-
GOLD group A. mMRC 0-1 or CAT <10 w/ 0-1 mod/severe exac/yr (w/o hospitalization) in past yr. Prescribe rescue short-acting BD (SABA or SAMA) to all pts for immediate sx relief. SABA options: albuterol, levalbuterol ( MDI, NEB). SAMA: ipratropium ( MDI, NEB). Start long- or short-acting BD. Long-acting preferred unless SOB is only occasional [A]. Inhaled is preferred vs. oral [A]. Regular and prn SAMA or SABA use improves FEV1 and sx [A]; SABA+SAMA combos more effective than mono-tx [A]. LABAs and LAMAs improve dyspnea, reduce exac rate [A]. LAMAs reduce exac [A]and hospitalizations [B]more than LABAs; combos more effective than mono-tx [B]. Tailor choice of inhaler to pt’s ability and preference. Minimize number of devices. - LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
- LABA options: arformoterol, formoterol, olodaterol, salmeterol
- SAMA: ipratropium (MDI, NEB)
- SABA options: albuterol, levalbuterol (MDI, NEB)
- Oral theophylline: has small bronchodilator effect [A]and assoc w/ modest sx benefit [B]. Disadvantages: low therapeutic ratio and many toxic effects (arrhythmias, sz, drug interactions, others).
After tx initiation, review, assess, and adjust if needed. Review sx and exac risk (hx and blood eos). Assess inhaler technique and benefits of non-pharm tx (e.g., pulm rehab, self-mgmt education) at every visit. If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Any change in regimen requires re-review. Mitigate risks - Smoking cessation [A]: Prescribe ≥1 first-line tx: varenicline, nortriptyline, bupropion SR, nicotine gum/lozenge/inhaler/spray/patch; use drugs along w/ intervention program; counsel1 at every visit. No evidence to support use of e-cigs as cessation aid.
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [B]. Tdap if not previously received [B]. Zoster if ≥50 yo [B]. CDC recommends 1 dose of PCV20, or 1 dose of PCV15 followed by PPSV23 in pts w/ COPD [B]. RSV vaccine [A].
- If environment risks: efficient ventilation, nonpolluting cooking stoves, etc. [B], avoidance of irritants if possible [D].
- Create written COPD exac action plan w/ educational component; maintain regular clinician contact.
- Encourage physical activity; ensure adequate sleep, healthy diet.
- Check spirometry q1y.
- Evaluate and treat comorbidities (CVD, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA).
- Screen all pts once for AATD.
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent exac in winter months.
- Follow COVID-19 mitigation strategies and test for SARS-CoV-2 if warranted (e.g., new or worsening resp sx, fever, loss of taste and/or smell). If SARS-CoV-2 pos, continue usual COPD meds.
Treatments w/ no or uncertain benefits: oral steroids [C], antitussives [C], vasodilators [B], drugs for primary pulm HTN [B], mepolizumab, benralizumab, dupilumab, nedocromil, leukotriene modifiers, infliximab, immunostimulants, beta-blockers (if no CV indication for use), simvastatin (if no CV indication) [A], vit D supplementation.
Footnotes 1 Brief cessation counseling:
• Ask tobacco users about tobacco use at every visit; use office-wide identification system.
• Advise quitting, in a clear, strong, personalized manner.
• Assess willingness to quit, determine when (e.g., w/in next 30 days).
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharm tx, educational resources.
• Arrange f/u in person or via phone, etc.
GOLD group B. mMRC ≥2 or CAT ≥10 w/ 0-1 mod/severe exac/yr (w/o hospitalization) in past yr. Give long-acting inhaled BD combo (LABA+LAMA) plus short-acting rescue BD; inhaled is preferred vs. oral [A]. LABAs and LAMAs improve dyspnea, reduce exac rate [A]. LAMAs reduce exac [A]and hospitalizations [B]more than LABAs; combos more effective than mono-tx [B]. Tailor choice of inhaler to pt’s ability and preference. Single-inhaler tx may be more effective/convenient than multiple inhalers and improves compliance. - Rescue short-acting BD (SABA or SAMA) for immediate sx relief. SABA options: albuterol, levalbuterol (MDI, NEB). SAMA: ipratropium (MDI, NEB).
- LABA+LAMA:
◦ LABA options: arformoterol, formoterol, olodaterol, salmeterol
◦ LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
◦ LAMA/LABA combo options: aclidinium/formoterol, glycopyrrolate/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol
◦ Oral SR theophylline: has small bronchodilator effect [A]and assoc w/ modest sx benefit [B]. Disadvantages: small therapeutic ratio and many toxic effects (arrhythmias, sz, drug interactions, others).
Offer pulmonary rehab [A]. Encourage physical activity; improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6- to 8-wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Can be done at a range of sites, including home programs. If hypoxemic per SpO2/ABG: Assess for long-term O2 tx indications: SpO2 ≤88% or PaO2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or sat 88% or PaO2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or hct >55%. Prescribe O2 for severe resting hypoxemia [A]. - If stable COPD w/ only moderate resting/exercise-induced desaturation, no benefit to O2 [A].
- If placed on long-term O2, titrate to keep sat ≥90%; re-evaluate at 60-90 days w/ pulse ox/ABG.
- Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
If stable w/ marked hypercapnia, consider NPPV. NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp. if daytime PaCO2 >53 mmHg [B]. Long-term NPPV beneficial in pts w/ severe chronic hypercapnia and hx of hospitalization for acute resp failure [B]. If COPD+OSA, CPAP has clear benefits. If severe dz / emphysema w/ hyperinflation, consider procedural interventions. - If giant bulla, consider bullectomy in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
- If no large bulla, consider ELVR or LVRS in select pts.
◦ LVRS improves survival in severe dz w/ upper-lobe emphysema + low post-rehab exercise capacity [A]; however, LVRS shows higher mortality vs. medical mgmt in pts w/ FEV1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
◦ ELVR (e.g., EBV [A], LVRC [B], VA [B]) ↓ end-exp lung volume and ↑ exercise tolerance, health status, and lung fxn at 6-12mo in select pts. - If progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO2 >50 mmHg and/or PaO2 <60 mmHg, and FEV1 <25% predicted, refer for lung txp eval. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV1 <30% predicted) [C]. Txp-list criteria (any 1 of): BODE >7, FEV1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
- If AATD, alpha-1 antitrypsin IV augmentation may slow emphysema progression [B].
After tx initiation, review, assess, and adjust if needed. Review sx and exac risk (hx and blood eos). Assess inhaler technique and benefits of non-pharm tx (e.g., pulm rehab, self-mgmt education) at every visit. If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Any change in regimen requires re-review. Mitigate risks - Smoking cessation [A]: Prescribe ≥1 first-line tx: varenicline, nortriptyline, bupropion SR, nicotine gum/lozenge/inhaler/spray/patch; use drugs along w/ intervention program; counsel1 at every visit. No evidence to support use of e-cigs as cessation aid.
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [B]. Tdap if not previously received [B]. Zoster if ≥50 yo [B]. CDC recommends 1 dose of PCV20, or 1 dose of PCV15 followed by PPSV23 in pts w/ COPD [B]. RSV vaccine [A].
- If environment risks: efficient ventilation, nonpolluting cooking stoves, etc. [B], avoidance of irritants if possible [D].
- Create written COPD exac action plan w/ educational component; maintain regular clinician contact.
- Encourage physical activity; ensure adequate sleep, healthy diet.
- Check spirometry q1y.
- Evaluate and treat comorbidities (CVD, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA).
- Screen all pts once for AATD.
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent exac in winter months.
- Follow COVID-19 mitigation strategies and test for SARS-CoV-2 if warranted (e.g., new or worsening resp sx, fever, loss of taste and/or smell). If SARS-CoV-2 pos, continue usual COPD meds.
Treatments w/ no or uncertain benefits: oral steroids [C], antitussives [C], vasodilators [B], drugs for primary pulm HTN [B], mepolizumab, benralizumab, dupilumab, nedocromil, leukotriene modifiers, infliximab, immunostimulants, beta-blockers (if no CV indication for use), simvastatin (if no CV indication) [A], vit D supplementation.
Footnotes 1 Brief cessation counseling:
• Ask tobacco users about tobacco use at every visit; use office-wide identification system.
• Advise quitting, in a clear, strong, personalized manner.
• Assess willingness to quit, determine when (e.g., w/in next 30 days).
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharm tx, educational resources.
• Arrange f/u in person or via phone, etc.
GOLD group E. Any mMRC or CAT score w/ ≥2 mod/severe exac/yr or ≥1 COPD hospitalization in past yr. Give long-acting inhaled BD combo (LABA+LAMA) plus short-acting rescue BD; inhaled is preferred vs. oral [A]. Add ICS if blood eos ≥300. LABA+ICS not recommended. LABAs and LAMAs improve dyspnea, reduce exac rate [A]. LAMAs reduce exac [A]and hospitalizations [B]more than LABAs; combos more effective than mono-tx [B]. Tailor choice of inhaler to pt’s ability and preference. Single-inhaler tx may be more effective/convenient than multiple inhalers and improves compliance. - Rescue short-acting BD (SABA or SAMA) for immediate sx relief. SABA options: albuterol, levalbuterol (MDI, NEB). SAMA: ipratropium (MDI, NEB).
- LABA+LAMA:
◦ LABA options: arformoterol, formoterol, olodaterol, salmeterol
◦ LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
◦ LAMA/LABA combo options: aclidinium/formoterol, glycopyrrolate/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol
◦ ICS/LAMA/LABA combo options: budesonide/glycopyrrolate/formoterol, fluticasone furoate/umeclidinium/vilanterol
◦ Oral SR theophylline: has small bronchodilator effect [A]and assoc w/ modest sx benefit [B]. Disadvantages: small therapeutic ratio and many toxic effects (arrhythmias, sz, drug interactions, others).
Offer pulmonary rehab [A]. Encourage physical activity; improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6- to 8-wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Can be done at a range of sites, including home programs. If hypoxemic per SpO2/ABG: Assess for long-term O2 tx indications: SpO2 ≤88% or PaO2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or sat 88% or PaO2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or hct >55%. Prescribe O2 for severe resting hypoxemia [A]. - If stable COPD w/ only moderate resting/exercise-induced desaturation, no benefit to O2 [A].
- If placed on long-term O2, titrate to keep sat ≥90%; re-evaluate at 60-90 days w/ pulse ox/ABG.
- Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
If stable w/ marked hypercapnia, consider NPPV. NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp. if daytime PaCO2 >53 mmHg [B]. Long-term NPPV beneficial in pts w/ severe chronic hypercapnia and hx of hospitalization for acute resp failure [B]. If COPD+OSA, CPAP has clear benefits. If severe dz / emphysema w/ hyperinflation, consider procedural interventions. - If giant bulla, consider bullectomy in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
- If no large bulla, consider ELVR or LVRS in select pts.
◦ LVRS improves survival in severe dz w/ upper-lobe emphysema + low post-rehab exercise capacity [A]; however, LVRS shows higher mortality vs. medical mgmt in pts w/ FEV1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
◦ ELVR (e.g., EBV [A], LVRC [B], VA [B]) ↓ end-exp lung volume and ↑ exercise tolerance, health status, and lung fxn at 6-12mo in select pts. - If progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO2 >50 mmHg and/or PaO2 <60 mmHg, and FEV1 <25% predicted, refer for lung txp eval. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV1 <30% predicted) [C]. Txp-list criteria (any 1 of): BODE >7, FEV1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
- If AATD, alpha-1 antitrypsin IV augmentation may slow emphysema progression [B].
After tx initiation, review, assess, and adjust if needed. Review sx and exac risk (hx and blood eos). Assess inhaler technique and benefits of non-pharm tx (e.g., pulm rehab, self-mgmt education) at every visit. If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Any change in regimen requires re-review. Mitigate risks - Smoking cessation [A]: Prescribe ≥1 first-line tx: varenicline, nortriptyline, bupropion SR, nicotine gum/lozenge/inhaler/spray/patch; use drugs along w/ intervention program; counsel1 at every visit. No evidence to support use of e-cigs as cessation aid.
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [B]. Tdap if not previously received [B]. Zoster if ≥50 yo [B]. CDC recommends 1 dose of PCV20, or 1 dose of PCV15 followed by PPSV23 in pts w/ COPD [B]. RSV vaccine [A].
- If environment risks: efficient ventilation, nonpolluting cooking stoves, etc. [B], avoidance of irritants if possible [D].
- Create written COPD exac action plan w/ educational component; maintain regular clinician contact.
- Encourage physical activity; ensure adequate sleep, healthy diet.
- Check spirometry q1y.
- Evaluate and treat comorbidities (CVD, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA).
- Screen all pts once for AATD.
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent exac in winter months.
- Follow COVID-19 mitigation strategies and test for SARS-CoV-2 if warranted (e.g., new or worsening resp sx, fever, loss of taste and/or smell). If SARS-CoV-2 pos, continue usual COPD meds.
Treatments w/ no or uncertain benefits: oral steroids [C], antitussives [C], vasodilators [B], drugs for primary pulm HTN [B], mepolizumab, benralizumab, dupilumab, nedocromil, leukotriene modifiers, infliximab, immunostimulants, beta-blockers (if no CV indication for use), simvastatin (if no CV indication) [A], vit D supplementation.
Footnotes 1 Brief cessation counseling:
• Ask tobacco users about tobacco use at every visit; use office-wide identification system.
• Advise quitting, in a clear, strong, personalized manner.
• Assess willingness to quit, determine when (e.g., w/in next 30 days).
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharm tx, educational resources.
• Arrange f/u in person or via phone, etc.
-
Suboptimal response to current COPD tx
Any GOLD group, dyspnea only, w/o exacerbations Check adherence, inhaler technique, and possible interfering comorbidities. Target dyspnea sx w/ additional tx; consider switching inhaler device or molecules. Implement or escalate non-pharm tx. Investigate and treat other causes of dyspnea. Mitigate risks. Consider pulmonary rehab [A]. Encourage physical activity; improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6- to 8-wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Can be done at a range of sites, including home programs. If hypoxemic per SpO2/ABG: Assess for long-term O2 tx indications: SpO2 ≤88% or PaO2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or sat 88% or PaO2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or hct >55%. Prescribe O2 for severe resting hypoxemia [A]. - If stable COPD w/ only moderate resting/exercise-induced desaturation, no benefit to O2 [A].
- If placed on long-term O2, titrate to keep sat ≥90%; re-evaluate at 60-90 days w/ pulse ox/ABG.
- Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
If stable w/ marked hypercapnia, consider NPPV. NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp. if daytime PaCO2 >53 mmHg [B]. Long-term NPPV beneficial in pts w/ severe chronic hypercapnia and hx of hospitalization for acute resp failure [B]. If COPD+OSA, CPAP has clear benefits. If severe dz / emphysema w/ hyperinflation, consider procedural interventions. - If giant bulla, consider bullectomy in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
- If no large bulla, consider ELVR or LVRS in select pts.
◦ LVRS improves survival in severe dz w/ upper-lobe emphysema + low post-rehab exercise capacity [A]; however, LVRS shows higher mortality vs. medical mgmt in pts w/ FEV1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
◦ ELVR (e.g., EBV [A], LVRC [B], VA [B]) ↓ end-exp lung volume and ↑ exercise tolerance, health status, and lung fxn at 6-12mo in select pts. - If progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO2 >50 mmHg and/or PaO2 <60 mmHg, and FEV1 <25% predicted, refer for lung txp eval. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV1 <30% predicted) [C]. Txp-list criteria (any 1 of): BODE >7, FEV1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
- If AATD, alpha-1 antitrypsin IV augmentation may slow emphysema progression [B].
After tx initiation, review, assess, and adjust if needed. Review sx and exac risk (hx and blood eos). Assess inhaler technique and benefits of non-pharm tx (e.g., pulm rehab, self-mgmt education) at every visit. If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Any change in regimen requires re-review. Mitigate risks - Smoking cessation [A]: Prescribe ≥1 first-line tx: varenicline, nortriptyline, bupropion SR, nicotine gum/lozenge/inhaler/spray/patch; use drugs along w/ intervention program; counsel1 at every visit. No evidence to support use of e-cigs as cessation aid.
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [B]. Tdap if not previously received [B]. Zoster if ≥50 yo [B]. CDC recommends 1 dose of PCV20, or 1 dose of PCV15 followed by PPSV23 in pts w/ COPD [B]. RSV vaccine [A].
- If environment risks: efficient ventilation, nonpolluting cooking stoves, etc. [B], avoidance of irritants if possible [D].
- Create written COPD exac action plan w/ educational component; maintain regular clinician contact.
- Encourage physical activity; ensure adequate sleep, healthy diet.
- Check spirometry q1y.
- Evaluate and treat comorbidities (CVD, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA).
- Screen all pts once for AATD.
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent exac in winter months.
- Follow COVID-19 mitigation strategies and test for SARS-CoV-2 if warranted (e.g., new or worsening resp sx, fever, loss of taste and/or smell). If SARS-CoV-2 pos, continue usual COPD meds.
Treatments w/ no or uncertain benefits: oral steroids [C], antitussives [C], vasodilators [B], drugs for primary pulm HTN [B], mepolizumab, benralizumab, dupilumab, nedocromil, leukotriene modifiers, infliximab, immunostimulants, beta-blockers (if no CV indication for use), simvastatin (if no CV indication) [A], vit D supplementation. Consider palliative approaches for all pts w/ sx [D]. - Discuss views on end-of-life care w/ pts and families, including resuscitation, advance directives, and place-of-death preferences [D].
- Options for relief of breathlessness: NMES, oxygen, fans [C].
- Consider nutritional supplementation in malnourished pts [B]; may improve resp muscle strength and overall health status [C].
- Improve fatigue w/ self-mgmt education, pulm rehab, nutritional support, and mind-body interventions [B].
Footnotes 1 Brief cessation counseling:
• Ask tobacco users about tobacco use at every visit; use office-wide identification system.
• Advise quitting, in a clear, strong, personalized manner.
• Assess willingness to quit, determine when (e.g., w/in next 30 days).
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharm tx, educational resources.
• Arrange f/u in person or via phone, etc.
Any GOLD group w/ exacerbations (+/- dyspnea) Check adherence, inhaler technique, and possible interfering comorbidities. Target exac (+/- dyspnea) w/ additional tx. Mitigate risks. If advanced COPD, consider palliative care and end-of-life support. - If on single LABA or LAMA: If eos <300 cells/µL, switch to LAMA+LABA combo; if eos ≥300 cells/µL, switch to ICS+LAMA+LABA.
- If on LAMA+LABA: If eos ≥100 cells/µL, consider ICS+LAMA+LABA. If eos <100 cells/µL: If FEV1 <50% w/ chronic bronchitis, consider roflumilast (improves lung fxn, reduces exac [A]); if not a current smoker, consider azithromycin (reduces exac [A]but increases bacterial resistance [A]and impairs hearing [B]).
- If on ICS+LAMA+LABA triple tx: Consider removing ICS if pneumonia or other considerable ADRs. If eos ≥300 cells/µL, de-escalation is more likely to lead to exac. If FEV1 <50% w/ chronic bronchitis, consider roflumilast (improves lung fxn, reduces exac [A]); if not a current smoker, consider azithromycin (reduces exac [A]but increases bacterial resistance [A]and impairs hearing [B]).
- If on LABA+ICS w/o features of asthma: If well controlled and no sx, continue. If further exac: If eos ≥100 cells/µL, treat w/ LABA+LAMA+ICS; if eos <100 cells/µL, switch to LABA+LAMA. If further sx, switch to LABA+LAMA.
- Continue short-acting BD for sx rescue: SAMA (ipratropium (MDI, NEB)), SABA (albuterol, levalbuterol (MDI, NEB)) for all pts
Consider pulmonary rehab [A]. Encourage physical activity; improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6- to 8-wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Can be done at a range of sites, including home programs. If hypoxemic per SpO2/ABG: Assess for long-term O2 tx indications: SpO2 ≤88% or PaO2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or sat 88% or PaO2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or hct >55%. Prescribe O2 for severe resting hypoxemia [A]. - If stable COPD w/ only moderate resting/exercise-induced desaturation, no benefit to O2 [A].
- If placed on long-term O2, titrate to keep sat ≥90%; re-evaluate at 60-90 days w/ pulse ox/ABG.
- Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
If stable w/ marked hypercapnia, consider NPPV. NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp. if daytime PaCO2 >53 mmHg [B]. Long-term NPPV beneficial in pts w/ severe chronic hypercapnia and hx of hospitalization for acute resp failure [B]. If COPD+OSA, CPAP has clear benefits. If severe dz / emphysema w/ hyperinflation, consider procedural interventions. - If giant bulla, consider bullectomy in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
- If no large bulla, consider ELVR or LVRS in select pts.
◦ LVRS improves survival in severe dz w/ upper-lobe emphysema + low post-rehab exercise capacity [A]; however, LVRS shows higher mortality vs. medical mgmt in pts w/ FEV1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
◦ ELVR (e.g., EBV [A], LVRC [B], VA [B]) ↓ end-exp lung volume and ↑ exercise tolerance, health status, and lung fxn at 6-12mo in select pts. - If progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO2 >50 mmHg and/or PaO2 <60 mmHg, and FEV1 <25% predicted, refer for lung txp eval. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV1 <30% predicted) [C]. Txp-list criteria (any 1 of): BODE >7, FEV1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
- If AATD, alpha-1 antitrypsin IV augmentation may slow emphysema progression [B].
After tx initiation, review, assess, and adjust if needed. Review sx and exac risk (hx and blood eos). Assess inhaler technique and benefits of non-pharm tx (e.g., pulm rehab, self-mgmt education) at every visit. If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Any change in regimen requires re-review. Mitigate risks - Smoking cessation [A]: Prescribe ≥1 first-line tx: varenicline, nortriptyline, bupropion SR, nicotine gum/lozenge/inhaler/spray/patch; use drugs along w/ intervention program; counsel1 at every visit. No evidence to support use of e-cigs as cessation aid.
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [B]. Tdap if not previously received [B]. Zoster if ≥50 yo [B]. CDC recommends 1 dose of PCV20, or 1 dose of PCV15 followed by PPSV23 in pts w/ COPD [B]. RSV vaccine [A].
- If environment risks: efficient ventilation, nonpolluting cooking stoves, etc. [B], avoidance of irritants if possible [D].
- Create written COPD exac action plan w/ educational component; maintain regular clinician contact.
- Encourage physical activity; ensure adequate sleep, healthy diet.
- Check spirometry q1y.
- Evaluate and treat comorbidities (CVD, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA).
- Screen all pts once for AATD.
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent exac in winter months.
- Follow COVID-19 mitigation strategies and test for SARS-CoV-2 if warranted (e.g., new or worsening resp sx, fever, loss of taste and/or smell). If SARS-CoV-2 pos, continue usual COPD meds.
Treatments w/ no or uncertain benefits: oral steroids [C], antitussives [C], vasodilators [B], drugs for primary pulm HTN [B], mepolizumab, benralizumab, dupilumab, nedocromil, leukotriene modifiers, infliximab, immunostimulants, beta-blockers (if no CV indication for use), simvastatin (if no CV indication) [A], vit D supplementation. Consider palliative approaches for all pts w/ sx [D]. - Discuss views on end-of-life care w/ pts and families, including resuscitation, advance directives, and place-of-death preferences [D].
- Options for relief of breathlessness: NMES, oxygen, fans [C].
- Consider nutritional supplementation in malnourished pts [B]; may improve resp muscle strength and overall health status [C].
- Improve fatigue w/ self-mgmt education, pulm rehab, nutritional support, and mind-body interventions [B].
Footnotes 1 Brief cessation counseling:
• Ask tobacco users about tobacco use at every visit; use office-wide identification system.
• Advise quitting, in a clear, strong, personalized manner.
• Assess willingness to quit, determine when (e.g., w/in next 30 days).
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharm tx, educational resources.
• Arrange f/u in person or via phone, etc.
|
