Chronic Obstructive Pulmonary Disease (COPD)

Updated : May 28, 2024


A condition of progressive lung disease where it restricts airflow, which causes breathing difficulties is known as COPD. 

32 million individuals are affected by COPD, and it is the third leading cause of death in the US. COPD arises emphysema and chronic bronchitis that causes breathlessness in progressive lung diseases. 

Major cause of COPD is prolonged inhalation of pollutants, mainly from smoking. 


NHIS finds 18 emphysema cases per 1000 persons and 34 chronic bronchitis cases per 1000. Global COPD prevalence is unclear, but it ranges from 7% to 19%. 

Burden of Obstructive Lung Disease study showed global obstructive lung disease prevalence at 10.1%, men at 11.8% and women at 8.5%. 

Underdiagnosed disease, patients seek care in late stages, which causes issues with diagnosis and treatment effectiveness. 



COPD causes chronic changes in large airways, small bronchioles, and lung parenchyma.  

Airway remodelling is a process characterized by the thickening of airway walls, increased mucus production, and fibrosis, which result in long-term inflammation in the airways. 


Smoking causes macrophages to release chemicals that destroy respiratory tissue. Second-hand smoke harms lungs, worsens asthma, and raises risk of respiratory infections.  

Airway responsiveness in smoking patients increases risk of COPD, that occurs accelerated decline in lung function. 


Prognostic Factors

The absolute mortality rates for US patients aged 25 and older due to COPD were 77.3 deaths per 100,000 males and 56.0 deaths per 100,000 females. 

It is found that heart disease, depression, underweight are linked to lower health-related quality of life in COPD. 

Clinical History

COPD affects older adults, mostly diagnosed individuals over 40 years old. 


Physical Examination

Respiratory Assessment 

Chest Examination 

Peripheral Examination 

Functional Assessment 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Initial mild symptoms progress to worsen severity and frequency with cough, shortness of breath during exertion. 

Exposure to irritants, weather changes, or illnesses may trigger symptoms. 

Differential Diagnoses


Congestive Heart Failure 

Pulmonary Embolism 


Laboratory Studies

Imaging Studies


Histologic Findings


Treatment Paradigm

The use of Bronchodilator therapy, oxygen therapy and pulmonary rehabilitation is very effective in the treatment of COPD. 

Supportive care and preventive measures should be considered to improve the overall health and quality of life of patients. 

Medication with inhaled corticosteroids and Phosphodiesterase-4 (PDE-4) Inhibitors should be given to patients.  

Appointments with medical physicians and preventing recurrence of disorder is an ongoing life-long effort. 

by Stage

by Modality


Radiation Therapy

Surgical Interventions

Hormone Therapy



Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of a non-pharmacological approach for treating COPD

Patients should stop smoking to prevent further damage to their lungs. 

Patients should avoid environments with high levels of smoke and always stay inside a smoke-free environment. 

Patient should stay in adequate conditions with good ventilation, air quality and a clean environment. 

Education should be given to individuals about cautious with activities that could cause pulmonary disease. 

Use of Anticholinergics drugs

Ipratropium bromide: It is used with a beta-2 agonist that enhances bronchodilation with 2 to 4 puffs administered every 6 to 8 hours. It has a slow onset and longer duration and is less ideal for as-needed use. 

Tiotropium: Quaternary ammonium compound causes bronchodilation through M3 receptor inhibition thus they have anticholinergic and antimuscarinic effects. 

Use of Xanthine Derivative

Theophylline metabolized by liver enzyme system which affected by age, heart conditions, liver issues. Monitor serum levels to prevent toxicity. 

Use of Phosphodiesterase-4 Inhibitors

Roflumilast inhibits PDE-4, which reduces exacerbations and symptoms in severe COPD patients. 

Use of Corticosteroids (Inhaled)

Fluticasone relaxes muscles, reduces inflammation, lowers hyperresponsiveness in airways, inhibiting bronchoconstriction. 

Use of Antibiotics

Cefuroxime: It is a second-gen cephalosporin, that binds to penicillin-binding proteins and inhibits transpeptidation for cell wall death. 


Use of Intervention with a procedure in treating COPD

Direct bronchoscopy administers bronchodilators for targeted airway relief. 

Bronchial Thermoplasty: Thermal energy delivered to airway walls reduces smooth muscle mass to improve airflow in patients. 

Endobronchial stents help manage severe airway blockage from COPD complications by maintaining airway openness and enhancing airflow. 

Use of phases in managing COPD

A detailed family history and physical examination of patient is conducted by healthcare specialist in diagnosis phase to identify signs and symptoms of pulmonary disease. 

The regular follow-up visits with the physician are required to check the improvement of patients and newly observed complaints. 

Long-term management phase is a very important phase which involves continuous monitoring, supportive care, and surveillance for late effects of treatment. 






inhaled by nebulizer twice a day
1 or 2 capsules inhaled every 12 hours (Do not exceed 4 capsules/day)




oral inhalation twice a day


1 capsule (75 mcg) is inhaled once a day


Nebulization solution: 0.63 mg to 1.25mg oral inhalation every 1 hour for 2 to 3 doses or as needed
Metered-dose inhaler: 1 to 2 oral inhalations every 1 hour for 2 to 3 doses or as needed





every 6 hrs

Do not exceed 12 actuations per day
Nebulizer: 2.5 mL every 6-8hours



1 - 1




3 times a day

1 - 1



Dose Adjustments







once a day




Inhalation mouth spray:

Mouth spray


Each actuation=2.5mcg tiotropium(3.124mcg tiotropium bromide monohydrate) and 2.5mcg olodaterol(2.736mcg olodaterol hydrochloride
Chronic obstructive pulmonary disorder
Two inhalations orally every day at the same time





every 12 hrs



Note: It is indicated for Acute Bronchitis & Acute Exacerbation of Chronic Bronchitis

glycopyrrolate inhaled and formoterol 

Mouth spray

Orally inhaled

twice a day

Two inhalations (Formoterol 18mcg/ Glycopyrrolate inhaled 9 mcg for each inhalation)
Do not exceed two inhalations per day





every 12 hrs or 500mg every 8hrs


Acute exacerbation:

500 mg oral tablet immediate release every 12 hours for 5 to 7 days
Note: Not recommended for with risk infection of Pseudomonas


chronic exacerbation

400mg orally/intravenous every day for five days


320mg orally every day for five days

aclidinium and formoterol 

One inhalation orally twice a day. Do not exceed one inhalation per day


Indicated for Acute Exacerbations of Chronic Bronchitis:




Single dose or divided every 12hr


Aerosol Metered dose inhaler
1 to 2 inhalations in 2-3 doses every hour, then every 2 to 4 hours


In the case of mild/moderate infections: 500 mg orally every 12 hours or 400 mg intravenously every 12 hours for 7-14 days
In the case of severe/complicated infections: 750 mg orally every 12 hours or 400 mg intravenously every 8 hours for 7-14 days
Limitations for usage: Reserve the fluoroquinolones for patients who are voided of available treatment options for chronic bronchitis


A dose of 500 mg orally every 12 hours or 250 mg orally every 6 hours is indicated in chronic bronchitis infection


3 days of 500 mg orally every day OR Instead, take 500 mg orally in a single dosage on Day 1, then 250 mg orally every day from Days 2 to 5

red clover 

Indicated for Cancer, skin sores, asthma, bronchitis :

4 mg of flower tops orally three times a day
4 gm of flower tops in 150 ml of water;1 cup of tea orally three times a day
1.5-3 ml of liquid extract orally three times a day;1:1 in 25% alcohol
1-2 ml of tincture orally three times a day;1:10 in 45% alcohol

red clover 

Indicated for Cancer, skin sores, asthma, bronchitis :

4 mg of flower tops orally three times a day
4 gm of flower tops in 150 ml of water;1 cup of tea orally three times a day
1.5-3 ml of liquid extract orally three times a day;1:1 in 25% alcohol
1-2 ml of tincture orally three times a day;1:10 in 45% alcohol


Exacerbation of chronic bronchitis by acute bacteria Take 400 mg orally after every 12 hours up to 10 days


inhaling 400 mcg (1 puff) orally two times daily


Using a mouthpiece on a nebulizer, inhale 175 mcg orally every day
Administer every day at the same time
Do not exceed 175mg daily once

Dose Adjustments

Renal impairment
Any level of impairment: No change in dose is necessary.
Patients with COPD with substantial renal impairment should be monitored for systemic antimuscarinic side effects.

Hepatic impairment
Mild-to-severe: Safety has not been determined; individuals with any degree of hepatic impairment are not recommended


It is indicated in the maintenance of bronchospasm that is linked to COPD, helping in COPD exacerbations
Spiriva Handihaler- 2 inhalations from a capsule orally each day through the HandiHaler device
Spiriva Respimat- 2 actuation of 2.5 mcg each, inhaled orally daily

indacaterol, inhaled/glycopyrrolate inhaled 

Indicated for long-term maintenance of COPD
Inhale the contents orally through one capsule every 12 hours by a neo haler device

umeclidinium bromide/vilanterol inhaled 

Indicated for long-term maintenance of COPD that includes emphysema and chronic bronchitis
62.5 mcg/25mcg as one actuation inhaled orally each day
Do not exceed more than one inhalation each day

budesonide inhaled/formoterol/glycopyrrolate inhaled 

2 inhalations orally two times daily
Dosage Modifications
Renal impairment
Study not carried out
Hepatic impairment
Study not carried out
Dosing Considerations
Limitations of use: Not suggested for in acute bronchospasm


Aerosol: Administer 100 mcg/20 mcg (1 metered-dose inhaler actuation) every six hours
Do not exceed more than six actuations daily.
Nebulizer: Administer 3ml inhalation every 6 hours.
Do not exceed 3ml every 4 hours.



By using a dry powder inhaler, The administration of batefenterol at a dose of 300 µg for a duration of 42 days
Note: The dosage of 300 µg of batefenterol could be considered as the most suitable for clinical trials (phase III)


Indicated as mucolytic agent:

Administer 750 mg to 2.25 g daily in three to four divided doses


Take a dose of 20 mcg orally two times a day
Daily dose should not be more than 60 mcg


Inhaled a dose of 20 mcg up to 4 times daily


Indicated for Chronic bronchitis
400 mg to 600 mg orally one time a day for nearly 10 days
Community-acquired pneumonia
600 mg orally one time a day for nearly 10 days
Uncomplicated gonorrhea
400 mg orally one time
Cervicitis or Nongonococcal urethritis
400 mg orally one time a day for nearly 7 days


For one week, take 400 mg two times a day by oral route


As metered-dose aerosol:
Inhaled dose of 250 to 500 mcg when required
Dose should not be more than 8 times in a day
Do not repeat dose in less than 1 hour


Take 400 mg by oral route one time daily for ten days duration


It assesses four separate inhaled abediterol dosages at 0.625 ug, 2.5 ug, 5 ug & 10 ug Comparing the results to a placebo, it was evident that all doses considerably improved bronchodilation Comparing the doses of 2.5, 5, and 10 ug to the active comparator, further improvements were observed


5 ml of this drug every 3 to 5 hours is recommended, which should be at most 30 ml daily
This drug is used for treating bronchial congestion and bronchospasm, which are associated with acute and chronic bronchitis

etophylline and theophylline 

115 mg of etophylline and 35 mg of theophylline is given once a day


It is used as a respiratory stimulant used in the therapy for acute respiratory failure such as COPD
The usual dose via oral administration given as a tablet is 50 -100 mg, which is divided into two doses per day
The usual dose via IV administration is 1-3 mg/kg per day, which is given in divided doses which is infused for over 2 hours

Dose Adjustments

Limited data is available


Administer 1 to 2 g once or twice a day intramuscularly or intravenous infusion.
Maximum dose-4 g/day.

Renal impairment
CrCl 10 to 30ml/min-Administer 1 to 2 g every day.
CrCl<10ml/min- Administer 0.5 to 1 g every day.


Take a dose of 100 mg orally two times daily


Aerosol: 100mcg albuterol /20mcg ipratropium bromide (1 actuation of metered-dose inhaler) every 6 hours; should not exceed more than 6 actuations/day
Nebulizer solution: 3 mL is inhaled every 6hours; should not exceed more than 3 mL every 4hours


Take one tablet/capsule after the breakfast with a glass of water. Dose can be repeated every six hours, should not exceed more than four capsules daily




Using the nebulization system, inhale the contents of the vial two times a day
Capsules for inhalation
using an inhaler, inhale the capsule contents twice daily


500 mg is given orally once every day for one week


Administer 2 inhaled aerosols dose at an interval of minimum 1 to 3 minutes followed by a third inhalation

ephedra sinica root 

Take a dose of 32 mg orally daily


Administer 150mg twice a day, can increase the dose to 300mg to 450mg twice a day based on the patient's tolerance.






twice a day



Dose Adjustments