COPD management. Part I. Strategies for managing the burden of established COPD [State of the Art Series. Chronic obstructive pulmonary disease in high- and low-income countries. Edited by G. Marks and M. Chan-Yeung. Number 5 in the series]

Effective management of chronic obstructive pulmonary disease (COPD) is dependent on an accurate diagnosis and assessment of severity. COPD is a clinical diagnosis, based on a history of exposure to known risk factors and the presence of airway obstruction that is not fully reversible. Maximal therapy and support for smoking cessation should be offered to all patients. Symptoms may only develop when a significant loss of lung function has occurred, and the diagnosis is frequently made late in the course of the disease. Earlier diagnosis is dependent on a high index of suspicion, particularly in current and ex-smokers or those exposed to occupational dusts and indoor pollution, and accurate performance and interpretation of spirometry. Established COPD associated with symptoms should initially be treated with bronchodilators as needed, but long-acting bronchodilators should be used when symptoms persist and inhaled corticosteroids added for moderate to severe airflow limitation, particularly when associated with exacerbations. Combination long-acting bronchodilators and inhaled corticosteroids reduce the exacerbation rate and improve the quality of life and symptoms, but they have not been shown to improve survival. Exacerbations are associated with worsening health status and can be managed effectively at home. When symptoms worsen despite optimal treatment for exacerbations, hospital admission is necessary. Non-invasive ventilation has reduced the need for mechanical ventilation, but hospital admission and respiratory failure are associated with a significantly worse prognosis. Pulmonary rehabilitation plays an important role in improving exercise capacity at all severities of COPD, and should be widely available.