnostic criteria for COPD before commencing treatment. Diagnosis is not covered in the guidance below. The information is supported by local respiratory specialists and is intended to guide and rationalise treatment choices when managing patients with COPD. Where recommendations have been made by NICE (2019) this is indicated in the text. The ATS addresses smoking cessation ( ) in a separate guideline.-Michael J.The following recommendations are largely based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for Prevention, Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD) 2019 Report. Only the ATS discusses the use of opioid therapy for refractory dyspnea. All three organizations recommend long-term oxygen therapy in COPD when associated with severe resting hypoxia, and the ATS alone suggests consideration of ambulatory oxygen with severe exertional hypoxia. All three organizations note that exacerbation risk is further reduced by adding an ICS at the cost of increased pneumonia risk. Based on cost, ease of use, and clinical equivalence, LAMA monotherapy recommended by the VA/DoD may be the best starting point. The GOLD does not recommend any treatment order. ![]() The ATS recommendation is based on a comparison of combination LABA/LAMA therapy with either monotherapy, which overstates the benefits because LABA monotherapy, but not LAMA monotherapy, is inferior to the combination. Although all three note that combination LABA/LAMA therapy is superior to monotherapy, the ATS recommends combination LABA/LAMA use by all symptomatic patients with COPD, whereas the VA/DoD recommend starting with LAMA monotherapy. Department of Defense (VA/DoD) recommendations and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations that were included in the most recent AFP COPD review ( ). Department of Veterans Affairs and the U.S. The recommendations by the ATS are similar to those of the U.S. ![]()
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