The continuum of care for COPD is illustrated on this table. The upper part shows risk factors, symptoms and exacerbations which are a frequent complication of this disease. Eventually the patient can go into respiratory failure. Different interventions are also listed. Across the board at any particular time, smoking cessation is the most important. The patient has to stop smoking, and we have to use interventions to help him or her accomplish this goal.

When the patient begins to develop symptoms it is time to begin management of the disease. Eventually, the patient will start having some impairment in functional capacity that will require other interventions like pulmonary rehabilitation. In a very small number of patients, further interventions might include lung transplantation or surgery, but this is a very small number of patients. The majority of patients will benefit most from pulmonary rehab and pharmacotherapy.

The table also shows the progression of the disease. As the FEV1 gets lower, patients are going to have more symptoms and are going to be more limited. You want to be ahead of the curve and intervene before the FEV1 gets so low that the patient is bed bound or chair bound and can't exercise or do anything due to the limitations and shortness of breath.

Therapy is given according to the severity of the disease. These recommendations are presented by severity of disease because it’s very likely that the patients who have severe or very severe COPD will be symptomatic. The caveat here is that your patient has to be symptomatic before you intervene. The symptoms are important in deciding what stage of therapy you want. There are patients who have mild disease who may be very symptomatic and will require pharmacotherapy like long-acting bronchodilators even before the FEV1 gets much lower. There are other patients who may have more severe disease but they are not limited by their symptoms, or at least they tell you they are not limited.

This is a progressive disease.We want to halt the progression of the disease. We want to stop the decline in lung function that otherwise will occur if we don’t use pharmacotherapy, if the patient does not stop smoking, if we don't take other measures and use other interventions. These interventions should include vaccinations. Influenza vaccination and pneumococcal vaccination are very important in this patient population.

Pharmacotherapy is also very important. COPD patients will have bronchitis once or twice a year, so they may wheeze, or be more symptomatic. You can prescribe short-acting bronchodilators, mainly albuterol or ipratropium, alone or in combination as a rescue.

Once the patients start to become symptomatic, that changes. The standard of care today is that these patients have to be started on long-acting bronchodilators that can be given once or twice a day. Some can be given in powder form, some can be given as a nebulized solution, but you want to give effective therapy to halt the progression of the lung disease. As the patient’s disease continues to progress, or when the disease has not been diagnosed before it has progressed to severe or very severe COPD, the recommendations are to add inhaled corticosteroids. In patients who have very severe lung disease or very severe COPD a combination is used. They are going to be on long-acting bronchodilators, long-acting beta2-agonists, long-acting anti-cholinergics, and inhaled corticosteroids.