Treatment of COPD depends on the severity of the condition with which patients present to their general practitioners and physicians. COPD can be classified as mild, moderate or severe. This classification is based on staging systems for COPD based on the value of FEV1 ("forced expiratory volume in one second" as indicator of airflow construction due to loss of alveolar-capillary unit) percentage predicted. The degree of airflow (FEV1) reduction has implications for the prognosis and relates with the mortality and morbidity. Four groups - the American Thoracic Society (ATS), the British Thoracic Society (BTS), the European Respiratory Society (ERS) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) - proposes 3-stage classifications of COPD, but the FEV1 criteria vary among the systems.

The Staging of Disease Severity

Disease Severity according to FEV1 % predicted	American Thoracic Society	European Respiratory Society	British Thoracic Society	Global Initiative for Chronic Obstructive Lung Disease
Stage 0: at risk	-	-	-	Normal
Stage 1: Mild	> 50	> 70	>60	>80, but FEV1/ FVC (Forced Vital Capacity) <70
Stage 2: Moderate	35 - 49	50 - 69	40 - 59	30 - 79
Stage 3: Severe	<35	<50	<40	<30

Once the diagnosis has been confirmed and the stage of the disease determined, the focus turns to:

• Patient education to help him/her understand the disease,
• Modification of risk factors - with smoking cessation of the utmost importance to slow the progression of the disease,
• Medication to treat the signs and symptoms of the disease to enhance survival, to enhance quality of life and functional status and lower mortality and morbidity. Drugs to treat COPD include bronchodilators, corticosteroids, influenza vaccination, antibiotics, mucolytics and others.

Treatment of Stable COPD

Mild disease

Step 1: Stop smoking.
The essential first step is the management of the risk factors, particularly cessation of smoking. It is an important preventative component of these patients' treatment as well as a step to slow to progression of the disease. If the person keep on smoking, his/her disease will progress at a rapid pace. Patients must be informed that secondary cigarette smoke, as well as exposure to noxious fumes, gases and dust at work needs to be addressed to preserve respiratory function.

Step 2: Vaccinate person against influenza and other respiratory viral diseases
Vaccination of these individuals against the predominant viral strains every year, is important. Vaccinate a person every 5 - 10 years with the 23-polyvalent pneumococcal vaccine. As soon as a vaccine against the new respiratory disease SARS (Severe acute respiratory syndrome) becomes available, people with COPD should be vaccinated against this disease as well.

Step 3: Open the airways - either "as needed" or long-term
The use of short-acting bronchodilator therapy (medications to dilate the bronchial airways), such as the well-known asthma inhalers, will provide temporary relief during episodes of wheezing. Bronchodilator choices include: Anticholinergics (tiotropium or iprapropium bromide), beta2-antagonists (albuterol, metaproterenol sulfate) or methylxanthines (theophylline or aminophylline).

Short- or long-acting Beta2-antagonists can alleviate symptoms like wheezing and a tight chest, improve exercise capacity and increase airflow out of the lungs.

Oral theophylline can lessen dyspnea (shortness of breath) despite a real increase in airflow out of the lungs.

In the early stages of COPD (Mild COPD) a short-acting beta2-angonist or a anticholinergic is used on as-needed basis. With long-acting anticholinergic tiotropium (it works for 12 hours) once-daily treatment to keep the airways as open as possible at all times, is now an option.

Step 4: Treat a bacterial respiratory infection
Doctors used to treat chronic bronchitis with low dosages of tetracycline antibiotics over an extended period. Now there is some doubt whether prophylactic antibiotics have any benefit in the management of stable COPD. According to the latests studies, the use of antibiotics for 7 - 14 days, is recommended only in the treatment of COPD exacerbations (usually accompanied by or caused by respiratory infections) or other bacterial infections .

Add (in some cases):
Mucolytics to thin the mucus, and expectorants to help the person to cough up mucus. Some groups recommend the use of mucolytics and according to others it has no proven advantage. The use of mucolytics are only recommended for people with viscous sputum. Overall benefits are small.

Step 5: In COPD sufferers with asthma: Reduce the inflammation in the airways.
If a COPD sufferer also have asthma, the airways will be inflamed, and needs to be treated with anti-inflammatory medications. These drugs include corticosteroids such as prednisone, usually as an inhaled aerosol. Inhaled anti-inflammatories are the cornerstone of asthma therapy, but used only very occasionally in COPD.

Step 6: Additional treatment may include oxygen as needed.
In the case of Mild COPD, oxygen therapy may be needed now and again, but it will be needed more often as the disease progresses.

Although there is no cure for COPD, a person diagnosed with "Mild COPD" may thus be prescribed at least a bronchodilator inhaler to make breathing easier.

Moderate disease

There is no evidence that long-term treatment with steroids will prevent a loss of lung function over time. Subsequently, patients who may benefit from long-term corticosteroid treatment and who may develop side-effects of the drug, should be carefully monitored.

Step 1: Stop smoking.
If the person keep on smoking, his/her disease will progress at a rapid pace. Secondary cigarette smoke, as well as exposure to noxious fumes, gases and dust at work needs to be addressed to preserve respiratory function.

Step 2: Vaccinate person against influenza and other respiratory viral diseases
Vaccination of these individuals against the predominant viral strains every year, every 5 - 10 years against pneumococcal infections as well as against SARS (as soon as a vaccine is available).

Step 3: Open the airways - mostly on a regular daily basis
As the disease progresses from Mild to Moderate and Severe COPD, regular (and even long-term use on a daily basis) use of one or more bronchodilators may become a necessity.

Bronchodilator choices include: Anticholinergics (tiotropium or iprapropium bromide), beta2-antagonists (albuterol, metaproterenol sulfate) or methylxanthines (theophylline or aminophylline).

With long-acting anticholinergic tiotropium (it works for 12 hours) once-daily treatment to keep the airways as open as possible at all times, is now an option. The best option may be a combination of a anticholinergic and a beta2-antagonist inhaler to provide both short-acting and long-acting bronchodilation.

Step 4: Treat a bacterial respiratory infection
Chronic bronchitis used to be treated with low dosages of tetracycline over an extended period. However, according to new studies, the prophylactic use of antibiotics to prevent infections have shown no benefits in the treatment/management of stable COPD. In the case of a COPD exacerbation - usually accompanied by or even caused by an infection - the bacterial infection should be treated with antibiotics for 7 - 14 days.

Add (in some cases):
Mucolytics to thin the mucus in cases where the mucus is viscous, but not in general, and expectorants to help the person to cough up mucus.

Step 5: If a COPD-sufferer also suffers from asthma, the inflammation in the airways needs to be reduced.
If a COPD sufferer also have asthma, the airways will be inflamed, and needs to be treated with anti-inflammatory medications. These drugs include corticosteroids such as prednisone, usually as an inhaled aerosol.

Although widely prescribed and used, inhaled and oral corticosteroids have a very limited use in managing people with stable COPD. Some groups advocate the brief use (2 weeks) of oral corticosteroids, followed by inhaled corticosteroids for 6 weeks, but four large trials of inhaled corticosteroids in patients with COPD have shown no improvement in airflow out of the lungs or a slowdown in the rate of airflow-decline. One study suggested that steroid recipients may experience less COPD exarcerbations.

Step 6: Additional treatment may include oxygen as needed.
A person with Moderate COPD may need to use oxygen on a regular basis - at night or after exercise or moving around.

A person diagnosed with "Moderate COPD" may be prescribed at least the following drugs - a bronchodialtor inhaler (or two) and an oxygen unit - to control his coughing and wheezing and to make breathing easier, as well as oral corticosteroids to use in the case of a COPD exacerbation.

Severe COPD

Management of Severe COPD includes:

1. Rehabilitation.
Rehabilitation is an important component of treatment in this group. This relates to strengthening the arm and leg muscles as well as the muscles of inspiration, which enable patients to carry on with their daily routine in spite of considerable loss of lung function. This state of “fitness” is only achieved after an intensive rehabilitation programme, which has to be conducted under supervision.

2. Continuous home oxygen
This has been shown to decrease mortality and morbidity of patients with respiratory failure and COPD. Oxygen devices that operate through home power sources generate enough oxygen to support patients for an essential 16 hours per day. This treatment provides wonderful symptomatic relief.

3. Regular, daily use of bronchodilators
A combination of bronchodilators may help breathing.

4. A type of surgery
Surgery known as lung volume reduction surgery was previously offered to patients with COPD, but was not found to be a long-term solution as symptoms tended to recur five years after the operation.

Treatment of Acute Exacerbations of COPD
Acute exacerbations are characterised by acute worsening of the symptoms of COPD, including:

• Increased shortness of breath; breathing will sound more and more like panting
• Increased wheezing
• Increased sputum production
• Hypoxia (person get blueish colour due to lack of oxygen in blood)
• Excessive levels of carbon dioxide (hypercapnia) due to fast but very shallow breathing. This will lead to respiratory acidosis.
• Worsening cor pulmonale (enlargement and strain on the right heart caused by chronic lung diseases. Lung damage leads to pulmonary hypertension, which can cause right-sided heart failure and oedema.
• Worsening oedema of the legs
• Altered mental status due to the hypoxia, hypercapnia, oedema and heart failure.

The percipitating factors must be reversed, optimising of gas exchange and improving the symptoms.

Treatment to achieve these goals include:

• Oxygen therapy to correct the hypoxia.
• Bronchodilators to improve airflow to and from the lungs. A combination of anticholinergic (long-acting, less side-effects) and beta-adrenergic agonists (fast-acting) are often used as first-line therapy.
• Antibiotics such as tetracyclines for 7 - 14 days to reduce the infection and phlegm production.
• Oral or injected corticosteroids for 5 - 10 days, but not longer as 2 weeks to enhance airflow, and reduce inflammation in the airways. Inhaled corticosteroids have not been proven effective in treating COPD exacerbations.
• Non-invasive ventilation if possible
• Mechanical ventilators. A person needs to be hospitalised and intubated. It carries risks and complications such as ventilator-acquired pneumonia and barotrauma.

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