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Guiding Principles For COPD Treatment Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Chronic obstru­ctive pulmonary disease (COPD) is a progre­ssive, incurable respir­atory disorder charac­terized by airflow obstru­ction. For health care profes­sionals working in long term care, it’s important to understand every aspect of this debili­tating disease and follow clear protocols in order to provide effective care.

COPD encomp­asses emphysema, chronic bronch­itis, irreve­rsible asthma, and some forms of bronch­iec­tasis. Cigarette smoking is the main cause of COPD, although air pollution and occupa­tional dusts are also common causes.

About 3 percent of indivi­duals have a genetic form of COPD called Alpha-1 Antitr­ypsin (ATT) Defici­ency. In the beginning stages of the disease, indivi­duals with COPD experience minimal shortness of breath that might be noticed only during exercise. As the disease progre­sses, shortness of breath worsens and physical activity is dimini­shed. Making a COPD diagnosis relies on a combin­ation of patient history, physical examin­ation, and confir­mation of airflow obstru­ction using a spirometry test.


Several guidelines for the diagnosis and management of COPD in long term care residents emphasize the need for a multid­isc­ipl­inary approach. The aim is to treat and prevent chronic symptoms, optimize and preserve activity level, and maximize pulmonary function.

Nonpha­rma­col­ogical interv­entions include smoking cessation, adequate exercise, healthy diet, and avoidance of secondhand smoke.

Several states and munici­pal­ities have enacted 100 percent smoke-free laws for all nursing homes, including common areas and private rooms, in order to protect employees, patients, and visitors from secondhand smoke exposure.

All COPD patients should receive annual influenza vaccine prophy­laxis and pneumo­coccal vaccine admini­str­ation, as well as pulmonary rehabi­lit­ati­on—an important interv­ention in patients who have severe exercise limita­tions.

Pharma­col­ogical therapies can improve symptoms, quality of life, and decrease exacer­bat­ions. Long-a­cting bronch­odi­lators are a primary treatment in the majority of patients with mild to moderate disease. Indivi­duals with severe disease and those with a history of recurrent exacer­bations may benefit from treatment with inhaled cortic­ost­eroids.

Long term care residents

Long term care residents with COPD often fall into a cycle of disabi­lity. They become short of breath and lose energy, which has a negative impact on their level of activity. In many cases, patients will avoid exercise and over time experience diminished mental acuity, depres­sion, and a physical decline that, in many cases, can be slowed down.

Prolonged sitting in a wheelchair may cause residents to adopt a flexed spinal posture and poster­iorly tilted pelvis. Because these indivi­duals may be unable to physically reposition without consid­erable assist­ance, their bodies can be subject to consid­erable positional strain and immobi­lity, with detrim­ental physical reperc­uss­ions, including the formation of pressure ulcers, low back pain, lumbar immobi­lity, and joint stiffness.


Inhaled bronch­odi­lators include beta-2 agonists and antich­oli­nergics (antim­usc­ari­nics), which are equally effective. These consist of short-­acting beta-2 agonists (SABAs) to relax bronchial smooth muscle (albut­erol) and long-a­cting beta-2 agonists (LABAs), which are preferable for indivi­duals with more signif­icant symptoms. Recently, “ultra­-lo­ng-­acting” LABAs have been developed that require once-daily dosing (indac­ate­rol).

Antich­oli­nergics relax bronchial smooth muscle through compet­itive inhibition of muscarinic receptors (M1, M2, and M3) (iprat­rop­ium). A long-a­cting quaternary antich­oli­nergic, which is M1- and M3-sel­ective (tiotr­opium), may have an advantage over ipratr­opium, as M2-rec­eptor blockade may limit bronch­odi­lation.

The frequency of exacer­bations can be reduced with the use of antich­oli­ner­gics, inhaled cortic­ost­eroids, or LABAs. The initial choice among SABAs, LABAs, antich­oli­nergics (which have a greater bronch­odi­lating effect), and combin­ation beta-2 agonist and antich­oli­nergic therapy is often a matter decided by a physician.

Inhaled Cortic­ost­eroids

Inhaled cortic­ost­eroids (ICSs) inhibit airway inflam­mation. Their effects are additive to the effect of bronch­odi­lators and diminish the frequency of COPD exacer­bat­ions. ICSs are highly effective at contro­lling asthma, but their effects on pulmonary and systemic inflam­mation in COPD are unclear. Therefore, their use in COPD is limited to specific indica­tions.

Long-term treatment with ICS is recomm­ended for indivi­duals with severe COPD and frequent exacer­bations that are not adequately controlled with long-a­cting bronch­odi­lators.

Combin­ations of a LABA (salme­terol or formot­erol) and an ICS (fluti­casone propionate or budeso­nide) are more effective than either drug alone in the treatment of stable disease.

Acute Exacer­bations

Treatment of acute COPD exacer­bations aims to minimize the impact of the current exacer­bation and prevent the develo­pment of subsequent exacer­bat­ions. The underlying cause of an acute exacer­bation is usually unknown, although most acute exacer­bations result from bacterial or viral infect­ions. Smoking, irritant inhalation exposure, and high levels of air pollution may also contri­bute.

Indivi­duals with comorb­idi­ties, a history of respir­atory failure, or acute changes in arterial blood gas measur­ements may need hospital treatment. Physicians may determine that indivi­duals with life-t­hre­atening exacer­bations manifested by uncorr­ected modera­te-­to-­severe acute hypoxemia, acute respir­atory acidosis, new arrhyt­hmias, or deteri­orating respir­atory function despite hospital treatment should be admitted to the intensive care unit and their respir­atory status monitored freque­ntly.