COPD

Definition

• Chronic obstructive pulmonary disease = chronic obstructive airway disease where the obstruction if not fully reversible.
• Includes chronic bronchitis, emphysema, and asthma with incomplete reversibility of airway obstruction.

Risk factors

• Current or past tobacco smoking smoking by far the biggest risk factor followed by passive smoking
• Environmental exposures (e.g., tobacco smoke, occupational dust, air pollution)
• Childhood respiratory history (e.g., premature birth, asthma)
• Genetic predispositions (e.g., alpha-1 antitrypsin deficiency)

Symptoms and Signs

• Symptoms: dyspnoea on exertion; chronic cough (esp productive); decreased exercise tolerance. Always consider other comorbidities (eg coronary).
• Signs: chest hyperinflation; wheeze; prolonged expiratory phase; Barrel shaped chest; Hoover’s sign; features of right HF / pulm HTN
• 

Investigations

(https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians)

• A diagnosis of COPD must rely on spirometry, as clinical features and imaging alone are insufficient.
• Spirometry Indications:
  • For individuals over 35 with recurrent respiratory symptoms and at least one risk factor.
  • For patients with suspected COPD exacerbations where spirometry confirmation is lacking.
  • Spirometry should be delayed in those with an active respiratory infection.
• High-Quality Spirometry:
  • Performed before and after administering a bronchodilator.
  • Executed by trained and competent clinicians.
  • Requires regular calibration and quality control of spirometers following ATS and ERS standards.
  • If unavailable, referral to specialized centers is recommended.
• Spirometry Results:
  • A post-bronchodilator FEV1/FVC ratio of less than 0.7 is diagnostic of COPD, with insignificant improvement post bronchodilator = COPD
  • FEV1 (% predicted) can be used to gauge disease severity.
  • Trap:
    • significant air trapping can cause reduction in FVC.
    • Plethysmographic studies useful to differentiate between gas trapping and mixed obstructive-restrictive lung diseases.
  • Near-threshold results warrant a repeat test for confirmation.
• CXR:
  • may show hyperinflation, flattened diaphragm, bullae.
  • ABG: useful during acute exacerbations if concerned about respiratory acidosis; also require for home O2 therapy (if <55mmHg, or <60mmHg with RVF).
• 6 min walk test:
  • functional capacity
  • Can be used to monitor treatment.
• If concerns about cor pulmonale, TTE and DLCO useful. 
• Investigations for comorbidities:
  • eg ischaemic heart disease (cigarette common risk factor for both conditions).

Pharmacological Management

Step 1: Initial Management with Short-Acting Bronchodilators

• Purpose: Relief of acute breathlessness and occasional symptoms.
• Medications:
  • Short-Acting Beta2-Agonists (SABA): Examples include salbutamol or terbutaline.
  • Short-Acting Muscarinic Antagonists (SAMA): Example includes ipratropium bromide.
• Usage: As-needed basis for short-term symptom control.

Step 2: Persistent Symptoms – Long-Acting Bronchodilator

• Indication: For patients experiencing persistent troublesome dyspnea despite using SABA/SAMA.
• Medications:
  • Long-Acting Beta2-Agonists (LABA): Examples include formoterol, salmeterol, or indacaterol.
  • Long-Acting Muscarinic Antagonists (LAMA): Examples include tiotropium, glycopyrronium, or umeclidinium.
  • Note: Do not combine a LAMA with a SAMA. Combining a LAMA with a SABA is permissible.
• Usage: Regular daily administration for maintenance therapy.

Step 3: Dual Long-Acting Bronchodilator Therapy

• Indication: Patients who continue to experience symptoms after using either a LABA or LAMA alone.
• Medications: Combination of LABA + LAMA.
  • Examples include indacaterol/glycopyrronium, vilanterol/umeclidinium, or formoterol/aclidinium.
• Action: Assess adherence and correct inhaler technique before advancing therapy.

Step 4: Addition of Inhaled Corticosteroids (ICS)

• Indication: For patients who have:
  1. A history of severe exacerbations (requiring hospitalization) or at least two moderate exacerbations in the past year.
  2. Severe symptoms persisting despite optimal LABA + LAMA therapy.
• Medications:
  • Examples include budesonide/formoterol, fluticasone/salmeterol, or fluticasone/vilanterol.
  • Note: Use with caution due to the risk of pneumonia, particularly in older adults. Should be reserved for patients with frequent exacerbations.
• Action: Regularly review the necessity of ICS to minimize long-term side effects.

Step 5: Macrolide Antibiotics (for Selected Patients)

• Indication: For severe COPD with frequent exacerbations despite maximal therapy.
• Medications:
  • Low-dose macrolides (e.g., azithromycin 250 mg 3 times per week).
  • Consider only after evaluation by a respiratory specialist.
• Risks: Cardiac toxicity, ototoxicity, and antibiotic resistance.
• Monitoring: Review after 6 months and post-exacerbation. Regular ECGs may be needed to monitor for QT prolongation.

Inhaler and Spacer Technique

1. Clinician Preparation:
   • Ensure all healthcare providers have a solid understanding of the correct inhaler techniques.
   • Misuse is common; up to 90% of patients may not use inhalers correctly, leading to suboptimal drug delivery.
2. Education and Demonstration:
   • Demonstrate proper inhaler use, including:
     • Breath-Actuated Inhalers: Ensure slow, steady inhalation.
     • Pressurized Metered-Dose Inhalers (pMDIs): Use a spacer device for optimal drug delivery.
     • Dry Powder Inhalers (DPIs): Ensure fast and deep inhalation.
   • Educate on cleaning, maintenance, and storage.
3. Regular Technique Checks:
   • Evaluate technique:
     • Before escalating treatment.
     • After any change in therapy.
     • Following an exacerbation.
   • Consider a
     • Home Medicines Review (HMR) or
     • Residential Medication Management Review (RMMR) to assess adherence and technique.
4. Simplification Strategies:
   • Use familiar devices or combination inhalers when possible.
   • Educate on the environmental impact of inhalers and recommend greener alternatives if suitable.

Acute Exacerbations

Recognizing Exacerbations:

• Key Symptoms:
  • Increased breathlessness beyond normal day-to-day variation.
  • Reduced exercise tolerance and increased fatigue.
  • Tachypnea, increased cough, and sputum production (especially if purulent).
  • Fever may indicate an infectious trigger.
• Differential Diagnoses: Consider heart failure, pulmonary embolism, pneumonia, and sepsis.

General Treatment Approach:

• An exacerbation of COPD can involve increased airflow limitation, excess sputum production, airway inflammation, infection, hypoxia, hypercarbia, and acidosis.
• Treatment is directed at addressing each of these problems.

Confirm Exacerbation and Categorize Severity:

• Medical History & Examination: Essential to gather a detailed history and conduct a thorough physical examination.
• Spirometry: Used to confirm COPD diagnosis, especially useful prior to discharge.
• Oxygenation Assessment:
  • Pulse Oximetry: Routine measurement alongside other vital signs.
  • Arterial Blood Gases (ABGs): Indicated if:
    • FEV1 < 1.0 L or < 40% predicted.
    • SpO2 < 92% with adequate perfusion.
    • Falling SpO2 and increased FiO2 needed.
    • Risk of hypercapnia.

Spirometry:

• Purpose: Confirms diagnosis of COPD by demonstrating airflow limitation.
• Timing: Can be performed prior to discharge to verify diagnosis.

Assess Oxygenation:

• Pulse Oximetry: Should be recorded routinely.
• Arterial Blood Gases: Crucial for:
  • FEV1 < 1.0 L or < 40% predicted.
  • SpO2 < 92%.
  • Declining SpO2 with increased FiO2.
  • Risk of hypercapnia.
  • Hypoxaemic respiratory failure: PaO2 < 60 mmHg.
  • Ventilatory failure: PaCO2 > 45 mmHg.
  • Respiratory acidosis: Indicates need for assisted ventilation.

Venous Blood Gases (VBG):

• Study by McKeever et al (2016):
  • VBG pH ≤7.34 had high sensitivity (88.9%) and specificity (95.6%) for ABG pH ≤7.35.
  • VBGs suggested for initial assessment, ABGs for further assessment if VBG pH ≤7.34.
  • Caution due to lesser precision with VBGs.

Chest X-ray and ECG:

• Purpose: Identify alternative diagnoses and complications (e.g., pulmonary oedema, pneumothorax, pneumonia, empyema, arrhythmias, myocardial ischaemia).

Clinical Prediction Score – BAP-65:

• Parameters: Age, basal urea nitrogen, acute mental status change, pulse.
• Utility: Predicts in-hospital mortality.
  • Mortality increases with higher score classification (from 1 to 5).
  • Highest class mortality: 14.1% to >25%.

CXR and Pneumonia:

• Study (2012): 920 patients with COPD exacerbation.
  • Higher mortality with CXR-confirmed pneumonia (20.1% vs. 5.8%, p<0.001).
• Dyspnoea Severity: Associated with in-hospital mortality and early readmission.

Medications

1. Bronchodilators:

• Inhaled Beta-Agonists:
  • Salbutamol: 400–800 mcg
  • Terbutaline: 500–1000 mcg
• Antimuscarinic Agents:
  • Ipratropium: 80 mcg
• Administration Methods:
  • Pressurised metered dose inhaler (pMDI) with spacer
  • Jet nebulisation:
    • Salbutamol: 2.5–5 mg
    • Terbutaline: 5 mg
    • Ipratropium: 500 mcg
• Dosing Interval: Titrate based on response, ranging from hourly to six-hourly.
• Delivery Method Efficacy: No significant difference between nebulisers and pMDI with spacer regarding FEV1 at one hour and serious adverse events (van Geffen 2016) [evidence level I].

3. Corticosteroids:

• Oral Corticosteroids: Hastens resolution and reduces relapse likelihood.
• Typical Regimen: Prednisolone 40–50 mg daily for up to two weeks.
• Longer Courses: Do not add benefit and increase risk of side effects.
• Recommended Regimen as per COPDx:
  • 5-day course of oral prednisolone at 30mg to 50mg.
  • Tapering may be necessary for patients on corticosteroids for longer than 14 days.
  • Long-term corticosteroid therapy (>7.5 mg prednisolone daily for more than 6 months) increases the risk of osteoporosis.
  • Prevention and treatment of corticosteroid-induced osteoporosis should be considered.
  • Longer courses of prednisolone may increase mortality and pneumonia risk (Sivapalan 2019).

4. Antibiotics:

• Indication: Clinical Features of Infection: Increased sputum volume, change in sputum color, and/or fever warrant antibiotic therapy (evidence level II, strong recommendation).
• Common Pathogens:
  • Haemophilus influenzae
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
• First-Line Antibiotics:
  • Amoxicillin 500 mg three times daily.
  • Doxycycline 100 mg daily.
  • Avoid Broad-Spectrum Antibiotics unless specific indications exist; they do not offer superior outcomes and may increase harm.
  • Intravenous Antibiotics: Reserved for patients unable to take oral medications.

5. Controlled Oxygen Therapy:

• Indication: For patients with hypoxia, aiming to improve oxygen saturation to 88-92%.
• Delivery Methods:
  • Nasal prongs: 0.5–2.0 L/min
  • Venturi mask: 24% or 28%
• Caution: Minimize excessive oxygen to avoid worsening hypercapnia.

6. Ventilatory Assistance:

• Indication: For increasing hypercapnia and acidosis.
• Preferred Method: Non-invasive ventilation (NIV) via mask.

Summary

• Antibiotics are beneficial in COPD exacerbations with signs of bacterial infection.
• Diagnostic indicators like sputum purulence, CRP, and procalcitonin levels can guide antibiotic use.
• Short courses of antibiotics are generally as effective as longer courses and have fewer adverse effects.
• Combination therapy with corticosteroids and antibiotics is effective, particularly in the early stages of treatment.

Chronic Management

1. Smoking Cessation

• Cease Smoking:
  • Smoking cessation is the most critical intervention for all COPD patients.
  • Use a combination of behavioral support and pharmacotherapy as recommended by Australian guidelines:
    • Nicotine Replacement Therapy (NRT): patches, gum, lozenges, sprays.
    • Prescription Medications: Varenicline (Champix) or bupropion (Zyban).
  • Access local Quitline services and utilize the ‘Ask, Advise, Help’ approach for smoking cessation.

2. Inhaler Therapy – Regularly assess and educate on correct inhaler technique and spacer use.

3. Vaccination Recommendations

• Annual Influenza Vaccine: Recommended for all COPD patients to prevent flu-related complications.
• Pneumococcal Vaccine:
  • 13-valent Pneumococcal Conjugate Vaccine (Prevenar 13) and 23-valent Pneumococcal Polysaccharide Vaccine (Pneumovax 23) based on age and risk factors.
• COVID-19 Vaccine: Ensure COPD patients are up to date with COVID-19 vaccinations.

4. Pulmonary Rehabilitation

• Multidisciplinary Pulmonary Rehabilitation Programs:
  • Strongly recommended for all symptomatic COPD patients.
  • Includes exercise training, education, and behavior change support.
  • Refer to local programs using resources like the Lung Foundation Australia’s Pulmonary Rehabilitation Finder.
  • Benefits include reduced breathlessness, improved quality of life, and fewer hospitalizations.

5. Long-Term Oxygen Therapy (LTOT)

• Indications for LTOT:
  • Resting PaO₂ < 55 mmHg, or 55–60 mmHg with evidence of right heart failure or polycythemia.
  • Must be non-smoker due to fire hazard.
  • Requires specialist referral for assessment and initiation.
• Duration: Minimum of 15 hours/day to improve survival in hypoxaemic patients.
• Intermittent Oxygen:
  • Consider for use during exertion if oxygen saturation falls below 88%.

6. Fitness to Fly

• Pre-Flight Assessment:
  • Assess the need for supplemental oxygen during air travel if SpO₂ < 92% at rest or during exertion.
  • Refer to the Lung Foundation Australia’s resources on fitness to fly for further guidelines.

7. Management of Comorbidities

• Cardiovascular Disease: Screen for and manage comorbidities like hypertension, ischemic heart disease, and heart failure.
• Diabetes: Monitor blood glucose regularly in COPD patients with comorbid diabetes.
• Osteoporosis: Consider bone density testing for patients on long-term corticosteroids.
• Mental Health:
  • Regularly assess for anxiety and depression. Refer to mental health professionals if needed.
  • Address social isolation with referrals to community programs or support groups.

8. Surgical and Advanced Interventions

• Lung Volume Reduction Surgery (LVRS):
  • Consider for select patients with upper-lobe predominant emphysema and low exercise capacity after rehabilitation.
• Bronchoscopic Interventions:
  • Endobronchial Valves for lung volume reduction in emphysema patients not suitable for surgery.
  • Requires specialist evaluation in tertiary centers.
• Lung Transplant:
  • Consider for end-stage COPD patients under 65 with severe disease not responsive to maximal medical therapy.

9. Multidisciplinary Team (MDT) Involvement

• (multidisciplinary team approach; see http://lungfoundation.com.au/wp-content/uploads/2014/02/Pulmonary-Rehab-Fact-Sheet-Feb-2015.pdf)
• Collaborate with a multidisciplinary team including:
  • Respiratory specialists
  • general practitioners
  • pharmacists
  • physiotherapists
  • dietitians
  • social workers
  • mental health professionals.
  • Ensure coordination between hospital and primary care for seamless follow-up post-hospitalization.

10. Regular Monitoring and Self-Management Education

• Patient Education:
  • Educate on COPD self-management, including recognizing symptoms of exacerbation and proper use of inhalers.
  • Encourage adherence to medications and inhaler technique.
  • Utilize tools like the COPD Action Plan to guide early management of exacerbations.
• Exacerbation Management:
  • Create a personalized action plan, including when to seek medical help.
  • Teach patients breathing techniques, energy conservation methods, and airway clearance techniques.

11. Telehealth and Remote Support

• Telehealth:
  • Utilize telehealth for regular follow-up, particularly for patients in rural and remote areas.
  • Leverage online education tools and apps endorsed by Lung Foundation Australia for self-management support.

(Controversial)

• Long term prophylactic antibiotics (usually macrolide): shown to decrease exacerbations, but promotes resistance. Specialist initiated only.
• Theophylline: reduced exacerbations, but multiple side effects.

Symptom Support and Palliative Care for COPD

Early Palliative Care Consideration:

• Start a palliative approach from diagnosis, especially for those with significant comorbidities.
• Address the misconception that palliative care is only for end-of-life patients

Factors Indicating Palliative Care Need:

• Poor respiratory function (e.g., FEV1 < 25% predicted, hypoxaemia).
• Need for advanced respiratory therapy (e.g., home oxygen).
• Severe comorbidities (e.g., heart failure).
• Unintended weight loss or cachexia.
• Functional decline or increasing dependence.
• Difficult physical or emotional symptoms.
• Disease progression or frequent hospitalisations.

Holistic Approach:

• Address all aspects of patient well-being.
• Offer referrals to specialists (e.g., physiotherapists, psychologists) based on patient needs.

Advance Care Planning:

• Discuss and establish an advance care plan if not already done.
• Document and upload to the patient’s My Health Record if applicable.

Cultural Safety and Equity for Aboriginal and Torres Strait Islander People in COPD Care

from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians

1. Culturally Safe Communication and Care

• Establish Trust: Building a trusting relationship is crucial. Take the time to engage with the patient, their family, and community to understand their perspective and healthcare goals.
• Self-Identification: Encourage patients to self-identify as Aboriginal or Torres Strait Islander, ensuring that systems are in place to facilitate this in a respectful manner.
• Language and Communication:
  • Use simple, clear language and avoid medical jargon.
  • Engage interpreter services or cultural translators when language barriers exist, especially if English is not the patient’s first language.
  • Be mindful of body language and non-verbal cues, which can differ between cultures.

2. Collaborative Approach to Treatment and Management

• Shared Decision-Making: Involve the patient in the decision-making process, respecting their autonomy and cultural values.
  • Use culturally appropriate resources and visual aids to explain conditions and treatment plans.
• Family and Community Involvement: Encourage the involvement of family, carers, or community members in care discussions and decisions.
  • Recognize the extended family structure in ATSI communities and accommodate family members in consultations.
  • Incorporate community or Elder input if requested by the patient.

3. Engagement with Aboriginal and Torres Strait Islander Health Professionals

• Multidisciplinary Care Team:
  • Integrate Aboriginal and Torres Strait Islander Health Workers or Health Practitioners into the care team. They provide culturally informed insights, act as liaisons, and improve communication between healthcare providers and the patient.
  • Consider including Aboriginal and Torres Strait Islander Health Workers in patient education, discharge planning, and follow-up care.
• Training for Clinicians: Ensure that healthcare providers undergo cultural safety training to recognize and address their own biases, understand cultural norms, and create a welcoming environment for ATSI patients.

4. Flexibility in Service Delivery

• Flexible Appointment Times: Offer flexible scheduling to accommodate patient needs, particularly those traveling from remote or rural areas.
• Outreach Services:
  • Consider home visits or community-based care options to support patients who may have difficulty accessing traditional healthcare settings.
  • Collaborate with Aboriginal Medical Services (AMS) or community-controlled health services when possible.

5. Tailoring COPD Management to Cultural Context

• Address Cultural Barriers: Acknowledge and respect traditional beliefs about health and illness that may impact COPD management.
  • Integrate traditional healing practices when appropriate and accepted by the patient.
  • Discuss treatment in a way that aligns with the patient’s worldview, emphasizing concepts of holistic health that include physical, emotional, and spiritual well-being.
• Diet and Lifestyle:
  • Provide dietary advice that is culturally appropriate and aligns with traditional food preferences where possible.
  • Encourage physical activity using culturally relevant examples (e.g., community-based activities or traditional sports).

6. Social and Environmental Considerations

• Home and Living Conditions:
  • Consider the impact of environmental factors such as housing conditions, overcrowding, exposure to dust, smoke, or mould—which are prevalent in some ATSI communities—and their role in COPD management.
  • Address barriers to adherence, such as difficulty in accessing medication or equipment due to remote living conditions.
  • Provide education on smoke exposure reduction, including traditional smoking practices and second-hand tobacco smoke.
• Social Determinants of Health:
  • Acknowledge and address broader social determinants like education, employment, and economic stability, which can significantly affect health outcomes.
  • Refer patients to social support services to assist with these factors if they impact health management.

7. Support for Preventative Measures and Early Diagnosis

• Screening and Prevention:
  • Implement early screening programs for COPD in ATSI communities, especially in those with a high prevalence of risk factors like smoking or exposure to environmental pollutants.
  • Offer culturally sensitive education on the importance of preventative health measures, such as vaccinations for influenza and pneumococcal disease, and emphasize their role in preventing exacerbations.
• Smoking Cessation:
  • Discuss smoking in a non-judgmental and sensitive manner, considering the cultural significance of smoking in some ATSI communities.
  • Utilize Aboriginal and Torres Strait Islander-specific smoking cessation resources, including culturally adapted Quitline services and community programs.
  • Consider pharmacological options while respecting the patient’s cultural preferences and willingness to engage.

8. Respect for Cultural Practices in End-of-Life Care

• Palliative and End-of-Life Care:
  • Engage in early discussions about palliative care and advance care planning in a culturally respectful manner.
  • Understand that discussions around death can be sensitive and may be approached differently within ATSI cultures.
  • Involve family and community members in palliative care planning and respect traditional rituals or practices that are important to the patient.
• Holistic Support:
  • Address spiritual needs and offer support for traditional practices in end-of-life care, including the involvement of community Elders or cultural leaders if desired.
  • Provide access to mental health support, recognizing the potential impact of grief, loss, and trauma on health outcomes.

9. Continuous Monitoring and Quality Improvement

• Data Collection:
  • Encourage the recording of ATSI status in patient records to ensure that cultural needs are consistently acknowledged.
• Audit and Feedback:
  • Regularly audit healthcare services to assess the effectiveness of cultural safety measures and adapt strategies based on feedback from ATSI patients and their families.
  • Involve ATSI communities in the development and review of health policies and guidelines to ensure they are culturally appropriate and effective.

10. Empowering Aboriginal and Torres Strait Islander Communities

• Education and Capacity Building:
  • Provide community-based education programs about COPD, including risk factors, symptoms, and management.
  • Empower ATSI communities to lead health initiatives, with the support of healthcare providers, to foster a sense of ownership and engagement in health outcomes.
• Promotion of Self-Management:
  • Encourage self-management strategies that align with traditional ways of life, ensuring they are practical and feasible within the patient’s cultural context.

COPDX approach

• C – confirm diagnosis and grade severity
  • Suspect the diagnosis with a suggestive history of chronic cough, sputum production, exertional dyspnoea, wheeze and frequent exacerbations
  • Confirm with Spirometry demonstrating FEV1/FVC<70% obstructive pattern.
  • Classify the severity into mild, moderate and severe by symptom severity, functional impairment, frequency of exacerbation and spirometry values.
• O – optimise function
  • Education
    • Involves information on
      • disease management
      • its progression
      • treatment options
      • self-management strategies
      • proper inhaler technique
      • recognition of exacerbations
  • Lifestyle measures
    • Exercise Training: Improves exercise tolerance, reduces dyspnea, and enhances quality of life. Recommended activities include aerobic exercises (walking, cycling) and resistance training.
  • Nutritional Support
    • Malnutrition: High-calorie, high-protein diets to prevent muscle wasting.
    • Obesity: Weight management programs to reduce the work of breathing
  • Medication measures
    • Step-wise management as per guidelines with SABA, SAMA, LABA, LAMA and ICS
    • Long-term oxygen therapy for patients with chronic respiratory failure (PaO₂ ≤ 55 mmHg or SaO₂ ≤ 88%).
    • Ambulatory oxygen therapy for those with significant desaturation during exercis
    • Chest Physiotherapy
      • Includes postural drainage, chest percussion, and vibration.
• P – prevent deterioration
  • Pulmonary rehabilitation
    • Refer all COPD patients, including those hospitalized for exacerbations, to pulmonary rehabilitation.
    • Ensure rehabilitation starts within four weeks after hospital discharge to prevent readmission and improve outcomes.
    • If hospital-based rehab is unavailable, consider telerehabilitation, local exercise programs, or specialists in pulmonary care.
      • Exercise
      • education
      • breathlessness management
      • medication guidance
      • nutrition
      • psychological support
  • Immunisation (influenza, pneumococcal)
    • Influenza Vaccine: Annually to reduce the risk of respiratory infections.
    • Pneumococcal Vaccine: Both PPSV23 and PCV13 are recommended to prevent pneumococcal disease.
  • Smoking cessation
    • Behavioural counselling.
    • Pharmacotherapy (e.g., nicotine replacement therapy, varenicline, bupropion).
    • Support groups and smoking cessation programs.
  • Avoidance of Environmental Pollutants
    • Minimizing exposure to indoor and outdoor air pollutants, dust, and occupational irritants.
    • Use of air purifiers and proper ventilation at home.
  • Psychosocial Support
    • Counseling or therapy for patients experiencing anxiety, depression, or social isolation.
    • Support groups for patients and caregivers.
• D – develop a management plan
  • GP management plan
  • COPD action plan
  • Advanced care directive
• X – manage acute exacerbations
  • Oxygen, NIV 
  • Bronchodilator
  • Steroids
  • Antibiotics