-
SOB only w/ strenuous exercise/hurrying @ level/walking uphill (or CAT <10) 0-1 mod/severe exac/yr (none requiring hospitalization) in past yr Inhaled BD1 for COPD Group A2 pts - Start long- or short-acting BD1 (long-acting preferred unless SOB is only occasional [A]): LAMA (aclidinium, glycopyrronium , tiotropium, umeclidinium); LABA (arformoterol, formoterol, indacaterol, olodaterol, salmeterol); SAMA (ipratropium), SABA (albuterol, levalbuterol)
- Eval response: If sx benefit, continue; otherwise, stop or try alternative BD class. De-escalate tx when appropriate. ✓inhaler technique every visit
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx:1 Nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel3 @ 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 prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- If environment risks: Reduce occupational dust/fume/gas and indoor [B]/outdoor pollutant exposure
- Encourage physical activity; ensure adequate sleep, healthy diet
- ✓Spirometry ≥q1y4
- Eval/tx comorbidities (CV, etc5)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies6 & 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 LABA; 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 monotherapy [A], theophylline, unless other bronchodilators unavailable/unaffordable [B], vasodilators [B], benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• No COPD med has conclusively been shown to modify lung-function decline long-term. However, a systematic review combining data from 9 studies showed 5.0 ml/yr reduction in rate of FEV1 decline compared w/ placebo.
2 Group A=few sx, low exac risk. Exac=acute worsening (beyond day-to-day variation) leading to change in medication.
3 Brief cessation counseling:
• Ask about tobacco use @ 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 dx of COPD 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 & inhaled resp meds for COPD.
≥2 mod/severe exac/yr (or ≥1 COPD hospitalization) in past yr Long-acting inhaled BD,1 consider O2 tx, surgery/procedures, ventilation for COPD Group C2 pts - Start LAMA:1 aclidinium, glycopyrronium , tiotropium, umeclidinium
- Add short-acting BD for sx rescue: SAMA (ipratropium), SABA (albuterol, levalbuterol)
- Eval response: De-escalate tx when appropriate. ✓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. 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:1 Nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel7 @ every visit. Efficacy of e-cig as cessation aid uncertain
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. Tdap if not prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- Avoid aggravating factors. If environment risks: Reduce occupational dust/fume/gas and indoor/outdoor pollutant exposure [B]
- Create written COPD exac action plan w/ ed component; maintain regular clinician contact
- ✓Spirometry ≥q1y8
- Eval/tx comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies10 & 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. LAMA superior to LABA for exac prevention. • 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.
• Roflumilast improves lung function 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 year [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 (500 mg bid) reduces exac over 1y [A]; azithromycin associated w/ increased bacterial resistance [A], hearing impairment [B]. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Vitamin D: Supplementation of vitamin D decreases 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 monotherapy [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-function decline long-term. However, a systematic review combining data from 9 studies showed 5.0 ml/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group C=few sx, high exac risk. Exac=acute worsening (beyond day-to-day variation) leading to change in medication.
3 If clinical signs of resp/heart failure: ✓pulse ox; if O 2 sat <92%: ✓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 @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 ≥52 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.
• LVRS. 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 vol and ↑exercise tolerance, heath status and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
• Txp. In pts w/ very severe (FEV 1 <30% predicted) 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 @ 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 dx of COPD 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 & inhaled resp meds for COPD.
SOB walking @ level: Slow for age or must make stops (or CAT ≥10) 0-1 mod/severe exac/yr (none requiring hospitalization) in past yr Long-acting inhaled BD;1 consider additional interventions in select pts for COPD Group B2 pts - Start long-acting BD:1 either LAMA (aclidinium, glycopyrronium, tiotropium, umeclidinium) or LABA (arfomoterol, formoterol, indacaterol, olodaterol, salmeterol). If severe SOB, consider starting LAMA+LABA combo1
- Add short-acting BD for sx rescue: SAMA (ipratropium), SABA (albuterol, levalbuterol)
- Eval response: De-escalate tx when appropriate. ✓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. Encourage physical activity. No demonstrated benefit for integrative care or telehealth [B]
Mitigate risks - If smoker, cessation tx [A] using ≥1 first-line tx:1 nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel8 @ every visit. Efficacy of e-cig as cessation aid uncertain
- If environment risks: Reduce occupational dust/fume/gas and indoor/outdoor pollutant exposure [B]
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. Tdap if not prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- ✓Spirometry ≥q1y6
- Eval/tx comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigation strategies10 & 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. Long-acting inhaled BDs superior to prn short-acting BDs. LABAs and LAMAs improve dyspnea, reduce exac rate [A]; no evidence of superiority of LAMA vs LABA as initial tx in Group B pts. 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 monotherapy [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 decreases hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).
• No existing COPD med has conclusively been shown to modify lung-function decline long-term. However, a systematic review combining data from 9 studies showed 5.0 ml/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group B=more sx, low exac risk. Exac=acute worsening (beyond day-to-day variation) leading to change in medication.
3 If clinical signs of resp/heart failure: ✓pulse ox; if O 2 sat <92%: ✓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 @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 ≥52 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
5 Procedural interventions.
• LVRS. 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 vol and ↑exercise tolerance, heath status and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
• Txp. In pts w/ very severe (FEV 1 <30% predicted) 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 dx of COPD 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 @ 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 & inhaled resp meds for COPD.
≥2 mod/severe exac/yr (or ≥1 COPD hospitalization) in past yr Combine long-acting inhaled BDs;1 consider O2 tx, ventilation, surgery/procedures for COPD Group D2 pts - Start long-acting BD: LAMA alone (aclidinium, glycopyrronium, tiotropium, umeclidinium) or if highly symptomatic, then LAMA+LABA combo1 aclidinium/formoterol, glycopyrronium/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol). If eos ≥300/uL, consider initial tx w/ ICS+LABA combo (budesonide/formoterol, mometasone/formoterol, fluticasone furoate/vilanterol)
- Add short-acting BD for sx rescue: SAMA (ipratropium), SABA (albuterol, levalbuterol)
- Eval response: De-escalate tx when appropriate. ✓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 hypercapnea)4
- Pulmonary rehab5 recommended. 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:1 Nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel7 @ every visit. Efficacy of e-cig as cessation aid uncertain
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. Tdap if not prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- Avoid aggravating factors. If environment risks: Reduce occupational dust/fume/gas and indoor/outdoor pollutant exposure [B]
- Create written COPD exac action plan w/ ed component; maintain regular contact w/ clinicians
- ✓Spirometry ≥q1y8
- Eval/tx 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 & 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. LAMA+LABA combo reduces dyspnea [A] and reduces exac rate [B] vs single agent tx; if single agent used, LAMA preferred over LABA to ↓exac rate [A], hospitalizations [B]. LAMA+LABA combo superior to ICS+LABA combo for exac prevention in COPD Group D pts [B]; such pts are @ increased pneumonia risk on ICS tx. 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 monotherapy [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. Triple inhaled LAMA/LABA/ICS improves lung function, sx, health status [A] and reduces exac [B] vs ICS/LABA or LAMA mono-tx. Combo LAMA/LABA improved QoL vs placebo or individual components in those w/ highest sx burden.
• Vitamin D: Supplementation of vitamin D decreases 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 year [A]. Improves lung function and reduces mod/severe exac in chronic bronchitis 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 (500 mg bid) reduces exac over 1y [A]; azithromycin associated w/ increased 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 (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-function decline long-term. However, a systematic review combining data from 9 studies showed 5.0 ml/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Group D=more sx, high exac risk. Exac=acute worsening (beyond day-to-day variation) leading to change in medication.
3 If clinical signs of resp/heart failure: ✓pulse ox; if O 2 sat <92%: ✓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 [A]. If placed on long-term O 2, titrate to keep sat ≥90%; re-eval @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.
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO 2 ≥52 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.
• LVRS. 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 vol and ↑exercise tolerance, heath status and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
• Txp. In pts w/ very severe (FEV 1 <30% predicted) 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 @ 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 follow-up in person or via phone, etc
8 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for dx of COPD 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 & 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
- If on single LABA or LAMA: Use LAMA+LABA combo1 (aclidinium/formoterol, glycopyrronium/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol)
- If on ICS+LABA: add LAMA; either remove steroid2 (LAMA+LABA: (aclidinium/formoterol, glycopyrronium/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol) or go to triple tx (ICS+LAMA+LABA) using multiple inhalers
- If on LAMA+LABA (+/- ICS): Switch inhaler device type and/or switch specific drugs in the combination. Investigate dyspnea causes. If on ICS, consider eliminating it2
- Continue short-acting BD for sx rescue: SAMA (ipratropium), SABA (albuterol, levalbuterol), for all pts
- Eval response, escalate and de-escalate as needed. ✓inhaler technique every visit
Assess for additional interventions, mitigate risks: - If hypoxemic per O2 sat/ABG: Assess for long-term O2 tx3
- Ventilation. Consider NPPV in select pts (eg, if persistent daytime hypercapnia)4
- Pulmonary rehab5 recommended. 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:1 Nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel7 @ every visit. Efficacy of e-cig as cessation aid uncertain
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. Tdap if not prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- Avoid aggravating factors. If environment risks: Reduce occupational dust/fume/gas and indoor/outdoor pollutant exposure [B]
- ✓Spirometry ≥q1y8
- Eval/tx comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigations strategies10 & 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. LAMA+LABA combo reduces dyspnea [A] and reduces exac rate [B] vs single agent tx; if single agent used, LAMA preferred over LABA to ↓exac rate [A], hospitalizations [B]. LAMA+LABA combo superior to ICS+LABA combo for exac prevention in COPD Group D pts [B]; such pts are @ increased pneumonia risk on ICS tx. • Not recommended: antitussives [C], long-term oral/inhaled steroid monotherapy [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. Triple inhaled LAMA/LABA/ICS improves lung fxn, sx, health status [A] and reduces exac [B] vs ICS/LABA or LAMA mono-tx. Combo LAMA/LABA improved QoL vs placebo or individual components in those w/ highest sx burden, in 1 trial. Fixed triple tx bested tiotropium in certain pts w/ hx exac in 1 RCT; single-inhaler triple tx bested ICS/LABA in advanced COPD pts in 1 RCT.
• Vitamin D: Supplementation of vitamin D decreases 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 year [A]. Improves lung fxn and reduces mod/severe exac in chronic bronchitis w/ FEV 1 <50% w/ hx exac [A]. Benefits greater in pts previously hospitalized for acute exac.
• Opioids. If severe dz, low-dose, long-acting (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 5.0 ml/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Consider removing ICS if any of these apply: pneumonia, lack of response to ICS, ICS indication lacking.
3 If clinical signs of resp/heart failure: ✓pulse ox; if O 2 sat <92%: ✓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 @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 ≥52 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.
• LVRS. 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 vol and ↑exercise tolerance, heath status and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
• Txp. In pts w/ very severe (FEV 1 <30% predicted) 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 @ 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 dx of COPD 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 & inhaled resp meds for COPD.
Exacerbations (+/- dyspnea) warrant targeting Target exacerbations (+/- dyspnea) w/ additional tx: - If on single LABA or LAMA: switch to LAMA+LABA combo (aclidinium/formoterol, glycopyrronium/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol); or if eos ≥300/uL (or ≥100 in pt w/ 2+ mod/severe exac or 1+ hospitalization; or if hx/exam consistent w/ asthma) ICS+LABA combo (budesonide/formoterol, mometasone/formoterol, fluticasone furoate/vilanterol)1
- If on ICS+LABA: Add LAMA; either remove steroid2 (LAMA+LABA: (aclidinium/formoterol, glycopyrronium/formoterol, tiotropium/olodaterol, umeclidinium/vilanterol) or go to triple tx1 (ICS+LAMA+LABA) using multiple inhalers
- If on LAMA+LABA: If eos ≥100/uL consider triple tx (ICS+LAMA+LABA) using multiple inhalers. If eos <100/uL: 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), SABA (albuterol, levalbuterol), for all pts
- Eval response, escalate and de-escalate as needed. ✓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. 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:1 Nicotine gum/lozenge/inhaler/spray/patch or meds (bupropion SR, nortriptyline, varenicline); use drugs along w/ intervention program; counsel7 @ every visit. Efficacy of e-cig as cessation aid uncertain
- Vaccinate: COVID-19 according to nat’l recs [B]. Flu annually [A]. Tdap if not prev received [B]. Zoster if ≥50 yo [B]. If ≥65 yo: both pneumococcal vax: PCV13 + PPSV23 [B]. If <65 yo w/ comorbidities: PPSV23 recommended [B]
- Avoid aggravating factors. If environment risks: Reduce occupational dust/fume/gas and indoor/outdoor pollutant exposure [B]
- Create written COPD exac action plan w/ ed component; maintain regular clinician contact
- ✓Spirometry q1y8
- Eval/tx comorbidities (CV, etc9)
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent exac in winter months
- Follow COVID-19 mitigations strategies10 & 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. LAMA+LABA combo reduces dyspnea [A] and reduces exac rate [B] vs single agent tx; if single agent used, LAMA preferred over LABA to ↓exac rate [A], hospitalizations [B]. LAMA+LABA combo superior to ICS+LABA combo for exac prevention in COPD Group D pts [B]; such pts are @ increased pneumonia risk on ICS tx. • Not recommended: antitussives [C], long-term oral/inhaled steroid monotherapy [A], theophylline, unless other bronchodilators are unavailable/unaffordable [B], vasodilators [B], benzodiazepines. Insufficient evidence for music or breath relaxation tx.
• Combo BDs from different classes may ↑efficacy, ↓side effects. Triple inhaled LAMA/LABA/ICS improves lung fxn, sx, health status [A] and reduces exac [B] vs ICS/LABA or LAMA mono-tx. Combo LAMA/LABA improved QoL vs placebo or individual components in those w/ highest sx burden, in 1 trial. Fixed triple tx bested tiotropium in certain pts w/ hx exac in 1 RCT; single-inhaler triple tx bested ICS/LABA in advanced COPD pts in 1 RCT.
• Vitamin D: Supplementation of vitamin D decreases 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 year [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 (500 mg bid) reduces exac over 1y [A]; azithromycin associated w/ increased bacterial resistance [A], hearing impairment [B]. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.
• Opioids. If severe dz, low-dose, long-acting (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 5.0 ml/yr reduction in rate of FEV 1 decline compared w/ placebo.
2 Consider removing ICS if any of these apply: pneumonia, lack of response to ICS, ICS indication lacking.
3 If clinical signs of resp/heart failure: ✓pulse ox; if O 2 sat <92%: ✓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 @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 ≥52 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.
• LVRS. 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 vol and ↑exercise tolerance, heath status and lung fxn at 6-12mo in select pts.
• Bullectomy may be considered in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
• Txp. In pts w/ very severe (FEV 1 <30% predicted) 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 @ 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 dx of COPD 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 & inhaled resp meds for COPD.
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