Facilities for diagnosis at the primary health care centers are generally few. Diagnosis can however be made with the help of a good history and physical examination following the algorithm shown in Fig. 1.Sputum examination for AFB should be done as per RNTCP guidelines which recommend this investigation in any patient with chronic cough because the disease (pulmonary tuberculosis) is rather common. If the sputum is negative, a provisional diagnosis of COPD can be made and treatment given depending on the disease severity, classified as per Table 2.

Mild COPD

1. Advice on smoking cessation (Tables 5,6) and reduction of exposures to other risk factors (for all stages)

2. Drug therapy:Salbutamol or terbutaline (inhalational): 2-4 inhalation/day on “as and when needed” basis

Moderate COPD

1. Start with oral theophylline – 300-600 mg per day

2. Inhalational ipratropium or tiotropium on regular basis.

3. Inhalational salmeterol or formeterol – twice daily

4. Salbutamol or terbutaline inhalation on “as and when needed” basis.

Severe COPD

1. Treatment steps (a to d) as above.

2. In the presence of infective complications: A short course of oral antibioticsamoxycillin, quinolones (levofloxacin or gatifloxacin), macrolides (azithromycin/clarithromycin/roxithromycin) or oral first/second generation cephalosporin (cephalexin, cefadroxil). If response is not good, refer to a secondary care level center.

1. Chest radiograph and sputum examination should be done to look for complications such as pneumonias, pneumothorax, chronic cor pulmonale etc.

2. Treat infective exacerbation with a course of antibiotic (as above). Higher grade antibiotics may be required.

3. Confirm diagnosis and severity of COPD with the help of spirometry

4. Institute drug treatment as at primary care level

5. Consider addition of inhaled corticosteroids (beclomethasone, fluticasone or budesonide) if COPD is severe. Add long term inhaled corticosteroid therapy, only if the patient shows good response to a trial of inhaled corticosteroids administered for about six weeks. A patient who shows frequent exacerbations can also be advised long term inhaled steroid treatment.

If the patient does not show good response to treatment, refer to a tertiary care level center. Faulty technique is perhaps the important cause of failure of response to inhalational therapy. It is therefore important to properly explain and let the patient practice inhalation technique in your presence.

It is important for a tertiary care center to establish facilities for specialty advice and intensive respiratory care. This should include assisted ventilation and all other steps of acute care such as the monitoring of vital parameters, blood gas assessment, maintenance of blood pressure, fluids, electrolytes, nutrition and general organ functions.

At a tertiary care center, acute exacerbation should be handled followed by stabilization and rehabilitation therapy.

Respiratory rehabilitation:Advice on respiratory rehabilitation is important at all levels of care. Advice on smoking cessation and avoidance of risk factors is an essential component of respiratory rehabilitation. Guidelines on advice to quit smoking are listed in Tables 5 and 6.

Rehabilitation at secondary and tertiary care level centers should include advice on nutrition, maintenance bronchodilators and inhalational corticosteroids, prophylactic vaccines and domiciliary oxygen.

Once the patient is stabilized, he should be sent back to the primary care doctor with appropriate briefing and advice on follow up management.