Managing high-risk COPD patients is one of the most complex challenges in pulmonary care. With limited treatment options, conflicting guidelines, and inadequate palliative care access, physicians are constantly adjusting treatment strategies to improve outcomes. 

 

 

Pharmacological therapies

 

Inhalational therapy

According to Dr. Lowe, a combination of inhalational long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA) remains the gold-standard symptomatic treatment of severe COPD. “The strategies currently developed are directed toward improving symptoms and inhibiting disease progression,” he tells MDLinx.

Dr. Lahey notes that triple-inhaler therapy, which includes LAMA, LABA, and inhaled corticosteroids (ICS), has been effective for patients with severe COPD. However, using ICS in combination therapies is contentious among the experts.

PDE4 Inhibitors

Dr. Lahey explains the role of phosphodiesterase-4 (PDE4) inhibitors like roflumilast, noting that they help to decrease airway inflammation in patients with serious chronic bronchitis and recurrent acute exacerbations, particularly in treatment-resistant patients. 

The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report describes the role of roflumilast as follows: ”Roflumilast reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.”

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Report. GOLDCOPD.org. 2023.

Essentially, it improves lung function and benefits those not fully controlled on LABA+ICS.

 

Biologics

Biologic agents are another area of growing interest. 

Like the treatments applied in asthma, the new group of biologics addressing distinct inflammation processes is now being studied for COPD.

Dr. Lowe shares, “One of the most desired innovations is the use of biologics directed at several inflammatory targets, including IL-5 and IL-4 blockers, which have the potential to prevent exacerbations in patients with high eosinophil counts.” 

GLP-1RAs

GLP-1 receptor agonists (GLP-1RAs) can lower the risk of severe exacerbations by 30% in COPD patients with comorbidities like diabetes or obesity.

Wang W, Mei A, Qian H, et al. The role of glucagon-like peptide-1 receptor agonists in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2023;18:129–137.

"Obesity, diabetes, and heart disease are linked to higher mortality in COPD patients,” Dr. Mohta explains. “More than a third of COPD cases are also obese. GLP-1RAs show promise in reducing mucus secretion, improving lung function, and potentially lowering mortality rates. However, we still need more data to understand their long-term benefits fully."

 

 

 

Short-term systemic therapy

Short-acting beta-agonists (SABA) and systemic corticosteroids are standard treatments for severe acute COPD exacerbations. According to current GOLD guidelines, systemic corticosteroids reduce treatment failure, prevent relapses, and shorten hospital stays in severe cases.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Report. GOLDCOPD.org. 2023.

 

Another short-term therapy useful in high-risk cases is antibiotics, says Dr. Mohta. However, their use is controversial due to resistance concerns. "Antibiotics can help, especially in infection-prone patients, but the risks must be weighed carefully," he says.

The GOLD 2023 report outlines criteria for antibiotic use in COPD exacerbations to minimize overuse and resistance.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Report. GOLDCOPD.org. 2023.

Antibiotics should be prescribed if patients satisfy any of the following three conditions:

 

1. They have all three key symptoms: dyspnea, high sputum volume, and purulent sputum.

2. They have any two of the above three symptoms, but one of them must be the thicker/discolored sputum.

3. They need mechanical ventilation, either through a mask or a breathing tube.

 

Oxygen therapy and non-invasive ventilation

 

Long-term oxygen therapy (LTOT) is a critical intervention for patients with severe hypoxemia. Studies demonstrate that using oxygen for more than 15 hours daily can improve survival.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Report. GOLDCOPD.org. 2023.

However, as Dr. Mohta cautions, “Not all COPD patients need oxygen, and overuse can do more harm than good. Since LTOT reduces hypoxic respiratory drive, you must monitor patients closely to avoid complications like hypercapnia.”

 

It’s important to note that the GOLD report indicates NIV is standard of care for “decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure.”

 

Multidisciplinary approach

 

Experts agree that the complex natures of COPD necessitates a multidisciplinary approach. ”We must look at the whole patient—their nutrition, mental health, and even their end-of-life care planning,” Dr. Mohta tells MDLinx. 

 

For high-risk COPD patients, the value of a multidisciplinary approach cannot be overstated.

“The best outcomes often come when pulmonologists, respiratory therapists, nutritionists, and palliative care specialists work in tandem,” he adds.

Research strongly supports this approach; consider the following:

• A 2024 study in The Netherlands showed that multidisciplinary consultation (MDC) improved care for severe COPD patients. In 84% of the 61 cases reviewed, different and more integrated treatments were recommended, improving care coordination and reducing unnecessary referrals.

  Hekking PP, van Meggelen M, Lie WJ, et al. Severe COPD: multidisciplinary consultation to get the right care at the right place. Int J Chron Obstruct Pulmon Dis. 2024;19:749–752.

   

• In a 2020 American cohort study, 24% of COPD patients showed improvement in their BODE scores (evaluates BMI, Obstruction in airflow, Dyspnea, and Exercise Capacity) with MDC. Cases with higher baseline symptom severity were more likely to improve.

  Mansoor S, Obaida Z, Ballowe L, et al. Clinical impact of multidisciplinary outpatient care on outcomes of patients with COPD. Int J Chron Obstruct Pulmon Dis. 2020;15:33–42.

   

   

 

Non-pharmacological interventions

 

 

In addition to drugs, elaborate pulmonary rehabilitation is showing itself to be a crucial element in enhancing the quality of life and functional status of COPD patients.

 

Dr. Lowe says that lung volume reduction surgery is valuable in “carefully selected patients,” noting that when medications alone aren't sufficient, surgery becomes an option for severe emphysema, drastically improving lung function and reducing symptoms. These techniques include removal of damaged tissue and endoscopic reduction with valves to shrink diseased areas. For the most advanced cases, lung transplants may be considered. In less extreme situations, bullectomy can help improve airflow.