MANAGEMENT OF

CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
[2nd Edition]

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HEALTHCARE PROVIDERS

Ministry of Health Malaysia

Academy of Medicine Malaysia

Malaysian Thoracic Society

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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Diagnosis and Assessment of COPD

A diagnosis of COPD should be considered in any individual with symptoms of chronic
cough, sputum production or dyspnoea and a history of exposure to risk factors for the
disease, especially cigarette smoking.
The diagnosis should be confirmed by spirometry showing a post-bronchodilator FEV1/
FVC ratio of less than 70%.
COPD severity should be assessed based on the severity of spirometric abnormality,
symptoms, exercise capacity, complications and the presence of co-morbidities.
Table 1: Classification of COPD Severity Based on Spirometric Impairment and
Symptoms
Severity

Classification by postbronchodilator spirometric

values

Classification by
symptoms and disability

Mild

FEV1/FVC < 0.70

FEV1 > 80% predicted

Shortness of breath when

hurrying on the level or
walking up a slight hill
(MMRC 1)

Moderate

FEV1/FVC < 0.70

50% < FEV1 < 80% predicted

Walks slower than

people of the same age
on the level because of
breathlessness; or stops
for breath after walking
about 100 m or after a
few minutes at own pace
on the level (MMRC 2 to 3)

III

Severe

FEV1/FVC < 0.70

30% < FEV1 < 50% predicted

Too breathless to leave the

house or breathless when
dressing or undressing
(MMRC 4)

IV

Very
severe

FEV1/FVC < 0.70

FEV1 < 30% predicted or
FEV1 < 50% predicted plus
chronic respiratory failure

Presence of chronic
respiratory failure or
clinical signs of
right heart failure

COPD
stage

II

*Should there be disagreement between FEV1 and symptoms, follow symptoms

2

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Managing Stable COPD

Objectives of managing stable COPD:
1. Prevent disease progression
2. Relieve symptoms
3. Improve exercise tolerance
4. Improve lung function and general health
5. Improve quality of life
7. Prevent exacerbations
8. Prevent and treat complications
9. Reduce mortality.
Figure 1: Algorithm for Managing Stable COPD
Clinical features

COPD severity
Mild

Moderate

Severe

Very severe

For all patients: education, smoking cessation, avoidance of exposure, exercise,

mantain ideal BMI, vaccination, short-acting bronchodilatora as needed
Pulmonary rehabilitation

Infrequent
symptoms

SABA as needed

SABA/SAAC combination as needed

Persistent
symptomsb

LAAC or LABA

If symptoms persist, add ICS/LABA combination to LAAC or

replace LABA with ICS/LABA combination
theophylline

Frequent
exacerbationsc
( 1 per yr)

Consider
alternative
caused

LAAC and/or LABA

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

LAAC + ICS/LABA combination

theophylline
Long-term oxygen therapy
Consider lung transplantation/LVRS

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Figure 2: Algorithm for Managing Stable COPD in Resource-Limited Settings

Clinical
feature
Clinical
features

COPD severity
Mild

Moderate

Severe

Very severe

For all patients: education, smoking cessation, avoidance of exposure, exercise,

maintain ideal BMI, vaccination, short-acting bronchodilatora as needed
Pulmonary rehabilitation

Infrequent
symptoms

SABA as needed

SABA/SAAC combination as needed

Persistent
symptomsb

SABA/SAAC
combination
regularly

SABA/SAAC combination regularly

If symptoms persist, add theophylline and/or ICS

Frequent
exacerbationsc
( 1 per yr)

Consider
alternative
caused

SABA/SAAC combination regularly + ICS

+ theophylline
(Consider referring to a tertiary centre to obtain
long-acting bronchodilators)

Respiratory failure

Consider alternative
caused

SABA/SAAC combination regularly

+ ICS + theophylline
Long-term oxygen therapy
Consider lung transplantation/LVRS

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

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Table 2: Evidence-based Interventions in Stable COPD

Intervention
Smoking cessation
Influenza vaccination
Pneumococcal vaccination

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

Inhaled long-acting b2-agonists

post-bronchodilator FEV1,
dyspnoea
post-bronchodilator FEV1, symptoms,
QoL, COPD exacerbations

Inhaled short-acting
anticholinergic

post-bronchodilator FEV1, dyspnoea

Inhaled long-acting anticholinergic

(tiotropium)

post-bronchodilator FEV1, symptoms,

exercise tolerance, QoL,
COPD exacerbations, mortality

Inhaled corticosteroids

FEV1, QoL, COPD exacerbations

Inhaled long-acting b2-agonist and

inhaled corticosteroid combination
[Seretide Accuhaler (salmeterol
50 g/fluticasone 500 g) twice
daily, and Symbicort Turbuhaler
(budesonide/formoterol 320/9 g)
twice daily]

post-bronchodilator FEV1, QoL,

COPD exacerbations

Oral theophylline

Small FEV1, symptoms

Long-term oxygen therapy

mortality
(in patients with respiratory failure)

Inhaled short-acting b2-agonists

Pulmonary rehabilitation

Lung volume reduction surgery

dyspnoea, exercise capacity, QoL,

anxiety and depression associated
with COPD
number of hospitalisations and days
in hospital
peripheral muscle strength
FEV1, exercise tolerance, QoL,
mortality

* Refer to Table 4
: reduces, : increases or improves, QoL : quality of life

I
I

II-1
I
I
II-1
II-2
I

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Managing Acute Exacerbations of COPD

Objectives of managing exacerbations of COPD:
Relieve symptoms and airflow obstruction
Maintain adequate oxygenation
Treat any co-morbid conditions that may contribute to the respiratory deterioration
Treat any precipitating factor such as infection
Table 3: Evidence-based Interventions in Acute Exacerbations of COPD
Intervention

Outcome

Inhaled short-acting 2-agonists

FEV1, dyspnoea

Inhaled short-acting anticholinergic FEV1, dyspnoea

Intravenous aminophylline
Systemic corticosteroids

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

Table 4: US / Canadian Preventive Services Task Force Level of Evidence Scale

Evidence obtained from at least one properly randomized controlled trial

II - 1

Evidence obtained from well-designed controlled trials without

randomization
Evidence obtained from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group
Evidence obtained from multiple time series with or without intervention.
Dramatic results in uncontrolled experiments (such as the results of the
introduction of penicillin treatment in the 1940s) could also be regarded as
this type of evidence
Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports; or reports of expert committees

II - 2
II - 3

III

Good response to
initial treatment

Failure to improve

Inhaled short-acting bronchodilator (SABA +

SAAC) from pMDI via a spacer device or
nebuliser depending on severity

Indications for hospital assessment or admission:

Marked increase in intensity of symptoms such as
sudden development of dyspnoea
Underlying severe COPD
Development of new physical signs e.g., cyanosis,
peripheral oedema
Haemodynamic instability
Reduced alertness
Failure of exacerbation to respond to initial medical
management
Significant co-morbidities
Newly occurring cardiac arrhythmias
Older age
Insufficient home support

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)

Discharge with follow-up

Check inhaler technique
Arrange appropriate investigations if this is a
new presentation
Refer to specialist if necessary

None

Any indication for hospital assessment or admission?

Refer to nearest hospital

or patients usual hospital

Administer initial treatment:

Inhaled short-acting bronchodilators
(SABA + SAAC) from pMDI via a
spacer device or nebuliser
Oral prednisolone (or intravenous
hydrocortisone if patient unable to
swallow or vomits)
Start initial dose of antibiotics
(if appropriate)
Supplemental oxygen therapy
(preferably via Venturi mask) if
SpO2 < 90%, aim for SpO2 90-93%

Hospital assessment or admission indicated

Obtain relevant history: Underlying COPD severity (if known), co-morbidities, present treatment regimen

Patient with AECOPD

Figure 3: Algorithm for Managing Acute Exacerbations of COPD: Home Management

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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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

Discharge with follow-up

Check inhaler technique
Refer to specialist if this is a new presentation

No indication for hospital admission

Good response

Indications for hospital admission:

Marked increase in intensity of symptoms
such as sudden development of
dyspnoea
Underlying severe COPD
Development of new physical signs e.g.,
cyanosis, peripheral oedema
Haemodynamic instability
Reduced alertness
Failure of exacerbation to respond to
initial medical management
Significant co-morbidities
Newly occurring cardiac arrhythmias
Older age
Insufficient home support

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

Administer initial treatment:

Controlled oxygen therapy if SpO2 < 90%, aim for SpO2 90-93%
Inhaled short-acting bronchodilators (SABA + SAAC) from pMDI via a spacer device or nebuliser
Oral prednisolone (intravenous hydrocortisone if patient unable to swallow or vomits)
Start antibiotics if patient has 2 out of 3 cardinal symptoms (i.e, purulent sputum, increased sputum volume, increased dyspnoea)

Patient with AECOPD

Figure 4: Algorithm for Managing Acute Exacerbations of COPD: Hospital Management

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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