Management of chronic obstructive airway disease

Confirm the diagnosis and assess. COPD requires post-bronchodilator spirometry showing a persistent airflow limitation. In older adults use the lower limit of normal rather than the fixed FEV /FVC < 0.70 ratio, 1 because ageing alone produces a "pseudo-obstructive" pattern and the fixed ratio over-diagnoses COPD in the old. Assess with the mMRC dyspnoea scale or CAT score, exacerbation history, and GOLD ABE grouping. Careful history and spirometry usually distinguish COPD from asthma and exclude comorbid conditions.

Non-pharmacological measures — the foundation. Smoking cessation is the single most effective intervention and works at any age. Pulmonary rehabilitation — a comprehensive, tailored programme of exercise training, education and behaviour change — improves symptoms, exercise capacity and quality of life. Add vaccination (influenza, pneumococcal, COVID-19, RSV, pertussis), nutritional support (low BMI predicts mortality), reduction of biomass fuel and indoor air pollution exposure — a major issue in Indian households — and treatment of anxiety and depression.

Inhaled pharmacotherapy. Long-acting bronchodilators are the mainstay: LAMA may be added to a LABA when breathlessness predominates. In patients who remain breathless or exacerbate frequently, regardless of FEV , a 1 LAMA can be added to an inhaled LABA–corticosteroid combination or vice versa (triple therapy). Inhaled corticosteroids reduce exacerbations, particularly with blood eosinophils ≥ 300 cells/µL or a history of asthma, but cause a small but significant increase in non-fatal pneumonia — a risk that does not outweigh their benefit in appropriate patients. Re-evaluate after starting therapy, judging success by symptoms, exercise tolerance and ability to perform activities of daily living rather than by lung function alone. Always check inhaler technique and prefer fixed-dose combinations to reduce device burden.

Additional oral therapy. If symptoms persist or the patient cannot use inhalers, slow-release theophylline may be tried at low dose in older people, watching for gastrointestinal effects and interactions with antibiotics during exacerbations. Roflumilast (a PDE-4 inhibitor) is an option in frequent exacerbators with chronic bronchitis and copious sputum — monitor for weight loss, diarrhoea and mood disturbance, and note the limited safety evidence in the elderly. A trial of mucolytics or high-dose N-acetylcysteine may help viscid sputum. Nebulised bronchodilators help very advanced disease or hopeless inhaler technique. Maintenance oral corticosteroids should generally be avoided — the risks outweigh the benefits.

Management of exacerbations. Exacerbations account for up to 10% of medical admissions; one-third are readmitted within 30 days and 15% die within three months. Common organisms: H. influenzae, S. pneumoniae and M. catarrhalis. Give bronchodilators, controlled oxygen to a target saturation of 88–92%, and oral corticosteroids for 5–7 (up to 14) days, which shorten stay and reduce treatment failure. Antibiotics when there is increased cough with purulent sputum — beta-lactam ± inhibitor, doxycycline or a fluoroquinolone; add antipseudomonal cover if bronchiectasis coexists; avoid antibiotics if the sputum is not purulent. Non-invasive ventilation if pH < 7.35 despite maximal therapy — this reduces mortality, intubation and length of stay; high-flow nasal oxygen is an alternative, especially with do-not-intubate orders. Screen for osteoporosis in anyone receiving repeated steroid courses.

Long-term support, comorbidity and end-of-life care. Assess for long-term oxygen therapy in severe disease or cor pulmonale, and for home NIV in persistent hypercapnia. Manage comorbidities actively — ischaemic heart disease and heart failure (cardioselective beta-blockers are safe and should be used when indicated), osteoporosis, obstructive sleep apnoea, anxiety, depression, sarcopenia and falls. Consider early-discharge and admission-avoidance teams for suitable non-acidotic patients with good social support. Patients judged to be in the last year of life should be placed on an end-of-life register and offered palliation including opioids and benzodiazepines for refractory breathlessness — the move from active to palliative care all too often comes too late.

Biologic therapy has entered COPD. The BOREAS (NEJM 2023) and NOTUS (NEJM 2024) trials showed that dupilumab (an anti-IL-4Rα monoclonal antibody) significantly reduced exacerbations and improved lung function and quality of life in COPD with a type-2 inflammatory phenotype (blood eosinophils ≥ 300 cells/µL) already on triple inhaled therapy, leading to regulatory approval in 2024–25 and its incorporation into the GOLD 2025/2026 reports as an add-on for this phenotype. GOLD also continues to emphasise single-inhaler triple therapy for exacerbators, the eosinophil count as the key biomarker for ICS use, and checking inhaler technique before any escalation.