Stable Chronic Obstructive Pulmonary Disease
Summary
Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable chronic respiratory condition characterised by persistent airflow limitation. It is caused primarily by smoking and is associated with chronic inflammation. Diagnosis requires spirometry demonstrating post-bronchodilator FEV1/FVC less than 0.70. GOLD classification grades severity by FEV1. Management involves smoking cessation (most important intervention), bronchodilators (LAMA, LABA), inhaled corticosteroids in selected patients, pulmonary rehabilitation, and vaccination. Exacerbations accelerate decline and increase mortality.
Key Facts
- Definition: Persistent airflow limitation (FEV1/FVC less than 0.70 post-bronchodilator)
- Prevalence: 10% of adults over 40; third leading cause of death globally
- Demographics: Smoking is cause in 90%; alpha-1 antitrypsin deficiency in 1-2%
- Classification: GOLD 1-4 based on FEV1; ABCD based on symptoms and exacerbations
- Gold Standard Investigation: Spirometry (post-bronchodilator)
- First-line Treatment: Smoking cessation + inhaled bronchodilators
- Prognosis: Progressive; FEV1 decline 30-50mL/year (vs 20-30mL normal)
Clinical Pearls
Smoking Pearl: Smoking cessation is THE most important intervention. It's the only intervention proven to slow FEV1 decline.
Spirometry Pearl: Must be POST-BRONCHODILATOR. FEV1/FVC less than 0.70 defines obstruction. FEV1 alone determines severity.
ICS Pearl: ICS should NOT be used in all COPD. Reserve for patients with frequent exacerbations (2+/year) AND eosinophils 300+. Increases pneumonia risk.
Pulmonary Rehab Pearl: Pulmonary rehabilitation is one of the most effective interventions - improves exercise tolerance, breathlessness, and quality of life.
Oxygen Pearl: Long-term oxygen therapy improves survival in hypoxic COPD (PaO2 less than 7.3 kPa).
Prevalence
- 10% of adults over 40 in developed countries
- Third leading cause of death globally
- Underdiagnosed (30-50% undiagnosed)
Risk Factors
| Factor | Contribution |
|---|---|
| Tobacco smoking | 90% of cases |
| Occupational exposure | Coal, silica, grain |
| Indoor air pollution | Biomass fuel (developing countries) |
| Alpha-1 antitrypsin deficiency | 1-2% |
| Childhood respiratory infections | Increased risk |
Mechanism
- Chronic inflammation in response to noxious particles (tobacco smoke)
- Small airway disease (obstructive bronchiolitis)
- Parenchymal destruction (emphysema)
- Loss of elastic recoil → airflow limitation
- Mucus hypersecretion
Phenotypes
| Type | Features |
|---|---|
| Chronic bronchitis ("blue bloater") | Productive cough, hypoxia, oedema |
| Emphysema ("pink puffer") | Dyspnoea, hyperinflation, thin habitus |
Symptoms
Signs
Spirometry (Diagnostic)
| Parameter | Finding |
|---|---|
| FEV1/FVC | Less than 0.70 post-bronchodilator |
| FEV1 | Determines severity |
| Reversibility | Less than 400mL change (vs asthma) |
GOLD Spirometric Classification
| Grade | FEV1 (% predicted) |
|---|---|
| GOLD 1 (Mild) | 80% or higher |
| GOLD 2 (Moderate) | 50-79% |
| GOLD 3 (Severe) | 30-49% |
| GOLD 4 (Very severe) | Less than 30% |
Additional Investigations
| Test | Purpose |
|---|---|
| CXR | Exclude other pathology, hyperinflation |
| Alpha-1 antitrypsin | If young, non-smoker, or family history |
| FBC | Polycythaemia, anaemia |
| ABG | If severe (assess for hypoxia, hypercapnia) |
| CT chest | If uncertain diagnosis, bullae, suspected cancer |
Management Algorithm
CONFIRMED COPD (SPIROMETRY)
↓
┌──────────────────────────────────────────────────────────┐
│ ALL PATIENTS │
│ - Smoking cessation (ESSENTIAL) │
│ - Vaccinations (influenza, pneumococcal, COVID) │
│ - Pulmonary rehabilitation │
│ - Optimise nutrition, activity │
└──────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────┐
│ ASSESS SYMPTOMS + EXACERBATIONS │
│ mMRC dyspnoea score, CAT score │
│ Exacerbation history (0-1 vs 2+ per year) │
└──────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────┐
│ INITIAL PHARMACOTHERAPY │
│ LAMA (e.g., tiotropium) OR LABA (e.g., formoterol) │
│ LAMA preferred if exacerbation risk higher │
└──────────────────────────────────────────────────────────┘
↓
Still symptomatic/exacerbating?
↓
┌──────────────────────────────────────────────────────────┐
│ ESCALATE TO DUAL THERAPY │
│ LAMA + LABA │
└──────────────────────────────────────────────────────────┘
↓
Still exacerbating?
↓
┌──────────────────────────────────────────────────────────┐
│ CONSIDER ICS ADDITION (TRIPLE THERAPY) │
│ Only if: Eosinophils 300+ AND 2+ exacerbations/year │
│ LAMA + LABA + ICS │
└──────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────┐
│ REFRACTORY │
│ - Azithromycin prophylaxis │
│ - Roflumilast (if chronic bronchitis phenotype) │
│ - Lung volume reduction (selected emphysema) │
│ - Transplant assessment │
└──────────────────────────────────────────────────────────┘
Inhaler Therapy
| Class | Examples | Notes |
|---|---|---|
| SABA | Salbutamol | Rescue only |
| SAMA | Ipratropium | Rescue alternative |
| LABA | Formoterol, salmeterol | BD dosing |
| LAMA | Tiotropium, glycopyrronium | Once daily; first-line |
| ICS | Budesonide, fluticasone | Only with eosinophils and exacerbations |
Long-Term Oxygen Therapy (LTOT)
Criteria:
- PaO2 less than 7.3 kPa stable, OR
- PaO2 7.3-8.0 kPa with cor pulmonale/polycythaemia/pulmonary HTN
- Use 15+ hours/day
- Progressive disease
- FEV1 decline 30-50 mL/year (vs 20-30 mL normal)
- Exacerbations accelerate decline
- BODE index predicts mortality
-
GOLD 2023. Global Strategy for the Diagnosis, Management, and Prevention of COPD.
-
NICE Guideline NG115. COPD in over 16s: diagnosis and management. 2018.
-
Calverley PM et al. Salmeterol and fluticasone propionate and survival in COPD (TORCH). N Engl J Med. 2007;356(8):775-789. PMID: 17314337
-
Lipson DA et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in COPD (IMPACT). N Engl J Med. 2018;378(18):1671-1680. PMID: 29668352
Viva Points
"COPD is defined by post-bronchodilator FEV1/FVC less than 0.70. Smoking cessation is the most important intervention. GOLD grades severity by FEV1. Treatment is stepwise: LAMA → LAMA+LABA → triple (+ ICS if eosinophils high). ICS increases pneumonia risk. Pulmonary rehabilitation and LTOT improve outcomes in appropriate patients."
Last Reviewed: 2026-01-01 | MedVellum Editorial Team