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Chronic obstructivepulmonary

disease (COPD)The right clinical information, right where it's needed

Last updated: Sep 12, 2019

Table of ContentsSummary 3

Basics 4

Definition 4

Epidemiology 4

Etiology 4

Pathophysiology 4

Prevention 6

Primary prevention 6

Screening 6

Secondary prevention 6

Diagnosis 7

Case history 7

Step-by-step diagnostic approach 7

Risk factors 9

History & examination factors 10

Diagnostic tests 12

Differential diagnosis 14

Diagnostic criteria 15

Treatment 17

Step-by-step treatment approach 17

Treatment details overview 22

Treatment options 26

Emerging 58

Follow up 59

Recommendations 59

Complications 60

Prognosis 61

Guidelines 62

Diagnostic guidelines 62

Treatment guidelines 62

References 63

Images 75

Disclaimer 79

Summary

◊ Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation thatis not fully reversible.

◊ Suspected in patients with a history of smoking, occupational and environmental risk factors, or apersonal or family history of chronic lung disease.

◊ Presents with progressive shortness of breath, wheeze, cough, and sputum production, includinghemoptysis.

◊ Diagnostic tests include pulmonary function tests, chest x-ray, chest computed tomography scan,oximetry, and arterial blood gas analysis.

◊ Patients should be encouraged to stop smoking or occupational exposure and be vaccinated againstviral influenza and Streptococcus pneumoniae .

◊ Treatment options include bronchodilators, inhaled corticosteroids, and systemic corticosteroids.

◊ Long-term oxygen therapy improves survival in severe COPD.

Chronic obstructive pulmonary disease (COPD) BasicsBA

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DefinitionChronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterizedby airflow limitation that is not fully reversible. It encompasses both emphysema and chronic bronchitis.The airflow limitation is usually progressive and is associated with an abnormal inflammatory response ofthe lungs to noxious particles or gases. It is primarily caused by cigarette smoking. Although COPD affectsthe lungs, it also has significant systemic consequences. Exacerbations and comorbidities are importantcontributors to the overall condition and prognosis in individual patients.[1]

EpidemiologyCOPD is more common in older people, especially those ages 65 years and older. Associated mortality inwomen has more than doubled over the past 20 years and now matches that in men. The number of COPDcases in the US has increased by 41% since 1982, and COPD affects 1% to 3% of white women and 4%to 6% of white men. COPD is projected to be the third leading cause of death in the world by 2020.[1] Thisis because of the expanding epidemic of smoking and aging of the world population and reduced mortalityfrom other causes of death such as cardiovascular disease.[1] [5] A systematic review and meta-analysis hasshown that the prevalence of COPD in adult offspring of people with COPD is greater than population-basedestimates.[6]

EtiologyTobacco smoking is by far the main risk factor for COPD. It is responsible for 40% to 70% of COPD casesand exerts its effect by causing an inflammatory response, cilia dysfunction, and oxidative injury. Air pollutionand occupational exposure are other common etiologies. Oxidative stress and an imbalance in proteinasesand antiproteinases are also important factors in the pathogenesis of COPD, especially in patients withalpha-1 antitrypsin deficiency, who have panacinar emphysema that usually presents at an early age.[1]

PathophysiologyThe hallmark of COPD is chronic inflammation that affects central airways, peripheral airways, lungparenchyma and alveoli, and pulmonary vasculature. The main components of these changes are narrowingand remodeling of airways, increased number of goblet cells, enlargement of mucus-secreting glands of thecentral airways, and, finally, subsequent vascular bed changes leading to pulmonary hypertension. This isthought to lead to the pathologic changes that define the clinical presentation.

Evidence suggests that the host response to inhaled stimuli generates the inflammatory reaction responsiblefor the changes in the airways, alveoli, and pulmonary blood vessels. Activated macrophages, neutrophils,and leukocytes are the core cells in this process. In contrast to asthma, eosinophils play no role in COPD,except for occasional acute exacerbations. However, a patient-level meta-analysis found that patients withCOPD with lower blood eosinophil counts have more pneumonia events than do those with higher counts.[7]

In emphysema, which is a subtype of COPD, the final outcome of the inflammatory responses is elastinbreakdown and subsequent loss of alveolar integrity.[8] In chronic bronchitis, another phenotype ofCOPD, these inflammatory changes lead to ciliary dysfunction and increased goblet cell size and number,which leads to the excessive mucus secretion. These changes are responsible for decreased airflow,hypersecretion, and chronic cough. In both conditions, changes are progressive and usually not reversible.

4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 12, 2019.BMJ Best Practice topics are regularly updated and the most recent versionof the topics can be found on bestpractice.bmj.com . Use of this content is

subject to our disclaimer. © BMJ Publishing Group Ltd 2020. All rights reserved.

https://bestpractice.bmj.com

Chronic obstructive pulmonary disease (COPD) Basics

Increased airway resistance is the physiologic definition of COPD. Decreased elastic recoil, fibrotic changesin lung parenchyma, and luminal obstruction of airways by secretions all contribute to increased airwaysresistance. Expiratory flow limitation promotes hyperinflation. This finding, in addition to destruction of lungparenchyma, predisposes COPD patients to hypoxia, particularly during activity. Progressive hypoxia causesvascular smooth muscle thickening with subsequent pulmonary hypertension, which is a late developmentconveying a poor prognosis.[9] [10]

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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 12, 2019.BMJ Best Practice topics are regularly updated and the most recent versionof the topics can be found on bestpractice.bmj.com . Use of this content is


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Chronic obstructive pulmonary disease (COPD) PreventionPR

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Primary preventionAvoidance of tobacco exposure (both active and passive measures) and toxic fumes are of invaluableimportance in primary prevention of COPD. All smokers should be offered interventions aimed at smokingcessation, including pharmacotherapy and counseling. Although smoking cessation may be associatedwith minor short-term adverse effects such as weight gain and constipation, its long-term benefits areunquestionable.[17] For disease due to occupational exposures, primary prevention is achieved byelimination or reduction of exposures in the workplace.

ScreeningThere are no data to show conclusively that screening spirometry is effective in directing managementdecisions or in improving COPD outcomes in patients who are identified before the development ofsignificant symptoms.[24] However, if COPD is diagnosed at an early stage and risk factors are eliminated,the rate of decline in lung function will dramatically decrease. Treatment is much more efficacious in the earlystages of disease.[25]

Screening can be done by asking about smoking history and environmental or occupational exposure. Inhigh-risk populations a screening spirometry should be obtained to document airway obstruction. Someexperts advocate conducting screening spirometry in all patients with findings compatible with emphysemaon chest x-ray or computed tomography of the chest. Significant pulmonary dysfunction may be present inasymptomatic smokers.

Secondary preventionVaccination against viral influenza and Streptococcus pneumoniae is strongly recommended in all patientswith cardiopulmonary diseases, including COPD.

Use of calcium and other medication may be necessary to prevent or treat osteoporosis in some patients,especially older women on long-term corticosteroid therapy. Bone density scans are done to evaluateprogression of this condition.

There are conflicting data with regards to prophylactic antibiotic therapies. Prophylactic antibiotics, suchas macrolides, may be considered for reducing the risk of acute exacerbation.[147] [148] While currentguidelines do not yet advocate the use of prophylactic antibiotics, evidence from the MACRO studysuggests that azithromycin reduces the risk of acute exacerbations in patients with COPD. However, whenadministered for 1 year, the most noted side effect was a decrement in hearing.[149] Azithromycin therapyis believed to be most effective in preventing acute exacerbation with a great efficacy in older patients andmilder Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages. Little evidence of treatmentbenefit is seen in current smokers.[114]

Physical activity is recommended for all patients with COPD.[1]




Chronic obstructive pulmonary disease (COPD) Diagnosis

Case historyCase history #1A 66-year-old man with a smoking history of 1 pack per day for the past 47 years presents withprogressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years.On examination he appears cachectic and in moderate respiratory distress, especially after walking to theexamination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examinationreveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing.Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting edema.

Case history #2A 56-year-old woman with a history of smoking presents to her primary care physician with shortnessof breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports achronic morning cough productive of white sputum, which has increased over the past 2 days. She hashad similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per dayfor 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not receivedany relief from over-the-counter cough preparations.

Other presentationsOther presentations include weight loss, hemoptysis, cyanosis, and morning headaches secondary tohypercapnia. Physical examination may demonstrate hypoxia, use of accessory muscles, paradoxicalrib movements, distant heart sounds, lower-extremity edema and hepatomegaly secondary to corpulmonale, and asterixis secondary to hypercapnia. Patients may also present with signs and symptomsof COPD complications. These include severe shortness of breath, severely decreased air entry, andchest pain secondary to an acute COPD exacerbation or spontaneous pneumothorax.[2] [3] Patients withCOPD often have other comorbidities, including cardiovascular disease,[4] skeletal muscle dysfunction,metabolic syndrome and diabetes, osteoporosis, depression, lung cancer, gastroesophageal refluxdisease, bronchiectasis, and obstructive sleep apnea.[1]

Step-by-step diagnostic approachFor updates on diagnosis and management of coexisting conditions during the pandemic, see our topic"Management of coexisting conditions in the context of COVID-19".

HistoryCOPD has an insidious onset and usually presents in older people. A history of productive cough,wheezing, and shortness of breath, particularly with exercise, is typical. Patients may complain offatigue as a result of disrupted sleep secondary to constant nocturnal cough and persistent hypoxiaand hypercapnia. The patient's smoking history, occupational exposures, and any family history of lungdisease should be determined.

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Chronic obstructive pulmonary disease (COPD) DiagnosisD

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Patients with COPD may also present with acute, severe shortness of breath, fever, and chest pain duringacute infectious exacerbation. See our topic on Acute exacerbation of chronic obstructive pulmonarydisease for further information.

Physical examExamination may show tachypnea, respiratory distress, use of accessory muscles, and intercostalretraction. Barrel chest is a common observation. There may be hyperresonance on percussion, anddistant breath sounds and poor air movement on auscultation. Wheezing, coarse crackles, clubbing,and cyanosis, as well as signs of right-side heart failure (distended neck veins, loud P2, hepatomegaly,hepatojugular reflux, and lower-extremity edema), may be present. Occasionally patients may exhibitasterixis - loss of postural control in the outstretched arms (commonly known as a flap) caused byhypercapnia. This is due to impaired gas exchange in lung parenchyma, worsens with exercise, and issuggestive of respiratory failure.

Initial testsSpirometry is the first test for diagnosis of COPD and for monitoring disease progress. Patients withCOPD have a distinctive pattern seen on spirometry, with a reduced FEV1 and FEV1/FVC ratio. Thepresence of airflow limitation is defined by the Global Initiative for Chronic Obstructive Lung Disease(GOLD) criteria as a postbronchodilator FEV1/FVC <0.70.[1] In cases where FVC may be hard tomeasure, FEV6 (forced expiratory volume at 6 seconds) can be used.[18] Chest x-ray (CXR) is rarelydiagnostic but can help exclude other diagnoses. Pulse oximetry screens for hypoxia.

In addition to airflow limitation, the GOLD guidelines recognize the importance of exacerbations inaffecting the natural course of COPD, and place emphasis on assessment of symptoms, risk factors forexacerbations, and comorbidities.[1]

The Modified British Medical Research Council (mMRC) questionnaire or the COPD Assessment Test(CAT) are recommended to assess symptoms. These can be found in the GOLD guidelines.[1]

The number of previously treated exacerbations (2 or more per year) is the best predictor of havinganother exacerbation. In addition to previous exacerbations, airflow limitation <50% is predictive ofexacerbations.

The GOLD guideline uses a combined COPD assessment approach to group patients according tosymptoms and previous history of exacerbations. Symptoms are assessed using the mMRC or CAT scale.

• Group A: low risk (0-1 exacerbation per year, not requiring hospitalization) and fewer symptoms(mMRC 0-1 or CAT <10)

• Group B: low risk (0-1 exacerbation per year, not requiring hospitalization) and more symptoms(mMRC ≥2 or CAT≥ 10)

• Group C: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and fewersymptoms (mMRC 0-1 or CAT <10)

• Group D: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and moresymptoms (mMRC≥ 2 or CAT≥ 10).

Other testsDetailed pulmonary function tests performed in specialist pulmonary function laboratories can measurediffusing capacity of the lung for carbon monoxide (DLCO), flow volume loops, and inspiratory capacity.





They are not used routinely but can be helpful in resolving diagnostic uncertainties and for preoperativeassessment.[1]

In young patients (<45 years) with a family history or with rapidly progressing disease and lower lobechanges on imaging tests, alpha-1 antitrypsin level should be checked. The World Health Organizationrecommends that all patients with a diagnosis of COPD should be screened once, especially in areas withhigh prevalence of alpha-1 antitrypsin deficiency.[19] This may aid in family screening and counseling.

Computed tomography scans show anatomic changes, but their usefulness in diagnosis is confined topatients considered for surgery and for ruling out other pathologies.[1]

Pulse oximetry should be used to assess all patients with clinical signs of respiratory failure or right heartfailure. If peripheral arterial oxygen saturation is less than 92%, then arterial or capillary blood gasesshould be measured.[1]

Obstructive sleep apnea is associated with increased risk of death and hospitalization in patients withCOPD.[20]

Exercise testing can be useful in patients with a disproportional degree of dyspnea.[21] It can beperformed on a cycle or treadmill ergometer, or by a simple timed walking test (e.g., 6 minutes, or duration<6 minutes).[22] Exercise testing is also of use in selecting patients for rehabilitation. Respiratory musclefunction may also be tested if dyspnea or hypercapnia are disproportionately increased with respect toFEV1, as well as in patients with poor nutrition and those with corticosteroid myopathy.[23]

In patients with frequent exacerbations, severe airflow limitation, and/or exacerbations requiringmechanical ventilation, sputum should be sent for culture.[1]

[VIDEO: Radial artery puncture animated demonstration ]

Risk factorsStrongcigarette smoking• Most important risk factor. It causes 40% to 70% of cases of COPD.[11]• Elicits an inflammatory response and causes cilia dysfunction and oxidative injury.

advanced age• The effect of age may be related to a longer period of cigarette smoking as well as the normal age-

related loss of FEV1.

genetic factors• Airway responsiveness to inhaled insults depends on genetic factors. Alpha-1 antitrypsin deficiency

is a genetic disorder, mostly encountered in people of northern European ancestry, which causespanacinar emphysema in lower lobes at a young age.

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white ancestry• Despite high rates of smoking among black Americans and other racial and ethnic groups, COPD is

more common in white people.

exposure to air pollution or occupational exposure• Chronic exposure to dust, traffic exhaust fumes, and sulfur dioxide increases risk of COPD.

developmentally abnormal lung• Frequent childhood infection may cause scarring of lungs, decrease elasticity, and increase risk for

COPD.

male sex• COPD is more common in men, but that is probably secondary to more smokers being male. However,

there is a suggestion that women may be more susceptible than men to the effects of tobaccosmoke.[12] [13] [14] [15]

low socioeconomic status• The risk for developing COPD is increased in people with lower socioeconomic status.[16] However,

this may reflect exposure to cigarette smoke, pollutants, or other factors.

History & examination factorsKey diagnostic factorscough (common)• Usually the initial symptom of COPD.• Frequently a morning cough, but becomes constant as disease progresses.• Usually productive, and sputum quality may change with exacerbations or superimposed infection.

shortness of breath (common)• Initially with exercise but may progress to shortness of breath even at rest.• Patients may have difficulty speaking in full sentences.

Other diagnostic factorsbarrel chest (common)• The anteroposterior diameter of the chest is increased.• This suggests hyperinflation and air trapping secondary to incomplete expiration.

hyperresonance on percussion (common)• Caused by hyperinflation and air trapping secondary to incomplete expiration.

distant breath sounds on auscultation (common)• Caused by barrel chest, hyperinflation, and air trapping.

poor air movement on auscultation (common)• Secondary to loss of lung elasticity and lung tissue breakdown.





wheezing on auscultation (common)• A common finding in exacerbations. The current accepted descriptive word for a continuous musical

lung sound.• Is indicative of airway inflammation and resistance.

coarse crackles (common)• A common finding in exacerbations. A discontinuous sound referring to mucus or sputum in airways.• Indicative of airway inflammation and mucus oversecretion.

tachypnea (uncommon)• An increased respiratory rate occurs to compensate for hypoxia and hypoventilation.• May involve use of accessory muscles.

asterixis (uncommon)• Loss of postural control in outstretched arms (commonly known as a flap) caused by hypercapnia.• This is due to impaired gas exchange in lung parenchyma, worsens with exercise, and is suggestive of

respiratory failure.

distended neck veins (uncommon)• Occurs secondary to increased intrathoracic pressure and cor pulmonale.

lower-extremity swelling (uncommon)• Suggests cor pulmonale and secondary pulmonary hypertension as a complication of advanced

chronic lung disease.

fatigue (uncommon)• Occurs because of disrupted sleep secondary to constant nocturnal cough and persistent hypoxia and

hypercapnia.

headache (uncommon)• May occur due to vasodilation caused by hypercapnia.

cyanosis (uncommon)• Seen in the late stages of COPD, usually with hypoxia, hypercapnia, and cor pulmonale.

loud P2 (uncommon)• Sign of advanced COPD.• Indicates secondary pulmonary hypertension as a complication of cor pulmonale.

hepatojugular reflux (uncommon)• Sign of advanced COPD complicated by cor pulmonale.

hepatosplenomegaly (uncommon)• Sign of advanced COPD complicated by cor pulmonale.

clubbing (uncommon)

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• COPD itself does not cause clubbing, but if tobacco exposure in COPD patients leads to lung cancerand/or bronchiectasis, then clubbing may occur in COPD. Clubbing is usually not present untilsignificant impairment of lung function has occurred.

Diagnostic tests1st test to order

Test Resultspirometry

• COPD is classified based on the patient's FEV1 and its percentageof the predicted FEV1. In cases where FVC may be hard to measure,FEV6 (forced expiratory volume at 6 seconds) can be used.[18]

FEV1/FVC ratio <0.70; totalabsence of reversibilityis neither required nor themost typical result

pulse oximetry• Checked as part of vital signs on acute presentation. A good pulse

wave should be picked up by the device. In patients with chronicdisease, an oxygen saturation of 88% to 90% may be acceptable.

• If <92% arterial or capillary blood gases should be checked.[1]

low oxygen saturation

ABG• Checked in patients who are acutely sick, especially if they have an

abnormal pulse oximetry reading. Should also be performed in stablepatients with FEV1 <35% predicted or with clinical signs suggestiveof respiratory failure, or if peripheral arterial oxygen saturation is<92%.

• Hypercapnia, hypoxia, and respiratory acidosis are signs ofimpending respiratory failure and possible need for intubation.

PaCO₂ >50 mmHg and/or PaO₂ of <60 mmHgsuggests respiratoryinsufficiency

CXR• Seldom diagnostic, but useful in ruling out other pathologies.• Increased anteroposterior ratio, flattened diaphragm, increased

intercostal spaces, and hyperlucent lungs may be seen.[Fig-1]

[Fig-2]• May also demonstrate complications of COPD, such as pneumonia

and pneumothorax.

hyperinflation

CBC• This test may be considered to assess severity of an exacerbation

and may show polycythemia (hematocrit >55%), anemia, andleukocytosis.[1]

elevated hematocrit,possible increased WBCcount

ECG• Risk factors for COPD are similar to those for ischemic heart disease,

so comorbidity is common.

signs of right ventricularhypertrophy, arrhythmia,ischemia





Other tests to consider

Test Resultpulmonary function tests

• Useful for resolving diagnostic uncertainties and for preoperativeassessment.[1] Requires specialist laboratory facilities.

• Decreased diffusing capacity of the lung for carbon monoxide (DLCO)is supportive of emphysema over chronic bronchitis.

obstructive pattern,decreased DLCO

chest CT scan• Provides better visualization of type and distribution of lung tissue

damage and bulla formation than CXR.[Fig-3]

• In contrast to smoking-related COPD, alpha-1 antitrypsin deficiencymainly affects lower fields.

• Useful in excluding other underlying pulmonary disease and inpreoperative assessment.

hyperinflation

sputum culture• In patients with frequent exacerbations, severe airflow limitation, and/

or exacerbations requiring mechanical ventilation, sputum should besent for culture.[1]

infecting organism

alpha-1 antitrypsin level• Low level in patients with alpha-1 antitrypsin deficiency. Test is done

if there is high suspicion for alpha-1 antitrypsin deficiency, such asa positive family history and atypical COPD cases (young patientsand nonsmokers). The World Health Organization recommendsthat all patients with a diagnosis of COPD should be screenedonce, especially in areas with high prevalence of alpha-1 antitrypsindeficiency.[19]

should be normal inpatients with COPD

exercise testing• Can be of value in patients with a disproportional degree of dyspnea

compared with spirometry.[21] It can be performed on a cycleor treadmill ergometer, or by a simple timed walking test (e.g., 6minutes, or duration <6 minutes).[22] Exercise testing is of use inselecting patients for rehabilitation.

poor exerciseperformance or exertionalhypoxemia is suggestiveof advanced disease

sleep study• Obstructive sleep apnea, a common finding in patients with COPD, is

associated with increased risk of death and hospitalization in patientswith COPD.[20]

elevated apnea-hypopneaindex and/or nocturnalhypoxemia

respiratory muscle function• Respiratory muscle function may be tested if dyspnea or hypercapnia

are disproportionately increased with respect to FEV1, as wellas in patients with poor nutrition and those with corticosteroidmyopathy.[23]

reduced maximalinspiratory pressure

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Differential diagnosis

Condition Differentiating signs /symptoms

Differentiating tests

Asthma • Onset of asthma is usuallyin early life. A personal orfamily history of allergy,rhinitis, and eczema isoften present. There is dailyvariability in symptoms, andpatients have overt wheezingthat usually rapidly respondsto bronchodilators. Coughvariant asthma mimics manyfeatures of COPD.

• Pulmonary function tests(PFTs) show reversibilitywith bronchodilators andno decrease in diffusingcapacity of the lung forcarbon monoxide (DLCO).Sputum or blood eosinophiliais suggestive of asthma.

Congestive heart failure • Usually a history ofcardiovascular diseasesis present. Patients reportsymptoms of orthopnea,and fine bibasilar inspiratorycrackles may be heard onauscultation.

• B-type natriuretic peptidelevels are usually elevated,and CXR reveals increasedpulmonary vascularcongestion. Echocardiogrammay confirm the diagnosis.

Bronchiectasis • There may be a historyof recurrent infection inchildhood. Large volumeof purulent sputum isusually present. Coarsecrackles may be heard onauscultation. History ofpertussis or tuberculosis is aclue to diagnosis.

• Chest CT reveals bronchialdilation and bronchial wallthickening.

Tuberculosis • A history of fever, nightsweats, weight loss, andchronic productive cough isusually present. Tuberculosisis more common in peopleliving in or originating fromendemic areas.

• The diagnosis requiresmicrobiologic confirmation.Infiltrates, fibrosis, orgranuloma seen on CXRor chest CT may suggesttuberculosis. Patients usuallyhave positive skin test fortuberculosis.

Bronchiolitis • Bronchiolitis may affectpatients at younger ages.The patient may havea history of connectivetissue disorders, especiallyrheumatoid arthritis, or fumeexposure. Some cases arepostinfectious.

• PFTs in bronchiolitis canpresent with obstructive,restrictive, or mixed pattern.CXR shows hyperinflation.High-resolution chestCT may show diffuse,small, centrilobular nodularopacities, but is rarely donein children due to radiationrisk.

Upper airway dysfunction • Can affect patients of anyage. History of prior trauma

• The flow-volume curve inpulmonary function testing





Condition Differentiating signs /symptoms

Differentiating tests

or intubation is very helpful.Lung examination is usuallynormal, but signs of upperairway restriction, such aswheezing and stridor, maybe present. Patients mayhave voice hoarseness ifvocal cords are involved.

may reveal a characteristicexpiratory or inspiratoryplateau, or both. Diagnosisis confirmed by directvisualization of the affectedairway by endoscopy.

Chronic sinusitis/postnasal drip

• Chronic sinusitis/rhinitis isa very common cause ofchronic cough. Patients maycomplain of sinus pressure,rhinorrhea, nonproductivecough, and/or headache.

• CT of sinuses and/or empirictrial of antihistamines arecommonly utilized to aid indiagnosis.

Gastroesophageal refluxdisease (GERD)

• Patients with GERD oftenhave dyspepsia and frequentbelching, and can have achronic cough that worsensat night when supine.

• Diagnosis is usually basedon response to empirictherapy with proton-pumpinhibitors.

ACE inhibitor-inducedchronic cough

• ACE inhibitors can causechronic cough; however,the cough is usuallynonproductive.

• Diagnosis is usuallybased on improvement ofsymptoms after empiriccessation of ACE inhibitor.

Lung cancer • Patients may have weightloss, night sweats,hemoptysis, and/or chest orback pain.

• People with COPD are alsoat increased risk of lungcancer.

• Radiography is importantin the assessment for lungcancer. Bronchoscopy maybe necessary to evaluatefor endobronchial cancer ifsuspicion is high.

Diagnostic criteriaGlobal Initiative for Chronic Obstructive Lung Disease (GOLD)criteria[1]Classification of severity of airflow limitation in COPD:

In pulmonary function testing, a postbronchodilator FEV1/FVC ratio of <0.70 is commonly considereddiagnostic for COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizesairflow limitation into stages. In patients with FEV1/FVC <0.70:

• GOLD 1 - mild: FEV1≥ 80% predicted• GOLD 2 - moderate: 50% ≤FEV1 <80% predicted• GOLD 3 - severe: 30% ≤FEV1 <50% predicted• GOLD 4 - very severe: FEV1 <30% predicted.

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The GOLD guideline uses a combined COPD assessment approach to group patients according tosymptoms and previous history of exacerbations. Symptoms are assessed using the Modified British MedicalResearch Council (mMRC) or COPD assessment test (CAT) scale. These can be found in the GOLDguidelines.[1]

• Group A: low risk (0-1 exacerbation per year, not requiring hospitalization) and fewer symptoms(mMRC 0-1 or CAT <10)

• Group B: low risk (0-1 exacerbation per year, not requiring hospitalization) and more symptoms(mMRC≥ 2 or CAT≥ 10)

• Group C: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and fewersymptoms (mMRC 0-1 or CAT <10)

• Group D: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and moresymptoms (mMRC≥ 2 or CAT≥ 10).




Chronic obstructive pulmonary disease (COPD) Treatment

Step-by-step treatment approachFor updates on diagnosis and management of coexisting conditions during the pandemic, see our topic"Management of coexisting conditions in the context of COVID-19".

The ultimate goals of treatment of COPD are to prevent and control symptoms, to reduce the severity andnumber of exacerbations, to improve respiratory capacity for increased exercise tolerance, and to reducemortality.[27] There is a stepwise approach to therapy, but it is important to remember that treatment shouldbe individualized for general health status and comorbid conditions.

The therapeutic approach involves reducing risk factor exposure, appropriate assessment of disease,patient education, pharmacologic and nonpharmacologic management of stable COPD, and prevention andtreatment of acute COPD exacerbations.

Continuous assessment and monitoring of diseaseOngoing monitoring and assessment in COPD ensures that the goals of treatment are being met.Quality of life and patients' sense of wellbeing will improve, and hospital admissions will be significantlydecreased in cases where self- or professional monitoring of disease is being utilized.[28] Suchassessment of the medical history should include:

Exposure to risk factors and preventive measures:

• Tobacco smoke• Occupational exposures (fumes, dust, etc.)• Influenza and pneumococcal vaccination.

Disease progression and development of complications:

• Decline in exercise tolerance• Increased symptoms• Worsened sleep quality• Missed work or other activities.

Pharmacotherapy and other medical treatment:

• How often rescue inhaler is used• Any new medicines• Compliance with medical regimen• Ability to use inhalers properly• Adverse effects.

Exacerbation history:

• Urgent care or emergency room visits• Recent oral corticosteroid bursts• Frequency, severity, and likely causes of exacerbations should be evaluated.

Comorbidities:

• Assessment of coexisting medical problems (e.g., heart failure).

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Chronic obstructive pulmonary disease (COPD) TreatmentTR

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In addition, objective assessment of lung function should be obtained yearly or more frequently if there isa substantial increase in symptoms.

Integrated disease management (IDM) in which several healthcare providers (physical therapist,pulmonologist, nurse, etc.) worked together with patients has been shown to improve quality of life anddecrease hospital admissions.[29]

Acute exacerbationsAn exacerbation of COPD is defined as an event characterized by a change in the patient's baselinedyspnea, cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset. See ourtopic on Acute exacerbation of chronic obstructive pulmonary disease for further information.

Chronic management: stepwise therapy according to GlobalInitiative for Chronic Obstructive Lung Disease (GOLD) classGOLD guidelines[27] recommend a stepwise approach to pharmacologic therapy:

• For group A patients (few symptoms and low risk of exacerbations), a bronchodilator is offeredfirst-line. This can be either a short- or a long-acting bronchodilator. This should be continued ifsymptomatic benefit is documented.

• For group B patients (more symptoms and low risk of exacerbations), a long-acting bronchodilatorshould be offered first-line. If the patient has persistent symptoms when taking one long-actingbronchodilator, then the use of two bronchodilators is recommended. For patients with severebreathlessness, initial treatment with two bronchodilators may be warranted.

• For group C patients (few symptoms but higher risk of exacerbations), first-line treatment should bea long-acting bronchodilator, and GOLD recommends starting a long-acting muscarinic antagonist(LAMA) in this group. Patients who experience further exacerbations may benefit from addinga second long-acting bronchodilator (long-acting beta-2-agonist [LABA] or LAMA) or using acombination of a LABA and an inhaled corticosteroid (ICS). GOLD recommends a LABA/LAMAcombination over LABA/ICS, as ICS increases the risk of developing pneumonia in some patients.

• For group D patients (more symptoms and high risk of exacerbations), GOLD recommends startingtherapy with a LABA/LAMA combination. If patients experience further exacerbations when onLABA/LAMA, they can either try escalation to LABA/LAMA/ICS, or they can switch to LABA/ICS.If patients treated with LABA/LAMA/ICS still have exacerbations, then additional options includeadding roflumilast, or a macrolide, or stopping the ICS.

All patients are candidates for education, vaccination, and smoking cessation interventions.

Bronchodilator therapy optionsBeta agonists are widely used in the treatment of COPD. They increase intracellular cAMP, leading torespiratory smooth muscle relaxation and reduced airway resistance. They are available as short-actingand long-acting preparations. Short-acting beta-2 agonists improve lung function and breathlessness andquality of life. These agents can be used as rescue therapy when the patient is using long-acting beta-2agonist therapy.[30] LABAs improve lung function, breathlessness, exacerbation rate, and number ofhospitalizations, but do not affect mortality or rate of decline of lung function.[27]

A muscarinic antagonist is a type of anticholinergic agent that acts as a bronchodilator by blockingthe cholinergic receptors on the respiratory smooth muscle. This causes muscle relaxation andreduces airflow limitation. Inhaled muscarinic antagonists are available as both short- and long-acting





preparations. Tiotropium, a LAMA, has been shown to reduce risk of exacerbation versus placebo orother maintenance treatments.[31] Newer LAMAs, such as aclidinium, glycopyrrolate, and umeclidinium,have at least comparable efficacy to tiotropium, in terms of change from baseline in trough forcedexpiratory volume in 1 second (FEV1), transitional dyspnea index focal score, St George's RespiratoryQuestionnaire score, and rescue medication use.[32] There is a suggestion of increased cardiovascular-related mortality in some studies of patients taking short-acting muscarinic antagonists and in somestudies of patients taking LAMAs.[33] [34] A population-based cohort study found that older men withCOPD newly started on LAMAs are at increased risk of urinary tract infections.[35]

Beta agonists and muscarinic antagonists, therefore, provide bronchodilator effects through differentpathways. Their combination may provide a better therapeutic effect without increasing the adverseeffects of each class.[36] [37] [38] [39] Compared to LABA/ICS, a LABA/LAMA combination has fewerexacerbations, a larger improvement of FEV1, a lower risk of pneumonia, and more frequent improvementin quality of life.[40] A systematic review and network meta-analysis found that all LABA/LAMA fixed-dosecombinations had a similar efficacy and safety.[41]

In cases of stable COPD, if the decision is made to use single-agent therapy, LAMA may be superiorto LABA agents.[36] Clinical trials have shown that LAMA have a greater effect on reducing rates ofexacerbations compared with LABA.[42] [43] The long-term safety of LAMA was demonstrated in theUPLIFT trial.[44] As outlined above, GOLD makes recommendations on the initial agent based on thepatient’s risk group (A, B, C, or D).[27]

Theophylline (a methylxanthine agent) is a bronchodilator that acts by increasing cAMP and subsequentrespiratory smooth muscle relaxation. It is not commonly used because of limited potency, narrowtherapeutic window, high-risk profile, and frequent drug-drug interactions. Theophylline is indicated forpersistent symptoms if inhaled therapy is insufficient to relieve airflow obstruction. Theophylline hasmodest effects on lung function in moderate to severe COPD.[45]

Umeclidinium/vilanterol is a LABA/LAMA approved for use in COPD.[46] Glycopyrrolate/formoterolfumarate is another LABA/LAMA combination approved for COPD patients,[47] as is indacaterol/glycopyrrolate.[48] [49] This once-daily inhaler showed superior efficacy compared with glycopyrrolateplus tiotropium in patients with moderate to severe COPD,[50] and compared with salmeterol/fluticasonein preventing COPD exacerbation.[51]

Inhaled corticosteroidsInhaled corticosteroids are indicated in patients with advanced stages of COPD who suffer from frequentexacerbations.[52] They should be added to the patient's existing bronchodilator therapy and shouldnot be used as monotherapy.[27] Inhaled corticosteroids are believed to be effective because of theiranti-inflammatory effects. Long-term inhaled corticosteroid use reduces the need to use rescue therapyand reduces exacerbations, and may also decrease mortality.[53] [54] Several studies have pointed toan increased risk of pneumonia in COPD patients taking inhaled corticosteroids.[55] This risk is slightlyhigher for fluticasone in comparison with budesonide.[56] A systematic review and meta-analysis foundthat, despite a significant increase in unadjusted risk of pneumonia associated with use of inhaledcorticosteroids, pneumonia fatality and overall mortality were not increased in randomized controlledtrials and were decreased in observational studies.[57] Therefore, an individualized treatment approachthat assesses a patient's risk of pneumonia versus the benefit of decreased exacerbations should beimplemented.[55] [58] [59] Concern is also raised with regards to increased risk of tuberculosis andinfluenza in adult patients with COPD who are on inhaled corticosteroid therapy.[60]

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According to the GOLD guideline, inhaled corticosteroids are not recommended as first-line therapy inany of the patient groups A to D. They are only recommended as part of escalation of therapy if patientscontinue to experience exacerbations despite taking a long-acting bronchodilator.[27]

Phosphodiesterase-4 inhibitorsRoflumilast is an oral phosphodiesterase-4 inhibitor that may reduce exacerbations in group D patients atrisk for frequent exacerbations when not adequately controlled by long-acting bronchodilators.[27] Thisagent offers benefit in improving lung function and reducing the likelihood of exacerbations. However, ithas little impact on quality of life or symptoms.[61]

Combined bronchodilator and corticosteroid preparationsA combination preparation of long-acting bronchodilator and inhaled corticosteroid may be used forpatients who require both these agents. This is convenient and may help with compliance in somepatients. The choice of therapy in this class is based on availability and individual response andpreference.[62] Combination therapy with inhaled corticosteroid and a long-acting beta agonist issuperior to use of either agent alone.[63] [64] The combination may be provided in separate inhalers or acombination inhaler.

Multiple studies support triple therapy with LABA/LAMA/ICS as being superior to single- or double-agenttherapy with LABA/LAMA or LABA/ICS regarding rate of moderate to severe COPD exacerbations[65][66] [67] [68] and rate of hospitalization.[69] [70]

Patient education and self-managementAll patients should be well educated about the disease course and symptoms of exacerbation ordecompensation. Their expectation of the disease, treatment, and prognosis should be realistic. It isimportant to remember that no medication has been shown to modify the long-term decline in lungfunction, and the primary goal of pharmacotherapy is to control symptoms and prevent complications.

One Cochrane review found that self-management interventions that include an action plan for acuteexacerbations of COPD are associated with improvements in health-related quality of life and feweradmissions to the hospital for respiratory problems. An exploratory analysis found a small, but significantlyhigher, respiratory-related mortality rate for self-management compared to usual care, although no excessrisk of all-cause mortality was seen.[71]

One randomized controlled trial found that a telephone health coaching intervention to promote behaviorchange in patients with mild COPD in primary care led to improvements in self-management activities, butdid not improve health-related quality of life.[72]

Physical activity is recommended for all patients with COPD.[27] One systematic review and meta-analysis of randomized controlled trials found that exercise training on its own can improve physicalactivity in COPD, and greater improvements can be made with the addition of physical activitycounseling.[73] Another systematic review and meta-analysis found that a combination of aerobicexercise and strength training was more effective than strength training or endurance training alone inincreasing the 6-minute walking distance.[74]

Smoking cessation and vaccinationSmoking cessation should be encouraged in all patients, in addition to guidance on avoiding occupationalor environmental tobacco smoke exposures.





Usual smoking cessation programs include counseling, group meetings, and drug therapy.[75] Somepatients may need frequent referrals to achieve success. Smoking cessation significantly reduces the rateof progression of COPD and risk of malignancies. It also reduces risk of coronary and cerebrovasculardiseases. Smoking cessation that includes pharmacotherapy and intensive counseling has a highersuccess rate and is cost effective in COPD, with low costs per quality-adjusted life year.[76] [77] [78]

Patients should be vaccinated against influenza virus and Streptococcus pneumoniae .[27] [79]Vaccination against influenza is associated with fewer exacerbations of COPD.[79] [80]

MucolyticsPatients with the chronic bronchitis phenotype of COPD often produce thick sputum on a frequent basis.Mucolytic agents are not associated with an increase in adverse effects and may be beneficial duringexacerbations of COPD. They result in a small reduction in the frequency of acute exacerbations, butdo not improve lung function or quality of life. Mucolytic agents may be most beneficial for patients noton inhaled corticosteroids.[81] The use of positive expiratory pressure (PEP) therapy to clear secretionsduring acute exacerbations has been found to improve subjective feelings of breathlessness but was notassociated with decreased hospitalizations or rate of exacerbations.[82]

Pulmonary rehabilitationPulmonary rehabilitation should be initiated for patients who remain symptomatic despite bronchodilatortherapy and is recommended to start early in the course of the disease, when they start feeling shortnessof breath with regular activity and walking on a level surface. Its effect is beneficial in improving exercisecapacity and quality of life. It also decreases the depression and anxiety related to this disease, andreduces hospitalization in COPD patients.[83] The benefit appears to subside after termination of thecourse unless patients follow a home exercise schedule.[84] Benefits of home- or community-basedpulmonary rehabilitation on respiratory symptoms and quality of life in patients with COPD could matchthose of the hospital-based rehabilitation programs.[85] [86] Although pulmonary rehabilitation relievesdyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderatelylarge and clinically significant extent,[87] it is important to remember that early progressive exerciserehabilitation beyond current standard physical therapy practice during hospital admission for COPD is notrecommended and could be associated with a higher 12-month mortality.[88] There is evidence to supportstarting pulmonary rehabilitation within 1 month of an acute exacerbation.[89] [90]

GOLD guidelines recommend pulmonary rehabilitation for patient groups B to D.[27]

Oxygen therapyGOLD guidelines recommend long-term oxygen therapy in stable patients who have:[27]

• PaO₂ ≤7.3 kPa (55 mmHg) or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or

• PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence ofpulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia(hematocrit > 55%).

Oxygen therapy helps minimize pulmonary hypertension by decreasing pulmonary artery pressure, andimproves exercise tolerance and quality of life. It has been shown to improve survival.[27] [91] [92]

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Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patientscould undergo testing to be evaluated for their predicted PaO₂ during flight.

There is some evidence that oxygen can relieve breathlessness when given during exercise to mildlyhypoxemic and nonhypoxemic people with COPD who do not otherwise qualify for home oxygentherapy.[93]

SurgerySurgical interventions (bullectomy, lung volume reduction surgery,[94] [95] and lung transplant) are thelast step in the management of COPD. They are used to improve lung dynamics, exercise adherence,and quality of life.[96] Endobronchial valve insertion can produce clinically meaningful improvements inappropriately selected COPD patients.[97]

Criteria for referral for lung transplantation include:[98]

• Progressive disease, despite maximal treatment including medication, pulmonary rehabilitation,and oxygen therapy.

• Patient is not a candidate for endoscopic or surgical lung volume reduction surgery (LVRS).Simultaneous referral of patients with COPD for both lung transplant and LVRS evaluation isappropriate.

• Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index of 5 to 6.• PaCO₂ >50 mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8 kPa.• FEV1 <25% predicted.

[VIDEO: BODE Index for COPD Survival Prediction ]

Palliative careFor some patients with very advanced end-stage COPD, palliative care and hospice admission shouldbe considered. Patient and family should be well educated about the process, and it is suggestedthat discussions should be held early in the course of the disease before acute respiratory failuredevelops.[99] One study has suggested that low doses of an opioid analgesic and a benzodiazepine aresafe and are not associated with increased hospital admissions or mortality.[100]

One Cochrane review concluded that there is no evidence for or against benzodiazepines for the relief ofbreathlessness in people with advanced cancer and COPD.[101]

Treatment details overviewPlease note that formulations/routes and doses may differ between drug names and brands, drugformularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer



http://bestpractice.bmj.com/procedural-videos/en-us/edfafb66-5b3f-4cb3-b595-6db322f0116e

https://bestpractice.bmj.com/info/disclaimer/



Acute ( summary )group A: few symptoms and low riskof exacerbations

1st short- or long-acting bronchodilator

plus patient education and vaccination

plus smoking cessation

group B: more symptoms and lowrisk of exacerbations

1st long-acting bronchodilator

plus short-acting bronchodilator as required



plus pulmonary rehabilitation

adjunct long-term oxygen therapy

2nd dual long-acting bronchodilator therapy






group C: few symptoms but higherrisk of exacerbations






adjunct theophylline







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Acute ( summary )adjunct theophylline


3rd long-acting beta-2 agonist plus inhaledcorticosteroid







group D: more symptoms and highrisk of exacerbations

1st dual long-acting bronchodilator therapy







adjunct surgical interventions

adjunct palliative care

2nd triple therapy: long-acting beta-2 agonist(LABA) plus long-acting muscarinicantagonist (LAMA) plus inhaledcorticosteroid (ICS)






adjunct phosphodiesterase-4 inhibitor

adjunct macrolide antibiotic







Acute ( summary )adjunct palliative care

2nd long-acting beta-2 agonist (LABA) plusinhaled corticosteroid (ICS)









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Treatment optionsPlease note that formulations/routes and doses may differ between drug names and brands, drugformularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer



https://bestpractice.bmj.com/info/disclaimer/



Acutegroup A: few symptoms and low riskof exacerbations

1st short- or long-acting bronchodilator

Primary options

» albuterol inhaled: (90 micrograms/doseinhaler) 90-180 micrograms (1-2 puffs) every4-6 hours when required

OR

» levalbuterol inhaled: (45 micrograms/doseinhaler) 45-90 micrograms (1-2 puffs) every4-6 hours when required

OR

» ipratropium bromide inhaled: (17micrograms/dose inhaler) 34 micrograms (2puffs) up to four times a day when required,maximum 204 micrograms/day

OR

» salmeterol inhaled: (50 micrograms/doseinhaler) 50 micrograms (1 puff) twice daily

OR

» indacaterol inhaled: (75 microgram/capsuleinhaler) 75 micrograms (1 capsule) once daily

OR

» arformoterol inhaled: 15 microgramsnebulized twice daily

OR

» olodaterol inhaled: (2.5 micrograms/doseinhaler) 5 micrograms (2 sprays) once daily

OR

» tiotropium inhaled: (18 micrograms/capsuleinhaler) 18 micrograms (1 capsule) oncedaily; (2.5 micrograms/dose inhaler) 5micrograms (2 sprays) once daily

OR

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Acute» umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) oncedaily

OR

» aclidinium bromide inhaled: (400micrograms/dose inhaler) 400 micrograms (1puff) twice daily

OR

» glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule)twice daily; (25 micrograms/vial nebulizerinhalation solution) 25 micrograms nebulizedtwice daily using Magnair® nebulizer device

» Global Initiative for Chronic Obstructive LungDisease (GOLD) guidelines state that all groupA patients should be offered bronchodilatortreatment based on its effect on breathlessness.This can be either a short- or a long-actingbronchodilator.[27]

» The effect of the bronchodilator should beevaluated. Depending on the response, it shouldbe continued or stopped or another class ofbronchodilator should be tried.[27]

» Short-acting bronchodilators providesymptomatic relief.

» Failure to respond to short-actingbronchodilator may signify an acuteexacerbation.

» Patients should not take short-actinganticholinergic agents if they have already beenstarted on tiotropium.[102] [103]

» Short-acting drugs include albuterol,levalbuterol, and ipratropium.

» Long-acting drugs include salmeterol,indacaterol, arformoterol, olodaterol, tiotropium,umeclidinium, aclidinium, and glycopyrrolate.


Treatment recommended for ALL patients inselected patient group

» Influenza and pneumococcal vaccinationshould be offered to every COPD patient.[27]Influenza vaccine is given annually.Pneumococcal vaccine should be given toCOPD patients older than 65 years of age andto younger patients with significant comorbid





Acuteconditions. This vaccine also reduces incidenceof community-acquired pneumonia in patientsyounger than 65 with an FEV1 of <40%.[104]

» Patients should be well educated about thedisease course and symptoms of exacerbationor decompensation. Physical activity isrecommended for all patients with COPD.[27]

» Discussions should be held early in the courseof the disease, before acute respiratory failuredevelops, about the possible need for andbenefits of palliative care in the future.[99]



» All patients should be strongly recommendednot to start smoking, or to stop if they are currentsmokers. Smoking cessation is a primary goal inmanagement of COPD.

» Nicotine-replacement therapy or other drugtherapies, in conjunction with appropriatenonpharmacologic therapies, should be used.

group B: more symptoms and low riskof exacerbations


Primary options

» salmeterol inhaled: (50 micrograms/doseinhaler) 50 micrograms (1 puff) twice daily

OR

» indacaterol inhaled: (75 microgram/capsuleinhaler) 75 micrograms (1 capsule) once daily

OR

» arformoterol inhaled: 15 microgramsnebulized twice daily

OR

» olodaterol inhaled: (2.5 micrograms/doseinhaler) 5 micrograms (2 sprays) once daily

OR


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AcuteOR

» umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) oncedaily

OR


OR

» glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule)twice daily; (25 micrograms/vial nebulizerinhalation solution) 25 micrograms nebulizedtwice daily using Magnair® nebulizer device

» Long-acting muscarinic antagonists (LAMA)or long-acting beta-2 agonists (LABA)[105] canbe used as first-line therapy in this group ofpatients.[27]

» According to Global Initiative for ChronicObstructive Lung Disease (GOLD) guidelines,long-acting inhaled bronchodilators are superiorto short-acting bronchodilators when taken asneeded and are, therefore, recommended in thispatient group.[27] [106] [107]

» According to GOLD guidelines, there is noevidence to recommend one class of long-actingbronchodilator over another for initial relief ofsymptoms in this group of patients. The choiceshould depend on the patient's perception ofsymptom relief.[27]

» For patients with severe breathlessness,initial therapy with two bronchodilators may beconsidered.[27]

» For patients with persistent breathlessness onmonotherapy, GOLD guidelines recommend theuse of two bronchodilators.[27]




Primary options





Acute» albuterol inhaled: (90 micrograms/doseinhaler) 90-180 micrograms (1-2 puffs) every4-6 hours when required

OR


OR


» Provides symptomatic relief.





» Influenza and pneumococcal vaccinationshould be offered to every COPD patient.[27]Influenza vaccine is given annually.Pneumococcal vaccine should be given toCOPD patients older than 65 years of age andto younger patients with significant comorbidconditions. This vaccine also reduces incidenceof community-acquired pneumonia in patientsyounger than 65 with an FEV1 of <40%.[104]





» All patients should be strongly recommendednot to start smoking, or to stop if they are current

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Acutesmokers. Smoking cessation is a primary goal inmanagement of COPD.




» Pulmonary rehabilitation should be startedearly.[27]

» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in significant andclinically meaningful improvements inmultiple outcome areas, including dyspnea,exercise ability, health status, and healthcareutilization.[27] [91]


Treatment recommended for SOME patients inselected patient group

» Criteria for long-term oxygen therapy include:PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%,with or without hypercapnia confirmed twiceover a 3-week period; or PaO₂ between 7.3kPa (55 mmHg) and 8.0 kPa (60 mmHg), orSaO₂ of 88%, if there is evidence of pulmonaryhypertension, peripheral edema suggestingcongestive cardiac failure, or polycythemia(hematocrit >55%).[27]

» Oxygen is suggested for patients in whomthe predicted PaO₂ during air travel is <6.7 kPa(<50 mmHg).[27] These patients usually havea saturation of <92% in room air at sea level. Ifin doubt, patients could undergo testing to beevaluated for their predicted PaO₂ during flight.

» The therapeutic goal is to increase thePaO₂ to at least 5 mmHg above the patient'sbaseline value and to a minimum of 60 mmHg.In addition, oxygen saturation should stay above90% during rest, exercise, and sleep.[91] [96]


Primary options

» umeclidinium/vilanterol inhaled: (62.5/25micrograms/dose inhaler) 1 puff once daily

OR





Acute» glycopyrrolate/formoterol fumarate inhaled:(9/4.8 micrograms/dose inhaler) 2 puffs twicedaily

OR

» indacaterol/glycopyrrolate inhaled:(27.5/15.6 micrograms/capsule inhaler) 1capsule twice daily

OR

» tiotropium/olodaterol inhaled: (2.5/2.5micrograms/dose inhaler) 2 puffs once daily

» For patients with persistent breathlessnesson monotherapy, Global Initiative for ChronicObstructive Lung Disease (GOLD) guidelinesrecommend the use of two bronchodilators.[27]

» If two bronchodilators do not improvesymptoms, GOLD guidelines suggest steppingdown again to a single bronchodilator.[27]

» Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol arecombinations of a long-acting beta-2 agonist(LABA) and a long-acting muscarinic antagonist(LAMA) approved for use in COPD.[46]



Primary options


OR


OR



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Acute» Failure to respond to short-actingbronchodilator may signify an acuteexacerbation.














» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in significant andclinically meaningful improvements inmultiple outcome areas, including dyspnea,





Acuteexercise ability, health status, and healthcareutilization.[27] [91]






group C: few symptoms but higherrisk of exacerbations


Primary options


OR

» umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) oncedaily

OR


OR

» glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule)

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Acutetwice daily; (25 micrograms/vial nebulizerinhalation solution) 25 micrograms nebulizedtwice daily using Magnair® nebulizer device

» Initial treatment in group C should be a singlelong-acting bronchodilator.[27] In two head-to-head comparisons, the tested long-actingmuscarinic antagonist (LAMA) was betterthan the long-acting beta-2 agonist (LABA) atpreventing exacerbations.[42] [43] Therefore,Global Initiative for Chronic Obstructive LungDisease (GOLD) guidelines recommend startingwith a LAMA in patient group C.




Primary options


OR


OR







» Influenza and pneumococcal vaccinationshould be offered to every COPD patient.[27]Influenza vaccine is given annually.





AcutePneumococcal vaccine should be given toCOPD patients older than 65 years of age andto younger patients with significant comorbidconditions. This vaccine also reduces incidenceof community-acquired pneumonia in patientsyounger than 65 with an FEV1 of <40%.[104]










» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise, quality of life, and emotionalfeelings.[27] [91]



Primary options

» theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every6-8 hours, increase to 400 mg/day after 3days, then 600 mg/day after another 3 days;adjust dose according to serum drug leveland response

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Acute» There is no clear recommendation about theexactly appropriate time to use theophylline,but most experts believe in its use whenpatients have exhausted bronchodilator andcorticosteroid options.

» Toxicity is dose-related.adjunct long-term oxygen therapy






Primary options


OR

» glycopyrrolate/formoterol fumarate inhaled:(9/4.8 micrograms/dose inhaler) 2 puffs twicedaily

OR


OR

» tiotropium/olodaterol inhaled: (2.5/2.5micrograms/dose inhaler) 2 puffs once daily





Acute» Patients in group C with persistentexacerbations may benefit from dual therapy witha long-acting beta-2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA).[27]

» Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol arecombinations of a LABA and a LAMA approvedfor use in COPD.[46]



Primary options


OR


OR








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Acute» Patients should be well educated about thedisease course and symptoms of exacerbationor decompensation. Physical activity isrecommended for all patients with COPD.[27]









» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise, quality of life, and emotionalfeelings.[27] [91]



Primary options


» There is no clear recommendation about theexactly appropriate time to use theophylline,but most experts believe in its use whenpatients have exhausted bronchodilator andcorticosteroid options.

» Toxicity is dose-related.





Acuteadjunct long-term oxygen therapy





3rd long-acting beta-2 agonist plus inhaledcorticosteroid

Primary options

» fluticasone furoate/vilanterol inhaled:(100/25 micrograms/dose inhaler) 1 puff oncedaily

OR

» fluticasone propionate/salmeterol inhaled:(250/50 micrograms/dose inhaler) 1 pufftwice daily

OR

» budesonide/formoterol inhaled: (160/4.5micrograms/dose inhaler) 2 puffs twice daily

OR

» mometasone/formoterol inhaled: (100/5micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily

» Patients with persistent exacerbations maybenefit from using a combination of a long-acting beta-2 agonist (LABA) and an inhaledcorticosteroid (ICS). As inhaled corticosteroids

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Acuteincrease the risk of developing pneumonia insome patients, the Global Initiative for ChronicObstructive Lung Disease (GOLD) guidelinesprefer dual long-acting bronchodilator therapyover a LABA/ICS combination.[27]

» A combination preparation of a LABA and anICS may be used for patients who require boththese agents. This is convenient and may helpwith compliance in some patients. The choice oftherapy in this class is based on availability andindividual response and preference. Combinationtherapy with a LABA and an ICS is superiorto use of either agent alone. The combinationmay be provided in separate inhalers or acombination inhaler (combination formulationsare detailed here).



Primary options


OR


OR







» Influenza and pneumococcal vaccinationshould be offered to every COPD patient.[27]Influenza vaccine is given annually.





AcutePneumococcal vaccine should be given toCOPD patients older than 65 years of age andto younger patients with significant comorbidconditions. This vaccine also reduces incidenceof community-acquired pneumonia in patientsyounger than 65 with an FEV1 of <40%.[104]










» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise capacity, quality of life, and emotionalfeelings.[27] [91]



Primary options


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Acute» There is no clear recommendation about theexactly appropriate time to use theophylline,but most experts believe in its use whenpatients have exhausted bronchodilator andcorticosteroid options.






group D: more symptoms and highrisk of exacerbations

1st dual long-acting bronchodilator therapy

Primary options


OR

» glycopyrrolate/formoterol fumarate inhaled:(9/4.8 micrograms/dose inhaler) 2 puffs twicedaily

OR


OR





Acute» tiotropium/olodaterol inhaled: (2.5/2.5micrograms/dose inhaler) 2 puffs once daily

» The Global Initiative for Chronic ObstructiveLung Disease (GOLD) guidelines recommendstarting treatment with a long-acting beta-2agonist (LABA) and long-acting muscarinicantagonist (LAMA) combination in group D.This is because the LABA/LAMA combinationsshowed superior results compared to the singledrugs in studies with patient reported outcomesas the primary endpoint.[27]

» In addition, a LABA/LAMA combination wassuperior to a LABA and an inhaled corticosteroid(ICS) combination in preventing exacerbationsand other patient reported outcomes in group Dpatients.[27]

» Group D patients are at a higher risk ofdeveloping pneumonia when receiving treatmentwith ICS.[42] [108]

» If a single bronchodilator is chosen as initialtreatment, a LAMA is preferred by GOLDguidelines over a LABA.[27]

» In some patients, initial treatment with LABA/ICS combination may be the first choice. Thesepatients may have a history and/or findingssuggestive of asthma-COPD overlap.[27]


» Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol arecombinations of a LABA and a LAMA approvedfor use in COPD.[46]



Primary options


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AcuteOR















» Pulmonary rehabilitation should be started asearly as patient group B or C disease.[27]

» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotional





Acuteparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise capacity, quality of life, and emotionalfeelings.[27] [91]



Primary options










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Acute» Criteria for referral for lung transplantationinclude: progressive disease, despite maximaltreatment including medication, pulmonaryrehabilitation, and oxygen therapy; patient isnot a candidate for endoscopic or surgical lungvolume reduction surgery (LVRS) (simultaneousreferral of patients with COPD for both lungtransplant and LVRS evaluation is appropriate);Body mass index, airflow Obstruction, Dyspnea,and Exercise (BODE) index of 5 to 6; PaCO₂ >50mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8kPa; FEV1 <25% predicted.[98]

» LVRS is indicated in patients with very severeairflow limitation and especially in patients withlocalized upper lobe disease and lower thannormal exercise capacity.[94] Bullectomy is anoption in COPD patients with dyspnea in whomCT reveals huge bullae occupying at least 30%of the hemithorax. Severely poor functionalstatus and severe decrease in FEV1 (<500 mL)make these options less favorable.

» Lung transplantation has been shownto improve quality of life and functionalcapacity.[109] [110] However, lungtransplantation does not appear to confer asurvival benefit.[111]

»

[VIDEO: BODE Index for COPDSurvival Prediction ]



» For some patients with very advanced end-stage COPD, palliative care and hospiceadmission should be considered. Patient andfamily should be well educated about theprocess, and it is suggested that discussionsshould be held early in the course of the diseasebefore acute respiratory failure develops.[99]One study has suggested that low doses of anopioid analgesic and a benzodiazepine are safeand are not associated with increased hospitaladmissions or mortality.[100] One Cochranereview concluded that there is no evidencefor or against benzodiazepines for the relief ofbreathlessness in people with advanced cancerand COPD.[101]

2nd triple therapy: long-acting beta-2 agonist(LABA) plus long-acting muscarinicantagonist (LAMA) plus inhaledcorticosteroid (ICS)







AcutePrimary options

» fluticasone furoate/umeclidinium/vilanterolinhaled: (100/62.5/25 micrograms/doseinhaler) 1 puff once daily

OR

» fluticasone furoate/vilanterol inhaled:(100/25 micrograms/dose inhaler) 1 puff oncedaily-or-» fluticasone propionate/salmeterol inhaled:(250/50 micrograms/dose inhaler) 1 pufftwice daily-or-» budesonide/formoterol inhaled: (160/4.5micrograms/dose inhaler) 2 puffs twice daily-or-» mometasone/formoterol inhaled: (100/5micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily

--AND--» tiotropium inhaled: (18 micrograms/capsuleinhaler) 18 micrograms (1 capsule) oncedaily; (2.5 micrograms/dose inhaler) 5micrograms (2 sprays) once daily-or-» umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) oncedaily-or-» aclidinium bromide inhaled: (400micrograms/dose inhaler) 400 micrograms (1puff) twice daily-or-» glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule)twice daily; (25 micrograms/vial nebulizerinhalation solution) 25 micrograms nebulizedtwice daily using Magnair® nebulizer device

» In group D patients who develop furtherexacerbations on LABA/LAMA therapy, theGlobal Initiative for Chronic Obstructive LungDisease (GOLD) guidelines suggest twoalternative pathways: escalation to LABA/LAMA/ICS or switch to LABA/ICS.[27]

» Multiple studies support triple therapy withLABA/LAMA/ICS as being superior to single-or double-agent therapy with LABA/LAMA orLABA/ICS regarding rate of moderate to severeCOPD exacerbations[65] [66] [67] [68] and rateof hospitalization.[69] [70]

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Acute» If patients treated with LABA/LAMA/ICS (tripletherapy) still have exacerbations, additionaloptions include adding roflumilast, adding amacrolide antibiotic, and stopping the ICS.[27]Stopping the ICS may be appropriate if a lack ofefficacy is reported, if there is an elevated risk ofadverse events (including pneumonia), or if therewould be no significant harm from withdrawal ofICS.[27]



Primary options


OR


OR












Acute» Patients should be well educated about thedisease course and symptoms of exacerbationor decompensation. Physical activity isrecommended for all patients with COPD.[27]








» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise capacity, quality of life, and emotionalfeelings.[27] [91]



Primary options



» Toxicity is dose-related.adjunct phosphodiesterase-4 inhibitor


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AcutePrimary options

» roflumilast: 500 micrograms orally oncedaily

» Roflumilast may be considered in patientswith an FEV1 <50% predicted and chronicbronchitis,[112] especially if they haveexperienced at least one hospitalization for anexacerbation in the previous year.[27] [113]

adjunct macrolide antibiotic


Primary options

» azithromycin: 250 mg orally once daily; or500 mg orally three times weekly

OR

» erythromycin base: 500 mg orally twicedaily

» The use of azithromycin is supported by thebest available evidence.[114] [115]

» Decision making should take into account thepotential development of resistant organisms.










Acuteadjunct surgical interventions


» Criteria for referral for lung transplantationinclude: progressive disease, despite maximaltreatment including medication, pulmonaryrehabilitation, and oxygen therapy; patient isnot a candidate for endoscopic or surgical lungvolume reduction surgery (LVRS) (simultaneousreferral of patients with COPD for both lungtransplant and LVRS evaluation is appropriate);Body mass index, airflow Obstruction, Dyspnea,and Exercise (BODE) index of 5 to 6; PaCO₂ >50mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8kPa; FEV1 <25% predicted.[98]



»





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Acute2nd long-acting beta-2 agonist (LABA) plus

inhaled corticosteroid (ICS)

Primary options

» fluticasone furoate/vilanterol inhaled:(100/25 micrograms/dose inhaler) 1 puff oncedaily

OR

» fluticasone propionate/salmeterol inhaled:(250/50 micrograms/dose inhaler) 1 pufftwice daily

OR

» budesonide/formoterol inhaled: (160/4.5micrograms/dose inhaler) 2 puffs twice daily

OR

» mometasone/formoterol inhaled: (100/5micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily

» In group D patients who develop furtherexacerbations while taking a combination of aLABA and a long-acting muscarinic antagonist(LAMA), the Global Initiative for ChronicObstructive Lung Disease (GOLD) guidelinessuggest two alternative pathways: escalation toLABA/LAMA/ICS or switch to LABA/ICS.[27]

» There is no evidence that switching fromLABA/LAMA to LABA/ICS results in betterprevention of exacerbations. If LABA/ICS therapydoes not positively impact exacerbations orsymptoms, a LAMA can be added.[27]

» In some patients, initial treatment with LABA/ICS may be the first choice. These patients mayhave a history and/or findings suggestive ofasthma-COPD overlap.[27]



Primary options


OR





Acute» levalbuterol inhaled: (45 micrograms/doseinhaler) 45-90 micrograms (1-2 puffs) every4-6 hours when required

OR
















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Acute» The principal goals of pulmonary rehabilitationare to reduce symptoms, improve quality oflife, and increase physical and emotionalparticipation in everyday activities. Pulmonaryrehabilitation can result in improvements inmultiple outcome areas, including dyspnea,exercise capacity, quality of life, and emotionalfeelings.[27] [91]



Primary options













AcuteTreatment recommended for SOME patients inselected patient group

» Criteria for referral for lung transplantationinclude: progressive disease, despite maximaltreatment including medication, pulmonaryrehabilitation, and oxygen therapy; patient isnot a candidate for endoscopic or surgical lungvolume reduction surgery (LVRS) (simultaneousreferral of patients with COPD for both lungtransplant and LVRS evaluation is appropriate);Body mass index, airflow Obstruction, Dyspnea,and Exercise (BODE) index of 5 to 6; PaCO₂ >50mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8kPa; FEV1 <25% predicted.[98]



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EmergingMedical therapiesThe increasing awareness of the role of inflammation in COPD has led to consideration of drugs that attackvarious targets in the inflammatory cascade. Many broad-spectrum anti-inflammatory drugs are now in phase3 development for COPD and may enter the COPD market within the next decade. Nitric oxide inhibitors,leukotriene modifiers, and tumor necrosis factor antagonists are among these novel therapies.[116] Long-term (≥6 months) treatment with acetylcysteine may decrease exacerbation prevalence but does notappear to affect exacerbation rate, lung volumes, or FEV1.[117] Antiplatelet therapy is associated withdecreased all-cause mortality in patients with COPD, independent of cardiovascular risk.[118] Epidermalgrowth factor receptor kinase has potential to combat mucus overproduction. Therapy to inhibit fibrosisis being developed. There is also a search for serine proteinase and matrix metalloproteinase inhibitorsto prevent lung destruction and the subsequent development of emphysema, as well as drugs such asretinoid that may even reverse this process.[119] HMG-CoA reductase inhibitors are emerging medicationsin COPD that have been shown to improve some outcomes, with some improvement in lung function ofCOPD patients with moderate to severe class.[120] Although retrospective studies showed decreased rateand severity of exacerbations, hospitalization, and mortality in patients using statin therapy, especially inpatients with coexisting cardiovascular disease (CVD) or hyperlipidemia, a prospective study failed to provethis benefit.[121] In a meta-analysis of randomized controlled trials of patients with COPD taking statins,clinical outcomes were better in patients with coexisting CVD, elevated baseline C-reactive protein, or ahigh cholesterol level.[122] Efficacy and safety of synthetic ghrelin hormone therapy in COPD patients withseverely decreased physical performance and cachexia is under investigation with some promising initialresults.[123] Palovarotene is a selective retinoic acid receptor gamma agonist that is under investigation forthe treatment of emphysema. It is hypothesized that retinoic acid signaling affects alveologenesis. Therehave been promising results in animal studies.[124] Many combinations of inhaler therapies are beingintroduced for COPD treatment. Aclidinium/formoterol is a long-acting muscarinic antagonist and long-acting beta-2 agonist (LABA/LAMA) combination therapy that is available in some countries, but is awaitingapproval by the Food and Drug Administration (FDA) in the US.

Interventional therapiesTarget lobe volume reduction, a novel technique for selective bronchoscopic lung volume resection, has nowbecome available. In this technique, a one-way valve is inserted into the hyperinflated and emphysematoussegment, leading to the collapse of the nonfunctional lung segment. Promising reports have been releasedfrom case series of patients undergoing this therapy. This approach is an alternative to surgical lung volumereduction in COPD patients who are likely to require surgery.[125] [126]

Pharmacogenomic therapyPharmacogenomic therapy may be important in COPD. It is important to identify the genetic factors thatdetermine why certain heavy smokers develop COPD and others do not. Identification of genes thatpredispose to the development of COPD may provide novel therapeutic targets.[127] [128]

Club cell protein 16 augmentationClub cell protein 16 (CC16) is mainly produced by the Club cells (formerly known as Clara cells) in therespiratory tract epithelium. CC16 has anti-inflammatory properties in smoke-exposed lungs, and COPDis associated with CC16 deficiency. Experimental augmentation of CC16 levels reduces inflammation andcellular injury, and so CC16 augmentation may be a new disease-modifying treatment for COPD.[129]




Chronic obstructive pulmonary disease (COPD) Follow up

RecommendationsMonitoringPatients with COPD should be evaluated on a regular basis depending on the severity of disease. Mildstable COPD patients may be followed up at 6-month intervals, while patients with severe, frequentexacerbations and recently hospitalized patients need follow-up at 2-week to 1-month intervals. In follow-up sessions, patients should be evaluated to determine adherence to medical regimen, response totherapy, and disease progression. The level of dyspnea at rest and with exercise should be determined,as well as number of exacerbations. Questionnaires such as the COPD Assessment Test (CAT) can beused to assess symptoms. These can be found in the GOLD guidelines.[1] Smoking status and smokeexposure should be determined at each appointment, followed by appropriate action.[1]

PFTs should be monitored at least every 3 years, to evaluate response to therapy and possible needfor change in medications. If any significant change in medication is made or if the patient is onsystemic corticosteroids, more frequent PFT monitoring is required. The GOLD guidelines recommendmeasuring FEV1 by spirometry at least once a year to identify patients who are declining quickly.[1]Oxygen saturation should be monitored and patients evaluated periodically for the need of supplementaloxygen. Patients need to be monitored for short-term and long-term complications of COPD. Patientweight, nutrition status, and physical activity should also be monitored. Cachexia and reduced physicalperformance are indicators of a poor prognosis.

Patient instructionsAll patients should be well educated about the disease course and symptoms of exacerbation ordecompensation. Their expectation of the disease, treatment, and prognosis should be realistic. It isimportant to remember that no medicine has been shown to modify the long-term decline in lung function,and the primary goal of pharmacotherapy is to control symptoms and prevent complications.

One Cochrane review found that self-management interventions that include an action plan for acuteexacerbations of COPD are associated with improvements in health-related quality of life and feweradmissions to hospital for respiratory problems. An exploratory analysis found a small, but significantlyhigher, respiratory-related mortality rate for self-management compared to usual care, although no excessrisk of all-cause mortality was seen.[71]

One randomised controlled trial found that a telephone health coaching intervention to promote behaviourchange in patients with mild COPD in primary care led to improvements in self-management activities, butdid not improve health-related quality of life.[72]

Patients should stay as healthy and active as possible. It is necessary to stop active or passive smokingand avoid environmental exposure to toxic fumes.

Regular medical follow-up is necessary to optimize the treatment. If there is any worsening of symptoms,immediate medical attention is required. Patients on continuous oxygen therapy may need increase inoxygen flow during air travel.

Physical activity is recommended for all patients with COPD and they should be encouraged to maintainit.[1] One systematic review and meta-analysis of randomised controlled trials found that exercise trainingon its own can improve physical activity in COPD, and greater improvements can be made with theaddition of physical activity counseling.[90] Another systematic review and meta-analysis found thata combination of aerobic exercise and strength training was more effective than strength training orendurance training alone in increasing the 6-minute walking distance.[91]

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Complications

Complications Timeframe Likelihoodcor pulmonale long term high

Cor pulmonale is right-sided heart failure secondary to longstanding COPD. It is caused by chronichypoxia and subsequent vasoconstriction in pulmonary vasculature that causes pulmonary hypertensionand right-sided heart failure.

Engorged neck veins, a loud P2, lower-extremity edema, and hepatomegaly are signs of cor pulmonale.

Continuous oxygen therapy is the mainstay of therapy. Judicious use of diuretics is warranted.[144]

recurrent pneumonia variable high

Recurrent pneumonia is a common complication of COPD and a frequent cause of COPD exacerbation.Either viral or bacterial infections can be the cause.

Chronic lung and airway damage, inflammation, compromised ciliary function, and bacterial colonizationare likely causes of increased vulnerability to infections. Use of long-term inhaled corticosteroids is alsoassociated with increased risk of pneumonia in patients with COPD.[141] [142]

Use of antibiotic therapy has shown some benefit.[143] Usual treatment time is around 7 to 14 days.Appropriate coverage for Haemophilus influenzae and Streptococcus pneumoniae is mandatory.Pneumococcal vaccination is strongly recommended in COPD patients.

depression variable high

Depression is a common consequence of COPD. If any mood change occurs, a psychiatric evaluation maybe necessary.

pneumothorax variable medium

Occurs because of lung parenchyma damage with subpleural bulla formation and rupture. Spontaneouspneumothorax is very common with chronic severe cough or chest trauma, and may be life-threatening.

High levels of suspicion are necessary for prompt diagnosis. CXR or chest CT confirms the diagnosis.[Fig-4]

Conservative management may be sufficient in minor cases. In severe cases, chest tube insertion isnecessary to prevent tension pneumothorax and hemodynamic instability. If recurrent pneumothoraxoccurs, then surgical interventions, such as video-assisted thoracoscopy pleurodesis or bullectomy, arewarranted.

respiratory failure variable medium

A study of a large number of COPD patients with acute respiratory failure reported inhospital mortalityof 17% to 49%.[140] Therapy includes noninvasive positive pressure ventilation and/or mechanicalventilation.

anemia variable medium




Chronic obstructive pulmonary disease (COPD) Follow up

Complications Timeframe LikelihoodAnemia is more prevalent than previously thought, affecting almost 25% of COPD patients.[145] A lowhematocrit indicates a poor prognosis in COPD patients receiving long-term oxygen treatment.[146]

polycythemia variable medium

Secondary polycythemia can develop in the presence of arterial hypoxemia, especially in continuingsmokers. It can be identified by hematocrit >55%. Many times these patients require supplemental homeoxygen.

Prognosis

COPD is a disease with an indeterminate course and variable prognosis. Its prognosis depends on severalfactors including genetic predisposition, environmental exposures, comorbidities and, to a lesser degree,acute exacerbations.

Although short-term survival for patients with COPD and respiratory failure depends on the overall severityof acute illness, long-term survival is primarily influenced by the severity of COPD and the presence ofcomorbid conditions. Traditionally, prognosis has been reported based on the FEV1, which is a part ofpulmonary function testing. A meta-regression analysis showed a significant correlation between increasedFEV1 and lower risk of COPD exacerbation.[133] In addition to the FEV1, other factors that predict prognosisare weight (very low weight is a negative prognostic factor[134]), distance walked in 6 minutes, and degreeof shortness of breath with activities. These factors, known as the Body mass index, airflow Obstruction,Dyspnea, and Exercise (BODE) index, can be used to provide information on prognosis for 1-year, 2-year, and 4-year survival.[135] One study revealed that plasma pro-adrenomedullin concentration plusBODE index is a better prognostic tool than BODE index alone.[136] Elevation of adrenomedullin, argininevasopressin, atrial natriuretic peptide, and C-reactive protein[137] is associated with increased risk ofdeath in patients with stable COPD.[138] Recently, more interest has been put on comorbidities and priorexacerbations as the predictor of COPD course. CODEX index (comorbidities, obstruction, dyspnea,and previous severe exacerbations) is proved to be superior to BODE index in predicting prognosis forCOPD patients.[139] Frequent COPD exacerbations and requirement for multiple intubation and invasivemechanical ventilation for acute respiratory failure in COPD patients are markers of poor prognosis.[140]

Among different therapeutic modalities in COPD, the only two factors that improve survival are smokingcessation and oxygen supplementation.

[VIDEO: BODE Index for COPD Survival Prediction ]

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Chronic obstructive pulmonary disease (COPD) GuidelinesG

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Diagnostic guidelines

International

Global strategy for the diagnosis, management, and prevention of COPD [26]Published by: Global Initiative for Chronic Obstructive Lung Disease Last published: 2019

Treatment guidelines

International

Global strategy for the diagnosis, management, and prevention of COPD [27]Published by: Global Initiative for Chronic Obstructive Lung Disease Last published: 2018

Enhancing implementation, use, and delivery of pulmonary rehabilitation [130]Published by: American Thoracic Society; European RespiratorySociety

Last published: 2015

BTS/ICS guidelines for the ventilatory management of acute hypercapnicrespiratory failure in adults [131]Published by: British Thoracic Society; Intensive Care Society Last published: 2017

Nursing care of dyspnea: the 6th vital sign in individuals with chronicobstructive pulmonary disease (COPD) [132]Published by: Registered Nurses Association of Ontario Last published: 2010



https://goldcopd.org/gold-reports/


https://www.thoracic.org/statements/pulmonary-rehab.php

https://www.brit-thoracic.org.uk/standards-of-care/guidelines/btsics-guidelines-for-the-ventilatory-management-of-acute-hypercapnic-respiratory-failure-in-adults/

https://www.brit-thoracic.org.uk/standards-of-care/guidelines/btsics-guidelines-for-the-ventilatory-management-of-acute-hypercapnic-respiratory-failure-in-adults/

https://rnao.ca/bpg/guidelines/dyspnea

https://rnao.ca/bpg/guidelines/dyspnea


Chronic obstructive pulmonary disease (COPD) References

Key articles

• Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis,management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication]. Full text

• Ford ES, Croft JB, Mannino DM, et al. COPD surveillance - United States, 1999-2011. Chest. 2013Jul;144(1):284-305. Full text Abstract

• Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaledanticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994 Nov16;272(19):1497-505. Abstract

• Siafakas NM, Vermeire P, Pride NB, et al. Optimal assessment and management of chronicobstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J.1995 Aug;8(8):1398-420. Full text Abstract

• Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis,management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication]. Full text

• Celli BR, MacNee W, Agusti A, et al; ATS/ERS Task Force. Standards for the diagnosis andtreatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004Jun;23(6):932-46. Full text Abstract

• Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplantcandidates: 2014 - an update from the Pulmonary Transplantation Council of the International Societyfor Heart and Lung Transplantation. J Heart Lung Transplant. 2015 Jan;34(1):1-15. Full text Abstract

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Chronic obstructive pulmonary disease (COPD) Images

Images

Figure 1: COPD chest x-ray (AP view): hyperinflated lung, flattened diaphragm, increased intercostal spaces

From the collection of Manoochehr Abadian Sharifabad, MD

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Figure 2: COPD chest x-ray (lateral view): hyperinflated lung, flattened diaphragm, increased antero-posteriordiameter (barrel chest) in lateral view





Chronic obstructive pulmonary disease (COPD) Images

Figure 3: COPD chest CT: hyperinflated lung, emphysematous changes, and increased antero-posteriordiameter (barrel chest)


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Figure 4: Chest CT: severe COPD changes with right pneumothorax





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Contributors:

// Authors:

Manoochehr Abadian Sharifabad, MDFountain Valley Regional Medical CenterFountain Valley, CADISCLOSURES: MAS declares that he has no competing interests.

// Acknowledgements:Dr Manoochehr Abadian Sharifabad would like to gratefully acknowledge Dr Jonathan P. Parsons andDr Michael Ezzie, the previous contributors to this topic. JPP has contributed at speakers' bureaus forGlaxoSmithKline, Inc., Schering-Plough, Inc., and AstraZeneca, Inc. ME declares that he has no competinginterests.

// Peer Reviewers:

Hormoz Ashtyani, MD, FCCPHackensack University Medical CenterHackensack, NJDISCLOSURES: HA declares that he has no competing interests.

William Janssen, MDAssistant Professor of MedicineNational Jewish Medical and Research Center, University of Colorado Health Sciences Center, Denver, CODISCLOSURES: WJ declares that he has no competing interests.

Francis Thien, MD, FRACP, FCCPAssociate ProfessorDirector of Respiratory Medicine, Eastern Health & Monash University, Victoria, AustraliaDISCLOSURES: FT declares that he has no competing interests.