Presentation

Patients have breathlessness, cough, sputum production and wheeze, and are susceptible to infections. Most patients have a smoking history.
Bronchiectasis is a less common cause of obstructive lung disease with chronic productive cough, and halitosis.
Chronic bronchitis, emphysema and asthma overlap, as some reversibility is present with COPD and some patients with asthma will develop irreversible components of the disease
Typically older than 35 who are smokers or ex smokers with breathlessness, cough, recurrent respiratory tract infection, sputum production
Suspect alpha-1-antitrypsin deficiency in patients in whom COPD develops at a young age (<40 years), particularly if they have a family history of COPD

Differences with Asthma Exacerbation

COPD features:
- Onset after age 40
- Persistent airflow limitation
- Lack of response to asthma therapy (e.g. symptoms persisting despite ICS treatment)
- Heavy tobacco smoke exposure
Asthma features:
- Onset before age 20
- Significant day-to-day variability in airflow limitation and symptoms
- normal lung function between symptoms
- Symptoms worse at night or in the early morning
- Family history of asthma or atopy
- Seasonal variability in symptoms
- Spontaneous improvement in symptoms

	Mild	Moderate	Severe
Symptoms and exacerbation history	Few symptoms Breathless on moderate exertion Daily activities minimally limited or unaffected Cough and sputum production	Breathless walking on level ground Daily activities increasingly limited Recurrent chest infections Exacerbations requiring oral corticosteroids or antibiotics	Breathless on minimal exertion Daily activities severely limited Exacerbations of increasing frequency and severity
Typical lung function	FEV1 60-80% of predicted	FEV1 40-59% of predicted	FEV1 < 40% of predicted

Non-pharmacological
- Smoking cessation
- Physical activity
- Pulmonary rehabilitation
- Maintenance of up-to-date vaccination
- Good nutrition
Pharmacological
- Usually progresses int he following order
  - SABA (salbutamol 100-200 mcg PRN or terbutaline 500 mcg PRN)
  - LABA or LAMA monotherapy
    - Indicated when SABA and non-pharm measures not adequate
    - Options include:
      - LAMA: aclidinium, glycopyrronium, tiotropium, umeclidinium
      - LABA: indacaterol
  - LABA + LAMA
  - LABA + LAMA + ICS
    - Indicated if both:
      - Patient has severe exacerbations (requiring hospitalisation) or at least two moderate exacerbations in previous 12 months and
      - Patient has significant symptoms despite dual therapy with LAMA + LABA
- Assess 3-6 months after starting treatment and in those who remain symptomatic or have continued exacerbations, check inhaler technique and adherence before stepping up therapy
Additional therapy
- Home oxygen
- Oral mucolytics (bromhexine)
- Long term macrolide antibiotics

Beta blockers should not be stopped in patients with COPD and HFrEF or a Myocardial Infarction within the last 3 years
Patients with COPD are at an increased risk of bone fractures; identify patients with Osteoporosis
Limit the use of oral corticosteroids in patients with COPD and diabetes
Mild to moderate Pulmonary Hypertension is common in patients with COPD