-
SOB only w/ strenuous exercise/hurrying at level/walking uphill (mMRC 0-1 or CAT <10) 0-1 mod/severe exac/yr (none requiring hospitalization) in past yr Inhaled BD1 for COPD Group A2 pts - 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 BD1 (long-acting preferred unless SOB is only occasional [A]):
o LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
o LABA options: arformoterol, formoterol, olodaterol, salmeterol
o SAMA: ipratropium (MDI, NEB)
o SABA options: albuterol, levalbuterol (MDI, NEB) - Eval response: If benefit is documented, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. Check inhaler technique every visit
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel3 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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 q1y4
- Eval and treat comorbidities (CV, etc5)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies6 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)7
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV1 decline compared w/ placebo.
2 Group A=few sx, low exac risk. Exac=dyspnea and/or cough and sputum that worsen over <14 days.
3 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
4 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
5 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
6 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
7 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
≥2 mod/severe exac/yr (or ≥1 COPD hospitalization) in past yr Long-acting inhaled BD combo;1 consider O2 tx, ventilation, surgery/procedures for COPD Group E2 pts - 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 LABA+LAMA:1
o LABA options: arformoterol, formoterol, olodaterol, salmeterol
o LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
o LAMA/LABA combo options: aclidinium/formoterol, glycopyrrolate/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol - If eos ≥300 cells/µL: Consider ICS+LAMA+LABA
o ICS/LAMA/LABA combo options: budesonide/glycopyrrolate/formoterol, fluticasone furoate/umeclidinium/vilanterol - Eval response: De-escalate tx when appropriate. Check inhaler technique every visit
- If hypoxemic per O2 sat/ABG:3 Assess for long-term O2 tx3
- Ventilation: Consider NPPV in select pts (eg, if persistent daytime hypercapnia)4
- Pulmonary rehab5 recommended [A]. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
- Surgery/Procedures: If severe dz, consider procedural interventions6
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel7 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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
- Check spirometry q1y8
- Eval and treat comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies10 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)11
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV 1 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Roflumilast improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV 1 <50% w/ hx exac [A], esp if hospitalized for COPD exac in past yr [A]. Benefits greater in pts previously hospitalized for acute exac.
• Antibiotics: Consider macrolides in former smokers w/ exac despite appropriate tx [B]. Azithromycin (250 mg/day or 500 mg 3x/wk) or erythromycin (250 mg bid) reduces exac over 1y [A]; azithromycin assoc w/ incr bacterial resistance [A], hearing impairment [B], and long QTc. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group E=high exac risk. Exac=dyspnea and/or cough and sputum that worsen over <14 days.
3 If clinical signs of resp/R heart failure: check pulse ox; if O 2 sat <92%: check blood gas.
Long-term O2 (≥15h/day) tx indications:
• Sat ≤88% or PaO 2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or
• Sat 88% or PaO 2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or Hct >55%
Prescribe O 2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O 2 [A]; however, consider individual factors. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval 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].
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
5 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
6 Procedural interventions:
• Lung volume reduction surgery. Consider 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/ FEV 1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV 1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO 2 >50 mmHg and/or PaO 2 <60 mmHg, and FEV 1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV 1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
7 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
8 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
9 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
10 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
11 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
SOB walking at level: Slow for age or must make stops (mMRC ≥2 or CAT ≥10) 0-1 mod/severe exac/yr (none requiring hospitalization) in past yr Long-acting inhaled BD combo;1 consider additional interventions in select pts for COPD Group B2 pts - 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 LABA+LAMA:1
o LABA options: arformoterol, formoterol, olodaterol, salmeterol
o LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
o LAMA/LABA combo options: aclidinium/formoterol, glycopyrrolate/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol - If LABA+LAMA not considered appropriate: No evidence favors LABA vs LAMA mono-tx; choice depends on pt’s perception of sx relief
- Eval response: De-escalate tx when appropriate. Check inhaler technique every visit
- Consider for select pts: If hypoxemic per O2 sat/ABG,3 assess for long-term O2 tx.3 For select pts, consider noninvasive ventilation,4 procedural interventions5,6
- Pulmonary rehab7 recommended [A]. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel8 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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
- Check spirometry q1y6
- Eval and treat comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies10 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)11
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV 1 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• Combo BDs from different classes may ↑efficacy, ↓side effects. Combo LAMA/LABA improved QOL vs placebo or individual components in those w/ highest sx burden, in 1 trial.
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• Opioids: If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B].
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group B=more sx, low exac risk. Exac=dyspnea and/or cough and sputum that worsen over <14 days.
3 If clinical signs of resp/R heart failure: check pulse ox; if O 2 sat <92%: check blood gas.
Long-term O2 (≥15h/day) tx indications:
• Sat ≤88% (or PaO 2 ≤55 mmHg) (w/ or w/o hypercapnia) 2x in 3wk, or
• Sat 88% (or PaO 2 55-60 mmHg) w/ pulm HTN, edema suggesting CHF, or Hct >55%
Prescribe O 2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O 2 [A]; however, consider individual factors. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval at 60-90 days w/ pulse ox/ABG. Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK w/o further assessment; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
5 Procedural interventions:
• Lung volume reduction surgery. Consider 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/ FEV 1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV 1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO 2 >50 mmHg and/or PaO 2 <60 mmHg, and FEV 1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV 1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
6 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
7 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
8 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
9 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
10 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
11 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
≥2 mod/severe exac/yr (or ≥1 COPD hospitalization) in past yr Long-acting inhaled BD combo;1 consider O2 tx, ventilation, surgery/procedures for COPD Group E2 pts - 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 LABA+LAMA:1
o LABA options: arformoterol, formoterol, olodaterol, salmeterol
o LAMA options: aclidinium, glycopyrrolate, revefenacin, tiotropium (DPI, MDI), umeclidinium
o LAMA/LABA combo options: aclidinium/formoterol, glycopyrrolate/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol
- If eos ≥300 cells/µL: Consider ICS+LAMA+LABA
o ICS/LAMA/LABA combo options: budesonide/glycopyrrolate/formoterol, fluticasone furoate/umeclidinium/vilanterol - Eval response: De-escalate tx when appropriate. Check inhaler technique every visit
- If hypoxemic per O2 sat/ABG:3 Assess for long-term O2 tx3
- Ventilation: Consider NPPV in select pts (eg, if persistent daytime hypercapnia)4
- Pulmonary rehab5 recommended [A]. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
- Surgery/Procedures: If severe dz, consider procedural interventions6
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel7 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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
- Check spirometry q1y8
- Eval and treat comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Discuss palliative strategies, advance directives
- Follow COVID-19 mitigation strategies10 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)11
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV 1 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Roflumilast improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV 1 <50% w/ hx exac [A], esp if hospitalized for COPD exac in past yr [A]. Benefits greater in pts previously hospitalized for acute exac.
• Antibiotics: Consider macrolides in former smokers w/ exac despite appropriate tx [B]. Azithromycin (250 mg/day or 500 mg 3x/wk) or erythromycin (250 mg bid) reduces exac over 1y [A]; azithromycin assoc w/ incr bacterial resistance [A], hearing impairment [B], and long QTc. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• Opioids: If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B].
• Roflumilast: Consider adding if FEV 1 <50% in chronic bronchitis, esp if hospitalized for COPD exac in past yr [A]. Improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV 1 <50% w/ hx exac [A]. Benefits greater in pts previously hospitalized for acute exac.
• If severe A1AT deficiency w/ emphysema: Consider A1AT replacement tx [B].
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group E=high exac risk. Exac=dyspnea and/or cough and sputum that worsen over <14 days.
3 If clinical signs of resp/R heart failure: check pulse ox; if O 2 sat <92%: check blood gas.
Long-term O2 (≥15h/day) tx indications:
• Sat ≤88% or PaO 2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or
• Sat 88% or PaO 2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or Hct >55%
Prescribe O 2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O 2 [A]; however, consider individual factors. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval 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].
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
5 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
6 Procedural interventions:
• Lung volume reduction surgery. Consider 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/ FEV 1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV 1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO 2 >50 mmHg and/or PaO 2 <60 mmHg, and FEV 1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV 1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
7 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
8 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
9 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
10 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
11 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
-
Suboptimal response to current COPD tx
Dyspnea only, not exacerbations, warrants targeting Target dyspnea sx w/ additional tx; assess for interventions; mitigate risks
Assess for additional interventions; mitigate risks: - If hypoxemic per O2 sat/ABG:2 Assess for long-term O2 tx2
- Ventilation: Consider NPPV in select pts (eg, if persistent daytime hypercapnia)3
- Pulmonary rehab4 recommended [A]. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
- Surgery/Procedures: If severe dz, consider procedural interventions5
- If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel6 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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
- Check spirometry q1y7
- Eval and treat comorbidities (CV, etc8)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies9 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)10
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV 1 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• Roflumilast: Consider adding if FEV 1 <50% in chronic bronchitis, esp if hospitalized for COPD exac in past yr [A]. Improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV 1 <50% w/ hx exac [A]. Benefits greater in pts previously hospitalized for acute exac.
• Antibiotics: Consider macrolides in former smokers w/ exac despite appropriate tx [B]. Azithromycin (250 mg/day or 500 mg 3x/wk) or erythromycin (250 mg bid) reduces exac over 1y [A]; azithromycin assoc w/ incr bacterial resistance [A], hearing impairment [B], and long QTc. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Opioids: If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B].
• If severe A1AT deficiency w/ emphysema: Consider A1AT replacement tx [B].
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 If clinical signs of resp/R heart failure: check pulse ox; if O 2 sat <92%: check blood gas.
Long-term O2 (≥15h/day) tx indications:
• Sat ≤88% or PaO 2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or
• Sat 88% or PaO 2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or Hct >55%
Prescribe O 2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O 2 [A]; however, consider individual factors. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval 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].
3 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
4 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
5 Procedural interventions:
• Lung volume reduction surgery. Consider 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/ FEV 1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV 1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO 2 >50 mmHg and/or PaO 2 <60 mmHg, and FEV 1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV 1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
6 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
7 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
8 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
9 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
10 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
Exacerbations (+/- dyspnea) warrant targeting Target exac (+/- dyspnea) w/ additional tx: - 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+LABA1
- 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;1 if former smoker, consider azithromycin1
- If on ICS+LAMA+LABA triple tx: Consider eliminating ICS.2 If FEV1 <50% w/ chronic bronchitis, consider roflumilast.1 If former smoker, consider azithromycin1
- Continue short-acting BD for sx rescue: SAMA (ipratropium (MDI, NEB)), SABA (albuterol, levalbuterol (MDI, NEB)) for all pts
- Eval response, escalate and de-escalate as needed. Check inhaler technique every visit
Assess for additional interventions; mitigate risks: - If hypoxemic per O2 sat/ABG:3 Assess for long-term O2 tx3
- Ventilation: Consider NPPV in select pts (eg, if persistent daytime hypercapnia)4
- Pulmonary rehab5 recommended [A]. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
- Surgery/Procedures: If severe dz, consider procedural interventions6
- If smoker, cessation tx [A] using ≥1 first-line tx: nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion, nortriptyline); use drugs along w/ intervention program; counsel7 at every visit. Efficacy of e-cig as cessation aid controversial
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. 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]
- 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
- Check spirometry q1y8
- Eval and treat comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies10 and test for SARS-CoV-2 if warranted (eg, new or worsening resp sx, fever, loss of taste and/or smell)11
Footnotes 1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV 1 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]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A].
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• Roflumilast: Consider adding if FEV 1 <50% in chronic bronchitis, esp if hospitalized for COPD exac in past yr [A]. Improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV 1 <50% w/ hx exac [A]. Benefits greater in pts previously hospitalized for acute exac.
• Antibiotics: Consider macrolides in former smokers w/ exac despite appropriate tx [B]. Azithromycin (250 mg/day or 500 mg 3x/wk) or erythromycin (250 mg bid) reduces exac over 1y [A]; azithromycin assoc w/ incr bacterial resistance [A], hearing impairment [B], and long QTc. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Opioids: If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B].
• If severe A1AT deficiency w/ emphysema: Consider A1AT replacement tx [B].
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Consider removing ICS if pneumonia or other considerable ADRs. If eos ≥300 cells/µL, de-escalation is more likely to lead to exac.
3 If clinical signs of resp/R heart failure: check pulse ox; if O 2 sat <92%: check blood gas.
Long-term O2 (≥15h/day) tx indications:
• Sat ≤88% or PaO 2 ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or
• Sat 88% or PaO 2 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or Hct >55%
Prescribe O 2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O 2 [A]; however, consider individual factors. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval 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].
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
5 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
6 Procedural interventions:
• Lung volume reduction surgery. Consider 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/ FEV 1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted.
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV 1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ BODE Index 5-6, PCO 2 >50 mmHg and/or PaO 2 <60 mmHg, and FEV 1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV 1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN.
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
7 Brief cessation counseling:
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system
• Advise quitting in a clear, strong, personalized manner
• Assess willingness to quit, determine when (eg, w/in next 30 days)
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources
• Arrange f/u in person or via phone, etc
8 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
9 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
10 COVID-19 mitigation strategies:
• Follow basic infxn control measures
• Wear a face covering in public
• Consider sheltering in place
11 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.
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