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CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
[2nd Edition]
Classification by
symptoms and disability
Mild
Moderate
III
Severe
IV
Very
severe
Presence of chronic
respiratory failure or
clinical signs of
right heart failure
COPD
stage
II
COPD severity
Mild
Moderate
Severe
Very severe
Infrequent
symptoms
SABA as needed
Persistent
symptomsb
LAAC or LABA
Frequent
exacerbationsc
( 1 per yr)
Consider
alternative
caused
Respiratory
failure
LAAC
or ICS/LABA combination
or LAAC + ICS/LABA combination
theophylline
Consider alternative
caused
Notes for Figure 1 (Please refer to the bottom of the next page)
3
COPD severity
Mild
Moderate
Severe
Very severe
Infrequent
symptoms
SABA as needed
Persistent
symptomsb
SABA/SAAC
combination
regularly
Frequent
exacerbationsc
( 1 per yr)
Consider
alternative
caused
Respiratory failure
Consider alternative
caused
Notes:
1. SABA Short-acting 2 agonist; SAAC Short-acting anticholinergic; LAAC Long-acting anticholinergic;
LABA Long-acting 2 agonist; ICS Inhaled corticosteroid; LVRS lung volume reduction surgery
2. ICS dose per day should be at least 500 g of fluticasone or 800 g of budesonide
a. All COPD patients, irrespective of disease severity, should be prescribed SABA or SABA/SAAC combination
(Berodual/Combivent) as needed. SABA has a more rapid onset of bronchodilatation than SAAC.
b. Defined as need for rescue bronchodilators more than twice a week.
c. Frequent exacerbation is defined as one or more episodes of COPD exacerbation requiring systemic
corticosteroids antibiotics and/or hospitalisation over the past one year
d. Consider alternative causes - it is less common for patients with mild COPD to have frequent exacerbations;
similarly, respiratory failure is uncommon in patients with mild to moderate COPD severity. Hence, in such
patients, an alternative cause should be explored even if the COPD diagnosis is firmly established.
4
Outcome
FEV1 decline, mortality
Level of
evidence*
I
COPD exacerbations,
all-cause mortality (in patients aged
65 years during influenza season)
II-1
community-acquired pneumonia
II-2
post-bronchodilator FEV1,
dyspnoea
post-bronchodilator FEV1, symptoms,
QoL, COPD exacerbations
Inhaled short-acting
anticholinergic
Inhaled corticosteroids
Oral theophylline
mortality
(in patients with respiratory failure)
Pulmonary rehabilitation
* Refer to Table 4
: reduces, : increases or improves, QoL : quality of life
I
I
II-1
I
I
II-1
II-2
I
Outcome
FEV1, dyspnoea
FEV1, dyspnoea
FEV1, shorten recovery time,
hypoxaemia
short-term mortality, treatment
failure, sputum purulence
(in patients with purulent sputum and
increased dyspnoea or increased
sputum volume, and in patients
requiring ventilatory support)
Antibiotics
Supplemental oxygen
Non-invasive ventilation
hypoxaemia
intubation, mortality, length of
hospital stay (in acute respiratory failure)
Level of
evidence*
I
I
II-1
I
II-1
III
I
* Refer to Table 4
: reduces, : increases or improves
II - 1
II - 2
II - 3
III
Good response to
initial treatment
Failure to improve
Home Management
Increase dose and frequency of inhaled short-acting bronchodilator (SABA + SAAC) from pMDI
Oral prednisolone 30-40 mg daily for 7-14 days (if there is significant dyspnoea or baseline FEV1 < 50% predicted)
Oral antibiotics if patient has 2 out of 3 cardinal symptoms (ie, purulent sputum, increased sputum volume, increased dyspnoea)
None
Obtain relevant history: Underlying COPD severity (if known), co-morbidities, present treatment regimen
Obtain relevant history: Current symptoms, recent treatment from other doctors, COPD severity, previous episodes
(AECOPD/hospital admission/ICU admission/invasive or non-invasive ventilation)
Examine for danger signs: Respiratory distress, tachyarrhythmia, cyanosis, heart failure, exhaustion.
Arrange appropriate investigations: ABG (note the FiO2), FBC, BUSECr, LFT, blood glucose, CXR, ECG, sputum C&S
Home Management
Increase dose and frequency of inhaled
short-acting bronchodilator (SABA + SAAC) from
pMDI
Oral prednisolone 30-40 mg daily for 7-14 days
Ensure adequate supply of oral antibiotics if started
Good response
Hospital Management
Controlled supplemental oxygen therapy to maintain PaO2 > 8 kPa or
SpO2 > 90% without worsening hypercapnia or precipitating acidosis
Inhaled short-acting bronchodilators from pMDI via a spacer device or
nebuliser
Consider intravenous aminophylline if inadequate response to inhaled
short-acting bronchodilators
Systemic corticosteroids for 7-14 days
Antibiotics (if appropriate)
Monitor fluid balance and nutrition
Consider subcutaneous heparin
Closely monitor condition of the patient
Consider invasive or non-invasive ventilation
Admit to hospital
Failure to improve