Chronic Obstructive Pulmonary Disease (COPD)

Description

General Measures

Medicine Treatment

Referral

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J43.0-2/J43.8-9/J44.0-1/J44.8-9

DESCRIPTION

• Also referred to as chronic obstructive airways disease (COAD), and comprises chronic bronchitis and emphysema which are characterised by:
  • Chronic cough with/ without sputum production on most days of ≥3 months for ≥2 consecutive years;
  • Dyspnoea or shortness of breath; and
  • Wheezing
• The onset is very gradual with progressively worsening symptoms. Due to the large reserve capacity of the lungs, patients often present when there is considerable permanent damage to the lungs. In addition to the symptoms listed above, patients may present with symptoms or signs of right heart failure. The airways obstruction is not fully reversible (in contrast to asthma)
• The main causes of COPD are chronic irritation of the airways caused by smoking, air pollution, previous TB, and previous cannabis (dagga) smoking, although there are many other causes
• If symptoms suggest TB (e.g. weight loss, night sweats, etc.), investigate and manage accordingly. See Pulmonary Tuberculosis (TB)

GENERAL MEASURES

• Smoking cessation, including cannabis (dagga), is the mainstay of therapy
• Chest physiotherapy where available
• Exercise

MEDICINE TREATMENT

See Appendix II: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.

Acute lower airways obstruction:

• Treat as for acute asthma but in addition, add antibiotics if patients have increased sputum purulence AND either increased sputum volume or increased dyspnoea
  • Amoxicillin, oral, 500 mg 8 hourly for 5 days

LoE:IIb²⁷

Severe penicillin allergy:
Z88.0

• Azithromycin, oral, 500 mg daily for 3 days

Chronic management:

• In a stable patient, check PEFR
• Then give a test dose of salbutamol, i.e. 2 puffs
• Repeat PEFR 15 minutes later
• If there is ≥20% improvement in peak flow, diagnose asthma and manage patient accordingly. See: Chronic Asthma
• Perform spirometry if available. Diagnose COPD if post-bronchodilator FEV1/FVC < 70%
• Short acting beta2 agonist, e.g.:
  • Salbutamol, inhalation, 100–200 mcg (1–2 puffs), 3–4 times daily via a spacer as needed for relief of wheeze

If not controlled on SABA alone and diagnosis was confirmed by spirometry (with <2 exacerbations per year):

• Long-acting β2-agonist (LABA), e.g.: 
• Formoterol, inhaled 12 mcg (1 puff) 12 hourly (Doctor initiated)

LoE:IVb²⁸

If not controlled on SABA alone and spirometry not available:

• Inhaled LABA/ corticosteroid combination e.g.: 
  • Salmeterol/ fluticasone, inhalation, 50/250 mcg (1 puff) 12 hourly (Doctor initiated)

If not controlled on a LABA alone or frequent exacerbations (≥ 2 per year): 

Measure blood eosinophil levels.
If eosinophils > 0.1 x109 cells/L, replace with:

• Inhaled LABA/corticosteroid combination e.g.:
  • Salmeterol/fluticasone, inhalation, 50/250 mcg (1 puff) 12 hourly (Doctor initiated)

LoE:IVb²⁹

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Note:
- Fluticasone and budesonide interact with protease inhibitors. Refer all patients on protease inhibitors requiring inhaled corticosteroids for further management
- Oral corticosteroids may be required for acute exacerbations, but these have severe long-term complications and should only be used long-term if advised by a specialist.
- Do not measure blood eosinophil levels while taking oral corticosteroids, as this may temporarily lower the eosinophil count. 

LoE:IIIb³⁰ 

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Prophylaxis against respiratory tract infections:
Z25.1

• Influenza vaccination, annually

REFERRAL

• Poor response to above therapy, for further investigations and adjustment of treatment
• Patient on protease inhibitors, requiring inhaled corticosteroids

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4-Version 1.0_16 September 2024

Chapter 17: Respiratory Conditions_17.1. Conditions with Predominant Wheeze_17.1.5. Chronic Obstructive Pulmonary Disease (COPD)