The important components of managing patients with stable COPD include (a) minimization of risk factors, (b) pharmacotherapy appropriate to the disease severity and (c) supportive nonpharmacological measures (such as patient education and rehabilitation).

Assess the risk factors and other complications and manage accordingly. Advise and help to quit smoking.⁴¹ Similar attempts should be made to minimize other risk factors (Table 4). Assess the disease severity on an individual basis by taking into account the patient’s symptoms, airflow limitations, frequency and severity of exacerbations, complications, respiratory failure, co-morbidities, and general health status. Start treatment depending upon the severity of the disease. None of the existing medication for COPD has been shown to modify the long-term decline in lung function.⁴² Therefore, pharmacotherapy for COPD is used only to decrease symptoms and complications. Patient education is necessary to improve skills, ability to cope with illness and the health status. Health education is particularly effective for sustained smoking cessation. In addition, appropriate information about the nature of the disease, instructions on how to use different medications and inhalers, and clues to recognize symptoms of exacerbation are mandatory.

Smoking cessation

Smoking cessation is the most important and effective step.^43,44 Follow the standard guidelines for helping patients with COPD to quit smoking (Tables 5,6).

Reduction in other risk factors

General measures aimed at reducing risk of COPD include the following: (1) avoiding open burning of crop residue, (2) use of water to suppress dust and (3) wearing masks at work place in areas of dust generation.

Specific measures such as the use of smokeless ‘chullahs’ should be aimed at reducing risk associated with solid fuel combustion and ETS exposure.

Substitution of solid fuels with LPG or electricity is the best approach. The “kitchen” at home should at least be located outside the living and sleeping areas. Kitchens should be adequately ventilated by providing ‘chimneys’, exhaust pipes and/or fans.

Exposure to products of solid fuel combustion can be minimized by the use of smokeless ‘chullahs’, reducing the duration of stay in the kitchen or place of fuel use, and by covering nose and mouth with a thin cloth near the source of combustion.

Exposure to ETS can be reduced by stopping/minimizing indoor smoking, especially in front of children, and by adequate ventilation in the living rooms.

Drug treatment

1. Bronchodilators

   Bronchodilator medication is central to the symptomatic management of COPD.⁴⁵ Inhaled drugs are preferred to oral preparations.⁴⁶ However, the choice of drugs depends on the availability of medications and patient’s affordability (Table 7). Short acting bronchodilators can be used ‘as-needed’ to relieve intermittent or worsening symptoms, and on regular basis to prevent or reduce persistent symptoms.⁴⁷ Stepwise treatment should be recommended. In general, nebulized therapy for stable patients is not appropriate unless it has been shown to be better than conventional dose therapy.^48-50

   Regular treatment with short-acting bronchodilators is cheaper but less convenient than treatment with long-acting bronchodilators^51,52. The long acting inhaled beta agonist salmeterol has been shown to improve health status significantly in doses of 50µg twice daily. Similar data for short acting beta agonists are not available. Use of inhaled tiotropium (an anticholinergic) once daily also improves symptoms and health status.⁵³

   Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilatation for equivalent or lesser side effects. A combination of a short-acting beta agonist and the anticholinergic drug ipratropium in stable COPD produces greater and more sustained improvements in FEV₁ than either alone and does not produce evidence of tachyphylaxis.⁵⁴

   The addition of oral theophylline should normally be considered only if inhaled treatments have failed to provide adequate relief. Sustained release preparations are better.⁵⁵ All studies that have shown efficacy of theophylline in COPD were done with slow-release preparations.

   Addition of theophylline to ß2-agonists or anticholinergics may produce additional improvements in lung function and health status^56,57. However, combination of salbutamol with theophylline in a single tablet is not recommended.

2. Corticosteroids

   Inhaled corticosteroids do not change the rate of decline in lung function, but can increase postbronchodilator FEV₁, reduce the number of exacerbations, and slow the rate of decline in health status.^58-61

   Regular treatment with inhaled glucocorticosteroids should be prescribed for symptomatic patients with COPD with a documented spirometric response to glucocorticosteroids or for those with FEV₁<50% predicted and repeated exacerbations requiring treatment with antibiotics or oral glucocorticoids.^62-65 Long-term treatment is required in such patients; in fact, withdrawal of inhaled corticosteroids can lead to increase in symptoms and exacerbation rate.

   Chronic treatment with systemic glucocorticosteroids should be avoided because of unfavorable benefit-to-risk ratio.

3. Role of other drugs

   The use of antibiotics other than treating infectious exacerbations of COPD and other bacterial infections is not recommended.⁶⁶ Although a few patients with viscous sputum may benefit from mucolytic agents (such as ambroxol, carbocysteine, iodinated glycerol, etc.) the overall benefit seems to be very small.⁶⁷

   Cough, although sometimes a troublesome symptom in COPD, has a significant protective role. Hence, the regular use of antitussives should be discouraged in stable COPD.

   The use of respiratory stimulants like doxapram, almitrine bismesylate are not recommended for regular use in stable patients. Sedatives and narcotics should be avoided in patients with COPD because of their respiratory depressant effects and potential to worsen hypercapnia.

   Malnutrition (both under nutrition and over nutrition) should be managed appropriately.^68,69 Nutritional supplements can increase fat free mass and muscle strength. A diet rich in proteins and fats, but low in carbohydrates, is preferred.

   Currently available prophylactic vaccines for influenza are not recommended for routine use, as insufficient information is available on serotypes prevalent in India. They may, however, be administered to the selected patients (especially the elderly). Similarly, routine administration of pneumococcal vaccine is not recommended.⁷⁰ Immuno-modulatory drugs may also have a moderate protective role in reducing infective exacerbations.⁷¹

   Pulmonary rehabilitation

   Pulmonary rehabilitation is a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community.

   Goals of pulmonary rehabilitation are (a) to reduce symptoms, disability and handicap, and (b) to improve functional independence. It should comprise of physical training programme, disease education, and nutritional, psychological, social and behavioural intervention (including smoking cessation).⁷² The programme should be tailored to individual functional needs and capacity, and should be targeted especially to patients with coexisting locomotor or cognitive impairment, and to those with associated cardiac disease. Clinicians, physiotherapists, dieticians, occupation therapists, social workers, nurses and pulmonary function technicians should be involved in rehabilitation programmes. Optimum medical management should continue along with the rehabilitation process.