Chronic Obstructive Pulmonary Disease (COPD)

Publication Date: April 1, 2021
Last Updated: March 14, 2022

Recommendations

Diagnosis and Assessment of COPD

We recommend that spirometry, demonstrating airflow obstruction (postbronchodilator forced expiratory volume in one second/forced vital capacity [FEV1/FVC] <70%, with age adjustment for more elderly individuals), be used to confirm all initial diagnoses of chronic obstructive pulmonary disease (COPD). (Strong for)
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We have no recommendations regarding utilization of existing clinical classification systems at this time. ()
(Not Applicable)
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We suggest classification of patients with COPD into two groups:
a. Patients who experience frequent exacerbations (two or more/year, defined as prescription of corticosteroids, prescription of antibiotics, hospitalization, or emergency department [ED] visit); and
b. Patients without frequent exacerbations.
(Weak for)
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We recommend offering prevention and risk reduction efforts including smoking cessation and vaccination. (Strong for)
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We recommend investigating additional comorbid diagnoses particularly in patients who experience frequent exacerbations (two or more/year, defined as prescription of corticosteroids, prescription of antibiotics, hospitalization, or ED visit) using simple tests and decision rules (cardiac ischemia [troponin, electrocardiogram], congestive heart failure [B-type natriuretic peptide (BNP), pro-BNP], pulmonary embolism [D-dimer plus clinical decision rule], and gastroesophageal reflux). (Strong for)
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We suggest that patients with COPD and signs or symptoms of a sleep disorder have a diagnostic sleep evaluation. (Weak for)
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We suggest that patients presenting with early onset COPD or a family history of early onset COPD be tested for alpha-1 antitrypsin (AAT) deficiency. (Weak for)
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We recommend that patients with AAT deficiency be referred to a pulmonologist for management of treatment. (Strong for)
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Management of Patients with COPD in the Outpatient Setting

Pharmacologic Therapy

We recommend prescribing inhaled short-acting beta 2-agonists (SABAs) to patients with confirmed COPD for rescue therapy as needed. (Strong for)
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We suggest using spacers for patients who have difficulty actuating and coordinating drug delivery with metered-dose inhalers (MDIs). (Weak for)
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We recommend offering long-acting bronchodilators to patients with confirmed, stable COPD who continue to have respiratory symptoms (e.g., dyspnea, cough). (Strong for)
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We suggest offering the inhaled long-acting antimuscarinic agent (LAMA) tiotropium as first-line maintenance therapy in patients with confirmed, stable COPD who continue to have respiratory symptoms (e.g., dyspnea, cough). (Weak for)
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We recommend inhaled tiotropium as first-line therapy for patients with confirmed, stable COPD who have respiratory symptoms (e.g., dyspnea, cough) and severe airflow obstruction (i.e., post bronchodilator FEV1 <50%) or a history of COPD exacerbations. (Strong for)
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For clinically stable patients with a confirmed diagnosis of COPD and who have not had exacerbations on short-acting antimuscarinic agents (SAMAs), we suggest continuing with this treatment, rather than switching to long-acting bronchodilators. (Weak for)
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For patients treated with a SAMA who are started on a LAMA to improve patient outcomes, we suggest discontinuing the SAMA. (Weak for)
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We recommend against offering an inhaled corticosteroid (ICS) in symptomatic patients with confirmed, stable COPD as a first-line monotherapy. (Strong against)
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We recommend against the use of inhaled long-acting beta 2-agonists (LABAs) without an ICS in patients with COPD who may have concomitant asthma. (Strong against)
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In patients with confirmed, stable COPD who are on inhaled LAMAs (tiotropium) or inhaled LABAs alone and have persistent dyspnea on monotherapy, we recommend combination therapy with both classes of drugs. (Strong for)
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In patients with confirmed, stable COPD who are on combination therapy with LAMAs (tiotropium) and LABAs and have persistent dyspnea or COPD exacerbations, we suggest adding ICS as a third medication. (Weak for)
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We suggest against offering roflumilast in patients with confirmed, stable COPD in primary care without consultation with a pulmonologist. (Weak against)
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We suggest against offering chronic macrolides in patients with confirmed, stable COPD in primary care without consultation with a pulmonologist. (Weak against)
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We suggest against offering theophylline in patients with confirmed, stable COPD in primary care without consultation with a pulmonologist. (Weak against)
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There is insufficient evidence to recommend for or against the use of Nacetylcysteine (NAC) preparations available in the US in patients with confirmed, stable COPD who continue to have respiratory symptoms (e.g., dyspnea, cough). ()
(Not Applicable)
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We suggest not withholding cardio-selective beta-blockers in patients with confirmed COPD who have a cardiovascular indication for beta-blockers. (Weak for)
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We suggest using non-pharmacologic therapy as first-line therapy and using caution in prescribing hypnotic drugs for chronic insomnia in primary care for patients with COPD, especially for those with hypercapnea or severe COPD. (Weak for)
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For patients with COPD and anxiety, we suggest consultation with a psychiatrist and/or a pulmonologist to choose a course of anxiety treatment that reduces, as much as possible, the risk of using sedatives/anxiolytics in this population. (Weak for)
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Oxygen Therapy

We recommend providing long-term oxygen therapy (LTOT) to patients with chronic stable resting severe hypoxemia (partial pressure of oxygen in arterial blood [PaO2] 88% and ≤90%) with signs of tissue hypoxia (hematocrit >55%, pulmonary hypertension, or cor pulmonale). (Strong for)
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We recommend that patients discharged home from hospitalization with acute transitional oxygen therapy are evaluated for the need for LTOT within 30-90 days after discharge. LTOT should not be discontinued if patients continue to meet the above criteria. (Strong for)
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We suggest against routinely offering ambulatory LTOT for patients with chronic stable isolated exercise hypoxemia, in the absence of another clinical indication for supplemental oxygen. (Weak against)
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For patients with COPD and hypoxemia and/or borderline hypoxemia (SaO2 <90%) who are planning to travel by plane, we suggest a brief consultation or an e-consult with a pulmonologist. (Weak for)
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When other causes of nocturnal hypoxemia have been excluded, we suggest against routinely offering LTOT for the treatment of outpatients with stable, confirmed COPD and isolated nocturnal hypoxemia. (Weak against)
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Stable Hypercapnea

In the absence of other contributors (e.g., sleep apnea), we suggest referral for a pulmonary consultation in patients with stable, confirmed COPD and hypercapnea. (Weak for)
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Supported Self-Management

We suggest supported self-management for selected high risk patients with COPD. (Weak for)
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We suggest against using action plans alone in the absence of supported self-management. (Weak against)
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Telehealth

We suggest using telehealth for ongoing monitoring and support of the care of patients with confirmed COPD. (Weak for)
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Pulmonary Rehabilitation

We recommend offering pulmonary rehabilitation to stable patients with exercise limitation despite pharmacologic treatment and to patients who have recently been hospitalized for an acute exacerbation. (Strong for)
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Breathing Exercise

We suggest offering breathing exercise (e.g., pursed lip breathing, diaphragmatic breathing, or yoga) to patients with dyspnea that limits physical activity. (Weak for)
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Nutrition Referral

We suggest referral to a dietitian for medical nutritional therapy recommendations (such as oral calorie supplementation) to support patients with severe COPD who are malnourished (body mass index [BMI] <20 kg/m2). (Weak for)
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Lung Volume Reduction Surgery and Lung Transplant

We recommend that any patient considered for surgery for COPD (lung volume reduction surgery [LVRS] and lung transplant) be first referred to a pulmonologist for evaluation. (Strong for)
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Management of Patients in Acute Exacerbation of COPD

We recommend antibiotic use for patients with COPD exacerbations who have increased dyspnea and increased sputum purulence (change in sputum color) or volume. (Strong for)
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We suggest basing choice of antibiotic on local resistance patterns and patient characteristics.
a. First-line antibiotic choice may include doxycycline, trimethoprim/sulfamethoxazole (TMP-SMX), secondgeneration cephalosporin, amoxicillin, amoxicillin/clavulanate, and azithromycin.
b. Despite the paucity of evidence regarding the choice of antibiotics, we suggest reserving broader spectrum antibiotics (e.g., quinolones) for patients with specific indications such as:
i. Critically ill patients in the intensive care unit (ICU);
ii. Patients with recent history of resistance, treatment failure, or antibiotic use; and
iii. Patients with risk factors for health care associated infections.
(Weak for)
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For outpatients with acute COPD exacerbation who are treated with antibiotics, we recommend a five-day course of the chosen antibiotic. (Strong for)
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There is insufficient evidence to recommend for or against procalcitoninguided antibiotic use for patients with acute COPD exacerbations. ()
(Not Applicable)
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For acute COPD exacerbations, we recommend a course of systemic corticosteroids (oral preferred) of 30-40 mg prednisone equivalent daily for 5-7 days. (Strong for)
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Management of Patients with COPD in the Hospital or Emergency Department

We suggest use of airway clearance techniques utilizing positive expiratory pressure (PEP) devices for patients with COPD exacerbations and difficulty expectorating sputum. (Weak for)
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We recommend the early use of non-invasive ventilation (NIV) in patients with acute COPD exacerbations to reduce intubation, mortality, and length of hospital stay. (Strong for)
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We recommend the use of NIV to support weaning from invasive mechanical ventilation and earlier extubation of intubated patients with COPD. (Strong for)
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Recommendation Grading

Overview

Title

Management of Chronic Obstructive Pulmonary Disease (COPD)

Authoring Organization

Veterans Health Administration / Department of Defense

Endorsing Organizations

American Thoracic Society

Centers for Disease Control and Prevention

National Heart, Lung, and Blood Institute

Publication Month/Year

April 1, 2021

Last Updated Month/Year

February 7, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Long term care, Medical transportation, Outpatient

Intended Users

Respiratory therapist, paramedic emt, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D029424 - Pulmonary Disease, Chronic Obstructive

Keywords

bronchodilators, pulmonary, COPD, breathing exercise, COPD exacerbation