Chronic obstructive pulmonary disease (COPD)

Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A patients are characterized by few symptoms (Modified British Medical Research Council [mMRC] 0-1 or COPD Assessment Test [CAT] <10) and low risk of exacerbations (zero moderate or severe exacerbations in the previous year).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

A short-acting bronchodilator or long-acting bronchodilator should be offered first-line. Long-acting beta-2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are preferred over short-acting bronchodilators, except for patients with only very occasional dyspnea.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide LABAs and LAMAs both significantly improve lung function, dyspnea, and health status and reduce exacerbation rates. [ ] How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1829/fullShow me the answer[Evidence A]1234286c-1c75-42a9-8a81-2f365d1602afccaAHow does umeclidinium compare with placebo for people with chronic obstructive pulmonary disease (COPD)?​​​ LAMAs have a greater effect on exacerbation reduction than LABAs.[105]Vogelmeier C, Hederer B, Glaab T, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med. 2011 Mar 24;364(12):1093-103. https://www.nejm.org/doi/full/10.1056/NEJMoa1008378 http://www.ncbi.nlm.nih.gov/pubmed/21428765?tool=bestpractice.com [106]Decramer ML, Chapman KR, Dahl R, et al; INVIGORATE investigators. Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study. Lancet Respir Med. 2013 Sep;1(7):524-33. http://www.ncbi.nlm.nih.gov/pubmed/24461613?tool=bestpractice.com

If a long-acting bronchodilator is prescribed, a short-acting bronchodilator should also be prescribed for rescue therapy. Regular use of short-acting bronchodilators is not generally recommended.

Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life. Ipratropium, a SAMA, may have a small benefit over SABAs in improving health-related quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com

SAMAs should be discontinued if a LAMA is prescribed.

SABAs include albuterol and levalbuterol. Ipratropium is a SAMA. LABAs include salmeterol, arformoterol, and olodaterol. LAMAs include tiotropium, umeclidinium, aclidinium, and glycopyrrolate. [ ] How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1829/fullShow me the answer

If the response to initial therapy results in low disease activity (with no persistent dyspnea/exercise limitation or exacerbations), initial treatment can be maintained long term.

Treatment recommended for ALL patients in selected patient group

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke and other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus, and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullShow me the answer​​​ 

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Global Initiative for Chronic Obstructive Lung Disease (GOLD) group B patients are characterized by more symptoms (Modified British Medical Research Council [mMRC] ≥2 or COPD Assessment Test [CAT] ≥10) and low risk of exacerbations (zero moderate or severe exacerbations in the previous year).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Combinations of a long-acting beta-2 agonist (LABA; e.g., vilanterol, formoterol, olodaterol) and a long-acting muscarinic antagonist (LAMA ;e.g., umeclidinium, glycopyrrolate, tiotropium, aclidinium) should be offered first-line in the absence of issues with adverse effects or availability.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Umeclidinium/vilanterol, glycopyrrolate/formoterol, tiotropium/olodaterol, and aclidinium/formoterol are LABA/LAMA combinations approved for use in COPD.[118]Wedzicha JA, Banerji D, Chapman KR, et al; FLAME Investigators. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016 Jun 9;374(23):2222-34. https://www.nejm.org/doi/10.1056/NEJMoa1516385 http://www.ncbi.nlm.nih.gov/pubmed/27181606?tool=bestpractice.com [236]Radovanovic D, Mantero M, Sferrazza Papa GF, et al. Formoterol fumarate + glycopyrrolate for the treatment of chronic obstructive pulmonary disease. Expert Rev Respir Med. 2016 Oct;10(10):1045-55. http://www.ncbi.nlm.nih.gov/pubmed/27552524?tool=bestpractice.com ​​ Umeclidinium/vilanterol decreases the risk of exacerbations in patients with mild/moderate COPD.[112]Maqsood U, Ho TN, Palmer K, et al. Once daily long-acting beta2-agonists and long-acting muscarinic antagonists in a combined inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 Mar 6;(3):CD012930. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012930.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30839102?tool=bestpractice.com [ ] How does a combined inhaler with once‐daily long‐acting beta2‐agonist (LABA) plus a long‐acting muscarinic antagonist (LAMA) compare with placebo for adults with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2551/fullShow me the answer​​ 

If the response to initial therapy results in low disease activity (with no persistent dyspnea/exercise limitation or exacerbations), initial treatment can be maintained long term.

Treatment recommended for ALL patients in selected patient group

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​ Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life.

Ipratropium, a SAMA, may have a small benefit over SABAs in improving health-related quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com SAMAs should be discontinued if a long-acting muscarinic antagonist (LAMA) is prescribed. SABAs include albuterol and levalbuterol.

Regular use of short-acting bronchodilators is not generally recommended. Failure to respond to short-acting bronchodilators may signify an acute exacerbation.

Treatment recommended for ALL patients in selected patient group

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke, or other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus, and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullShow me the answer​​​

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Treatment recommended for ALL patients in selected patient group

Pulmonary rehabilitation comprises aerobic exercise, strength training, and education, and should be started early in the disease course.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [195]Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-26. https://www.atsjournals.org/doi/10.1164/rccm.202306-1066ST http://www.ncbi.nlm.nih.gov/pubmed/37581410?tool=bestpractice.com [196]Man W, Chaplin E, Daynes E, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(suppl 5):s2-15. https://thorax.bmj.com/content/78/Suppl_5/s2 http://www.ncbi.nlm.nih.gov/pubmed/37770084?tool=bestpractice.com ​​​ Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pulmonary rehabilitation for patient groups B and E.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​​

Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderately large and clinically significant extent.[197]McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/25705944?tool=bestpractice.com

One large US cohort study found that initiation of pulmonary rehabilitation within 90 days of hospital discharge following an acute exacerbation of COPD was significantly associated with lower mortality risk at 1 year and fewer rehospitalizations at 1 year.[200]Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among medicare beneficiaries. JAMA. 2020 May 12;323(18):1813-23. https://jamanetwork.com/journals/jama/fullarticle/2765730 http://www.ncbi.nlm.nih.gov/pubmed/32396181?tool=bestpractice.com [201]Stefan MS, Pekow PS, Priya A, et al. Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021 Nov 1;204(9):1015-23. https://www.atsjournals.org/doi/10.1164/rccm.202012-4389OC http://www.ncbi.nlm.nih.gov/pubmed/34283694?tool=bestpractice.com ​ However, starting pulmonary rehabilitation before hospital discharge could be associated with a higher 12-month mortality, so is not recommended.[202]Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ. 2014 Jul 8;349:g4315. https://www.bmj.com/content/349/bmj.g4315 http://www.ncbi.nlm.nih.gov/pubmed/25004917?tool=bestpractice.com

Global Initiative for Chronic Obstructive Lung Disease (GOLD) group B patients are characterized by more symptoms (Modified British Medical Research Council [mMRC] ≥2 or COPD Assessment Test [CAT] ≥10) and low risk of exacerbations (zero moderate or severe exacerbations in the previous year).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

If there are issues with adverse effects or availability, monotherapy with either a long-acting muscarinic antagonist (LAMA) or a long-acting beta-2 agonist (LABA) may be prescribed.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​ There is no evidence to recommend one class of long-acting bronchodilator over another for initial treatment in this group of patients. The choice should depend on the patient's perception of symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

LABAs and LAMAs both significantly improve lung function, dyspnea, and health status and reduce exacerbation rates. [ ] How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1829/fullShow me the answer​ 

LABAs include salmeterol, arformoterol, and olodaterol. LAMAs include tiotropium, umeclidinium, aclidinium, and glycopyrrolate. [ ] How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1829/fullShow me the answer​ Revefenacin is a nebulized LAMA approved for the maintenance treatment of moderate to severe COPD.

If the response to initial therapy results in low disease activity (with no persistent dyspnea/exercise limitation or exacerbations), initial treatment can be maintained long term.

Treatment recommended for ALL patients in selected patient group

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life.

Ipratropium, a SAMA, may have a small benefit over SABAs in improving health-related quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com SAMAs should be discontinued if a LAMA is prescribed. SABAs include albuterol and levalbuterol.

Regular use of short-acting bronchodilators is not generally recommended. Failure to respond to short-acting bronchodilators may signify an acute exacerbation.

Treatment recommended for ALL patients in selected patient group

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke, or other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullMostre-me a resposta​ 

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Pulmonary rehabilitation comprises aerobic exercise, strength training, and education, and should be started early in the disease course.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [195]Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-26. https://www.atsjournals.org/doi/10.1164/rccm.202306-1066ST http://www.ncbi.nlm.nih.gov/pubmed/37581410?tool=bestpractice.com [196]Man W, Chaplin E, Daynes E, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(suppl 5):s2-15. https://thorax.bmj.com/content/78/Suppl_5/s2 http://www.ncbi.nlm.nih.gov/pubmed/37770084?tool=bestpractice.com ​​​ Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pulmonary rehabilitation for patient groups B and E.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderately large and clinically significant extent.[197]McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/25705944?tool=bestpractice.com

One large US cohort study found that initiation of pulmonary rehabilitation within 90 days of hospital discharge following an acute exacerbation of COPD was significantly associated with lower mortality risk at 1 year and fewer rehospitalizations at 1 year.[200]Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among medicare beneficiaries. JAMA. 2020 May 12;323(18):1813-23. https://jamanetwork.com/journals/jama/fullarticle/2765730 http://www.ncbi.nlm.nih.gov/pubmed/32396181?tool=bestpractice.com [201]Stefan MS, Pekow PS, Priya A, et al. Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021 Nov 1;204(9):1015-23. https://www.atsjournals.org/doi/10.1164/rccm.202012-4389OC http://www.ncbi.nlm.nih.gov/pubmed/34283694?tool=bestpractice.com ​ However, starting pulmonary rehabilitation before hospital discharge could be associated with a higher 12-month mortality, so is not recommended.[202]Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ. 2014 Jul 8;349:g4315. https://www.bmj.com/content/349/bmj.g4315 http://www.ncbi.nlm.nih.gov/pubmed/25004917?tool=bestpractice.com

Global Initiative for Chronic Obstructive Lung Disease (GOLD) group E patients are characterized by a high risk of exacerbations (≥1 moderate or severe exacerbations in the previous year) and any level of symptoms.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

GOLD recommends starting therapy with a long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​ LABAs include vilanterol, formoterol, olodaterol, and salmeterol; LAMAs include umeclidinium, glycopyrrolate, tiotropium, and aclidinium.

Addition of an inhaled corticosteroid (ICS; e.g., fluticasone, budesonide, mometasone) to a LABA/LAMA combination should be considered if the patient's blood eosinophil count is ≥300 cells/microliter.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide The effect of treatment regimens containing ICS is higher in patients at higher risk of exacerbations (two or more exacerbations and/or one hospitalization for an exacerbation in the previous year).[89]Papi A, Vestbo J, Fabbri L, et al. Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial. Lancet. 2018 Mar 17;391(10125):1076-84. http://www.ncbi.nlm.nih.gov/pubmed/29429593?tool=bestpractice.com [91]Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018 May 3;378(18):1671-80. https://www.nejm.org/doi/10.1056/NEJMoa1713901 http://www.ncbi.nlm.nih.gov/pubmed/29668352?tool=bestpractice.com [118]Wedzicha JA, Banerji D, Chapman KR, et al; FLAME Investigators. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016 Jun 9;374(23):2222-34. https://www.nejm.org/doi/10.1056/NEJMoa1516385 http://www.ncbi.nlm.nih.gov/pubmed/27181606?tool=bestpractice.com ​​​​​​​ Blood eosinophil count may predict the effectiveness of adding inhaled corticosteroids to regular long-acting bronchodilator treatment to prevent exacerbations.[76]Harries TH, Rowland V, Corrigan CJ, et al. Blood eosinophil count, a marker of inhaled corticosteroid effectiveness in preventing COPD exacerbations in post-hoc RCT and observational studies: systematic review and meta-analysis. Respir Res. 2020 Jan 3;21(1):3. https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-1268-7 http://www.ncbi.nlm.nih.gov/pubmed/31900184?tool=bestpractice.com [77]Oshagbemi OA, Odiba JO, Daniel A, et al. Absolute blood eosinophil counts to guide inhaled corticosteroids therapy among patients with COPD: systematic review and meta-analysis. Curr Drug Targets. 2019;20(16):1670-9. http://www.ncbi.nlm.nih.gov/pubmed/31393244?tool=bestpractice.com [78]Pascoe S, Barnes N, Brusselle G, et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. Lancet Respir Med. 2019 Sep;7(9):745-56. http://www.ncbi.nlm.nih.gov/pubmed/31281061?tool=bestpractice.com ​​​​​​​ Little or no effect is seen at blood eosinophil counts of <100 cells/microliter, while maximal effect is seen at blood eosinophil counts of ≥300 cells/microliter.[75]Bafadhel M, Peterson S, De Blas MA, et al. Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. Lancet Respir Med. 2018 Feb;6(2):117-26. http://www.ncbi.nlm.nih.gov/pubmed/29331313?tool=bestpractice.com [79]Cazzola M, Rogliani P, Calzetta L, et al. Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. Eur Respir J. 2018 Dec 13;52(6):1801586. https://erj.ersjournals.com/content/52/6/1801586 http://www.ncbi.nlm.nih.gov/pubmed/30309975?tool=bestpractice.com ​​​​​​​ These thresholds indicate approximate cut-off values that may help clinicians predict the likelihood of a treatment benefit.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Use of ICS also slows the rate of decline in lung function following an exacerbation in patients with mild to moderate COPD and elevated blood eosinophils.[133]Kerkhof M, Voorham J, Dorinsky P, et al. Association between COPD exacerbations and lung function decline during maintenance therapy. Thorax. 2020 Sep;75(9):744-53. https://thorax.bmj.com/content/75/9/744 http://www.ncbi.nlm.nih.gov/pubmed/32532852?tool=bestpractice.com Former smokers are more corticosteroid-responsive than current smokers at any eosinophil count.[78]Pascoe S, Barnes N, Brusselle G, et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. Lancet Respir Med. 2019 Sep;7(9):745-56. http://www.ncbi.nlm.nih.gov/pubmed/31281061?tool=bestpractice.com Both current and former smokers with COPD can benefit from ICS in terms of lung function and rates of exacerbations, although the effect is smaller for heavy or current smokers compared with light or former smokers.[91]Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018 May 3;378(18):1671-80. https://www.nejm.org/doi/10.1056/NEJMoa1713901 http://www.ncbi.nlm.nih.gov/pubmed/29668352?tool=bestpractice.com [119]Sonnex K, Alleemudder H, Knaggs R. Impact of smoking status on the efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review. BMJ Open. 2020 Apr 15;10(4):e037509. https://bmjopen.bmj.com/content/10/4/e037509 http://www.ncbi.nlm.nih.gov/pubmed/32300001?tool=bestpractice.com

ICS increases the risk of developing pneumonia in some patients, so should only be used as initial therapy after the possible clinical risks and benefits have been evaluated.

Umeclidinium/vilanterol, glycopyrrolate/formoterol, tiotropium/olodaterol, and aclidinium/formoterol are LABA/LAMA combinations approved for use in COPD.[118]Wedzicha JA, Banerji D, Chapman KR, et al; FLAME Investigators. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016 Jun 9;374(23):2222-34. https://www.nejm.org/doi/10.1056/NEJMoa1516385 http://www.ncbi.nlm.nih.gov/pubmed/27181606?tool=bestpractice.com [236]Radovanovic D, Mantero M, Sferrazza Papa GF, et al. Formoterol fumarate + glycopyrrolate for the treatment of chronic obstructive pulmonary disease. Expert Rev Respir Med. 2016 Oct;10(10):1045-55. http://www.ncbi.nlm.nih.gov/pubmed/27552524?tool=bestpractice.com ​ Umeclidinium/vilanterol decreases the risk of exacerbations in patients with mild/moderate COPD.[112]Maqsood U, Ho TN, Palmer K, et al. Once daily long-acting beta2-agonists and long-acting muscarinic antagonists in a combined inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 Mar 6;(3):CD012930. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012930.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30839102?tool=bestpractice.com [ ] How does a combined inhaler with once‐daily long‐acting beta2‐agonist (LABA) plus a long‐acting muscarinic antagonist (LAMA) compare with placebo for adults with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2551/fullMostre-me a resposta

Fluticasone/umeclidinium/vilanterol (a LABA/LAMA/ICS combination) is available as a proprietary combination inhaler.

If the response to initial therapy results in low disease activity (with no persistent dyspnea/exercise limitation or exacerbations), initial treatment can be maintained long term.

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide  Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com

Ipratropium, a SAMA, may have a small benefit over SABAs in improving health-related quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com SAMAs should be discontinued if a long-acting muscarinic antagonist (LAMA) is prescribed. SABAs include albuterol and levalbuterol.

Regular use of short-acting bronchodilators is not generally recommended. Failure to respond to short-acting bronchodilator may signify an acute exacerbation.

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke, or other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus, and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullMostre-me a resposta​​​

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Pulmonary rehabilitation comprises aerobic exercise, strength training, and education, and should be started early in the disease course.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [195]Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-26. https://www.atsjournals.org/doi/10.1164/rccm.202306-1066ST http://www.ncbi.nlm.nih.gov/pubmed/37581410?tool=bestpractice.com [196]Man W, Chaplin E, Daynes E, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(suppl 5):s2-15. https://thorax.bmj.com/content/78/Suppl_5/s2 http://www.ncbi.nlm.nih.gov/pubmed/37770084?tool=bestpractice.com ​​​ Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pulmonary rehabilitation for patient groups B and E.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderately large and clinically significant extent.[197]McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/25705944?tool=bestpractice.com

One large US cohort study found that initiation of pulmonary rehabilitation within 90 days of hospital discharge following an acute exacerbation of COPD was significantly associated with lower mortality risk at 1 year and fewer rehospitalizations at 1 year.[200]Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among medicare beneficiaries. JAMA. 2020 May 12;323(18):1813-23. https://jamanetwork.com/journals/jama/fullarticle/2765730 http://www.ncbi.nlm.nih.gov/pubmed/32396181?tool=bestpractice.com [201]Stefan MS, Pekow PS, Priya A, et al. Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021 Nov 1;204(9):1015-23. https://www.atsjournals.org/doi/10.1164/rccm.202012-4389OC http://www.ncbi.nlm.nih.gov/pubmed/34283694?tool=bestpractice.com ​ However, starting pulmonary rehabilitation before hospital discharge could be associated with a higher 12-month mortality, so is not recommended.[202]Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ. 2014 Jul 8;349:g4315. https://www.bmj.com/content/349/bmj.g4315 http://www.ncbi.nlm.nih.gov/pubmed/25004917?tool=bestpractice.com

Further treatment is determined by the patient’s symptom burden (dyspnea/exercise limitation), exacerbation history, and evidence of ongoing disease activity, and is independent of the patient’s Global Initiative for Chronic Obstructive Lung Disease (GOLD) group at diagnosis. GOLD recommends different treatment pathways depending on whether the primary treatment goal is relieving dyspnea/exercise limitation symptoms or reducing exacerbations. If treatment is required for both purposes, clinicians should follow the exacerbation pathway.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

If the response to initial therapy results in low disease activity and clinical stability, initial treatment can be maintained. Patients with persistent dyspnea/exercise limitation while on a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA) alone should switch to dual long-acting bronchodilator therapy with a LABA/LAMA combination. If symptoms do not improve, changing inhaler device or molecules may be considered.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

LABAs include vilanterol, formoterol, and olodaterol. LAMAs include umeclidinium, glycopyrrolate, tiotropium, and aclidinium). A LABA/LAMA combination may provide a better therapeutic effect without increasing the adverse effects of each class.[104]Rabe KF, Timmer W, Sagkriotis A, et al. Comparison of a combination of tiotropium plus formoterol to salmeterol plus fluticasone in moderate COPD. Chest. 2008 Aug;134(2):255-62. http://www.ncbi.nlm.nih.gov/pubmed/18403672?tool=bestpractice.com [108]Tashkin DP, Littner M, Andrews CP, et al. Concomitant treatment with nebulized formoterol and tiotropium in subjects with COPD: a placebo-controlled trial. Respir Med. 2008 Apr;102(4):479-87. http://www.ncbi.nlm.nih.gov/pubmed/18258423?tool=bestpractice.com [109]Tashkin DP, Pearle J, Iezzoni D, et al. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD. 2009 Feb;6(1):17-25. http://www.ncbi.nlm.nih.gov/pubmed/19229704?tool=bestpractice.com [110]Vogelmeier C, Kardos P, Harari S, et al. Formoterol mono- and combination therapy with tiotropium in patients with COPD: a 6-month study. Respir Med. 2008 Nov;102(11):1511-20. http://www.ncbi.nlm.nih.gov/pubmed/18804362?tool=bestpractice.com [111]Maltais F, Bjermer L, Kerwin EM, et al. Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial. Respir Res. 2019 Oct 30;20(1):238. https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-1193-9 http://www.ncbi.nlm.nih.gov/pubmed/31666084?tool=bestpractice.com ​​​​ Systematic reviews and meta-analyses have found that combination therapy with a LABA/LAMA reduces exacerbation rate compared with monotherapy and is associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild/moderate COPD, compared with placebo.[112]Maqsood U, Ho TN, Palmer K, et al. Once daily long-acting beta2-agonists and long-acting muscarinic antagonists in a combined inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 Mar 6;(3):CD012930. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012930.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30839102?tool=bestpractice.com [ ] How does a combined inhaler with once‐daily long‐acting beta2‐agonist (LABA) plus a long‐acting muscarinic antagonist (LAMA) compare with placebo for adults with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2551/fullMostre-me a resposta​ Combination therapy improves FEV₁ and modestly reduces risk of pneumonia in patients with stable chronic obstructive pulmonary disease, but increases odds of all-cause death from 1% to 1.4%.[113]Fukuda N, Horita N, Kaneko A, et al. Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2023 Jun 5;6(6):CD012066. https://www.doi.org/10.1002/14651858.CD012066.pub3 http://www.ncbi.nlm.nih.gov/pubmed/37276335?tool=bestpractice.com [ ] How does long‐acting muscarinic antagonist (LAMA) plus long‐acting beta‐agonist (LABA) compare with LABA plus inhaled corticosteroid (ICS) for people with stable chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.4356/fullMostre-me a resposta​​ 

Dyspnea due to other causes should be considered, investigated, and treated. Inhaler technique and adherence should also be re-assessed, as these may have led to an inadequate response to treatment.

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide  

Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com

Regular use of short-acting bronchodilators is not generally recommended. Failure to respond to short-acting bronchodilator may signify an acute exacerbation.

SAMAs should not be prescribed with a long-acting muscarinic antagonist (LAMA). SABAs include albuterol and levalbuterol.

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke, or other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus, and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullMostre-me a resposta​​​ 

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Pulmonary rehabilitation comprises aerobic exercise, strength training, and education, and should be started early in the disease course.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [195]Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-26. https://www.atsjournals.org/doi/10.1164/rccm.202306-1066ST http://www.ncbi.nlm.nih.gov/pubmed/37581410?tool=bestpractice.com [196]Man W, Chaplin E, Daynes E, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(suppl 5):s2-15. https://thorax.bmj.com/content/78/Suppl_5/s2 http://www.ncbi.nlm.nih.gov/pubmed/37770084?tool=bestpractice.com ​​​ Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pulmonary rehabilitation for patient groups B and E.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderately large and clinically significant extent.[197]McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/25705944?tool=bestpractice.com

One large US cohort study found that initiation of pulmonary rehabilitation within 90 days of hospital discharge following an acute exacerbation of COPD was significantly associated with lower mortality risk at 1 year and fewer rehospitalizations at 1 year.[200]Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among medicare beneficiaries. JAMA. 2020 May 12;323(18):1813-23. https://jamanetwork.com/journals/jama/fullarticle/2765730 http://www.ncbi.nlm.nih.gov/pubmed/32396181?tool=bestpractice.com [201]Stefan MS, Pekow PS, Priya A, et al. Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021 Nov 1;204(9):1015-23. https://www.atsjournals.org/doi/10.1164/rccm.202012-4389OC http://www.ncbi.nlm.nih.gov/pubmed/34283694?tool=bestpractice.com ​ However, starting pulmonary rehabilitation before hospital discharge could be associated with a higher 12-month mortality, so is not recommended.[202]Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ. 2014 Jul 8;349:g4315. https://www.bmj.com/content/349/bmj.g4315 http://www.ncbi.nlm.nih.gov/pubmed/25004917?tool=bestpractice.com

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend long-term oxygen therapy in stable patients who have: partial pressure of oxygen, arterial (PaO₂) ≤7.3 kPa (55 mmHg) or arterial oxygen saturation (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 of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Guidelines from the American Thoracic Society (ATS) recommend prescribing long-term oxygen therapy for at least 15 hours per day in adults with COPD who have severe chronic resting room air hypoxemia. The ATS defines severe hypoxemia as either: PaO₂ ≤7.3 kPa (55 mmHg) or oxygen saturation as measured by pulse oximetry (SpO₂) ≤88%; or PaO₂ 7.5 to 7.9 kPa (56-59 mmHg) or SpO₂ of 89% plus one of the following: edema, hematocrit ≥55%, or P pulmonale on an ECG.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

For patients prescribed home oxygen therapy, the ATS recommends that the patient and their caregivers should receive instruction and training on the use and maintenance of all oxygen equipment and education on oxygen safety, including smoking cessation, fire prevention, and tripping hazards.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

Supplemental oxygen should be titrated to achieve SaO₂ ≥90%.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide  The patient should be reassessed after 60-90 days to determine whether oxygen is still indicated and is therapeutic.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Among different therapeutic modalities in COPD, the only two factors that improve survival are smoking cessation and oxygen supplementation.

Oxygen therapy helps minimize pulmonary hypertension by decreasing pulmonary artery pressure, and improves exercise tolerance and quality of life. It has been shown to improve survival.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​​

The ATS suggests prescribing ambulatory oxygen (oxygen delivered during exercise or activities of daily living) in adults with COPD who have severe exertional room air hypoxemia.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com However, the ATS suggests not prescribing long-term oxygen therapy in adults with COPD who have moderate chronic resting room air hypoxemia (SpO₂ of 89% to 93%).[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

For patients who have COPD and obstructive sleep apnea, ventilatory support with continuous positive airway pressure (CPAP) can improve survival and reduce hospital admissions.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [72]Marin JM, Soriano JB, Carrizo SJ, et al. Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome. Am J Respir Crit Care Med. 2010 Aug 1;182(3):325-31. https://www.atsjournals.org/doi/10.1164/rccm.200912-1869OC http://www.ncbi.nlm.nih.gov/pubmed/20378728?tool=bestpractice.com ​ Noninvasive ventilation (NIV) is occasionally used in patients with very severe but stable COPD, although the optimal timing for initiation and best selection criteria for candidates is unclear.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [214]Wilson ME, Dobler CC, Morrow AS, et al. Association of home noninvasive positive pressure ventilation with clinical outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2020 Feb 4;323(5):455-65. https://jamanetwork.com/journals/jama/fullarticle/2760390 http://www.ncbi.nlm.nih.gov/pubmed/32016309?tool=bestpractice.com

Guidelines from the ATS suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD.[217]Macrea M, Oczkowski S, Rochwerg B, et al. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice fuideline. Am J Respir Crit Care Med. 2020 Aug 15;202(4):e74-87. https://www.atsjournals.org/doi/10.1164/rccm.202006-2382ST http://www.ncbi.nlm.nih.gov/pubmed/32795139?tool=bestpractice.com The European Respiratory Society (ERS) and Canadian Thoracic Society (CTS) have issued similar guidance.[218]Ergan B, Oczkowski S, Rochwerg B, et al. European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD. Eur Respir J. 2019 Sep 28;54(3):1901003. https://erj.ersjournals.com/content/54/3/1901003 http://www.ncbi.nlm.nih.gov/pubmed/31467119?tool=bestpractice.com [219]Kaminska M, Rimmer KP, McKim DA, et al. Long-term non-invasive ventilation in patients with chronic obstructive pulmonary disease (COPD): 2021 Canadian Thoracic Society clinical practice guideline update. Can J Respir Crit Care Sleep Med. 2021 May 7;5(3):160-83. https://www.tandfonline.com/doi/full/10.1080/24745332.2021.1911218

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Ensifentrine is a selective phosphodiesterase-3 (PDE-3) and PDE-4 inhibitor approved in the US for the maintenance treatment of COPD in adults. It combines bronchodilator and nonsteroidal anti-inflammatory effects within a single molecule. Ensifentrine may be considered as an add-on bronchodilator for patients with stable COPD taking long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA) who have persistent dyspnea symptoms.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​ Clinical benefits were apparent when used as monotherapy and with other maintenance therapies.[140]Anzueto A, Barjaktarevic IZ, Siler TM, et al. Ensifentrine, a novel phosphodiesterase 3 and 4 inhibitor for the treatment of chronic obstructive pulmonary disease: randomized, double-blind, placebo-controlled, multicenter phase III trials (the ENHANCE trials). Am J Respir Crit Care Med. 2023 Aug 15;208(4):406-16. https://www.atsjournals.org/doi/10.1164/rccm.202306-0944OC?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/37364283?tool=bestpractice.com [141]Yappalparvi A, Balaraman AK, Padmapriya G, et al. Safety and efficacy of ensifentrine in COPD: a systemic review and meta-analysis. Respir Med. 2025 Jan;236:107863. https://www.resmedjournal.com/article/S0954-6111(24)00338-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39557208?tool=bestpractice.com ​ Nonetheless, enfensitrine’s place in therapy requires further study.

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Patients with the chronic bronchitis phenotype of COPD often produce thick sputum on a frequent basis. Oral mucolytic agents (erdosteine, carbocysteine, and acetylcysteine) result in a small reduction in the frequency of acute exacerbations and in days of disability per month, but do not improve lung function or quality of life.[192]Poole P, Sathananthan K, Fortescue R. Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 May 20;(5):CD001287. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001287.pub6/full http://www.ncbi.nlm.nih.gov/pubmed/31107966?tool=bestpractice.com [193]Rogliani P, Matera MG, Page C, et al. Efficacy and safety profile of mucolytic/antioxidant agents in chronic obstructive pulmonary disease: a comparative analysis across erdosteine, carbocysteine, and N-acetylcysteine. Respir Res. 2019 May 27;20(1):104. https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-1078-y http://www.ncbi.nlm.nih.gov/pubmed/31133026?tool=bestpractice.com ​​​[194]Wei J, Pang CS, Han J, et al. Effect of orally administered N-acetylcysteine on chronic bronchitis: a meta-analysis. Adv Ther. 2019 Dec;36(12):3356-67. http://www.ncbi.nlm.nih.gov/pubmed/31598901?tool=bestpractice.com ​ Treatment with mucolytic agents such as carbocysteine and acetylcysteine may reduce exacerbations and modestly improve health status in patients not receiving inhaled corticosteroid (ICS).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide However, erdosteine may have a significant effect on mild exacerbations whether or not the patient is taking ICS.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Erdosteine and carbocysteine are not available in the US.

UK guidelines recommend that mucolytic drugs should not be routinely used to prevent exacerbations in patients with stable COPD, and should only be continued if there is symptomatic improvement.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Theophylline (a methylxanthine agent) is not commonly used because of limited potency, narrow therapeutic window, high-risk profile, and frequent drug-drug interactions. Theophylline has modest effects on lung function in moderate to severe COPD.[155]Ram FSF, Jones P, Jardim J, et al. Oral theophylline for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002;(4):CD003902. https://pmc.ncbi.nlm.nih.gov/articles/PMC7047557 http://www.ncbi.nlm.nih.gov/pubmed/12519617?tool=bestpractice.com One large randomized controlled trial found no effect of oral theophylline alone or with prednisone on exacerbations of severe COPD.[156]Jenkins CR, Wen FQ, Martin A, et al; TASCS study investigators. The effect of low-dose corticosteroids and theophylline on the risk of acute exacerbations of COPD: the TASCS randomised controlled trial. Eur Respir J. 2021 Jun 10;57(6):2003338. https://erj.ersjournals.com/content/57/6/2003338 http://www.ncbi.nlm.nih.gov/pubmed/33334939?tool=bestpractice.com Toxicity is dose-related. UK guidelines recommend that oral theophylline is only used if a patient has already trialed short-acting and long-acting bronchodilator therapy or is unable to use inhaled therapies.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Surgical interventions are the last step in the management of COPD, and include bullectomy, lung volume reduction, and lung transplantation.[220]van Agteren JE, Hnin K, Grosser D, et al. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb 23;(2):CD012158. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012158.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/28230230?tool=bestpractice.com [221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com [ ] How does bronchoscopic lung volume reduction compare with medical therapy in people with chronic obstructive pulmonary disease?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1680/fullMostre-me a resposta​​​​ They are used to improve lung dynamics, exercise adherence, and quality of life.[221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com Severely limited functional status and severe decrease in forced expiratory volume in the first second of expiration (FEV₁) (<500 mL) make these options less favorable.

Bullectomy is an option in COPD patients with dyspnea in whom computed tomography (CT) reveals huge bullae occupying at least 30% of the hemithorax.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Lung volume reduction surgery may be most beneficial in patients with emphysema whose dyspnea is primarily due to hyperinflation and air trapping distal to the terminal bronchioles. It is indicated in patients with very severe airflow limitation, and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [220]van Agteren JE, Hnin K, Grosser D, et al. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb 23;(2):CD012158. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012158.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/28230230?tool=bestpractice.com [ ] How does bronchoscopic lung volume reduction compare with medical therapy in people with chronic obstructive pulmonary disease?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1680/fullMostre-me a resposta​​​​​ One meta-analysis found an increased risk of early mortality in patients who underwent lung volume reduction surgery compared to standard care; however, no significant difference was observed in overall mortality.[223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com

Bronchoscopic approaches to lung volume reduction, such as endobronchial valve insertion, can produce clinically meaningful improvements in appropriately selected patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com [224]Klooster K, Slebos DJ, Zoumot Z, et al. Endobronchial valves for emphysema: an individual patient-level reanalysis of randomised controlled trials. BMJ Open Respir Res. 2017 Nov 2;4(1):e000214. https://bmjopenrespres.bmj.com/content/4/1/e000214 http://www.ncbi.nlm.nih.gov/pubmed/29441206?tool=bestpractice.com [225]Labarca G, Uribe JP, Pacheco C, et al. Bronchoscopic lung volume reduction with endobronchial zephyr valves for severe emphysema: a systematic review and meta-analysis. Respiration. 2019 May 22;98(3):268-78. http://www.ncbi.nlm.nih.gov/pubmed/31117102?tool=bestpractice.com ​​​​ Contraindications include active lung infection and incomplete lobar fissures (<80%).[226]Abia-Trujillo D, Johnson MM, Patel NM, et al. Bronchoscopic lung volume reduction: a new hope for patients with severe emphysema and air trapping. Mayo Clin Proc. 2021 Feb;96(2):464-72. http://www.ncbi.nlm.nih.gov/pubmed/32829903?tool=bestpractice.com The most common adverse events associated with endobronchial valve insertion are pneumothorax and exacerbation.[223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com

Lung transplantation has been shown to improve quality of life and functional capacity.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com ​ However, lung transplantation does not appear to confer a survival benefit for most patients.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​ 

Patients may benefit from referral for lung transplantation if they have a Body mass index, airflow Obstruction, Dyspnea and Exercise (BODE) score of 5-6 with additional factors which are suggestive of increased mortality risk.[227]Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021 Nov;40(11):1349-79. https://www.jhltonline.org/article/S1053-2498(21)02407-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34419372?tool=bestpractice.com ​ These factors are: frequent acute exacerbations; increase in BODE score >1 over the past 2 years; pulmonary artery to aorta diameter >1 on CT scan; and FEV₁ 20% to 25% predicted. 

Patients may also benefit from referral if they clinically deteriorate despite maximal treatment (including pharmacotherapy, pulmonary rehabilitation, oxygen therapy, and if appropriate, nocturnal noninvasive positive pressure ventilation) or deem their quality of life to be unacceptable.[227]Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021 Nov;40(11):1349-79. https://www.jhltonline.org/article/S1053-2498(21)02407-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34419372?tool=bestpractice.com

For a patient who is a candidate for bronchoscopic or surgical lung volume reduction (LVR), simultaneous referral for both lung transplant and LVR evaluation is appropriate.

[ BODE Index for COPD Survival Prediction Opens in new window ]

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Palliative therapies to improve symptoms of dyspnea, offer nutritional support, address anxiety and depression, and reduce fatigue may benefit patients with COPD who experience these despite optimal medical therapy. End-of-life care and hospice admission should be considered for patients with very advanced disease. Patient and family should be well educated about the process, and it is suggested that discussions should be held early in the course of the disease before acute respiratory failure develops.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [228]Janssen DJA, Bajwah S, Boon MH, et al. European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease. Eur Respir J. 2023 Aug;62(2):2202014. https://erj.ersjournals.com/content/62/2/2202014 http://www.ncbi.nlm.nih.gov/pubmed/37290789?tool=bestpractice.com ​ Opioid analgesics, fans, neuromuscular electrical stimulation, and chest wall vibration can relieve dyspnea.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide One study has suggested that low doses of an opioid analgesic and a benzodiazepine are safe and are not associated with increased hospital admissions or mortality.[229]Ekström MP, Bornefalk-Hermansson A, Abernethy AP, et al. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014 Jan 30;348:g445. https://www.bmj.com/content/348/bmj.g445.long http://www.ncbi.nlm.nih.gov/pubmed/24482539?tool=bestpractice.com Another study found that regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD and refractory breathlessness.[230]Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, et al. Effect of sustained-release morphine for refractory breathlessness in chronic obstructive pulmonary disease on health status: a randomized clinical trial. JAMA Intern Med. 2020 Oct 1;180(10):1306-14. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769373 http://www.ncbi.nlm.nih.gov/pubmed/32804188?tool=bestpractice.com

One Cochrane review concluded that there is no evidence for or against benzodiazepines for the relief of breathlessness in people with advanced cancer and COPD.[231]Simon ST, Higginson IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2016 Oct 20;(10):CD007354. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007354.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27764523?tool=bestpractice.com

Acupuncture and acupressure may also improve breathlessness and quality of life in patients with advanced COPD.[232]von Trott P, Oei SL, Ramsenthaler C. Acupuncture for breathlessness in advanced diseases: a systematic review and meta-analysis. J Pain Symptom Manage. 2020 Feb;59(2):327-38.e3. http://www.ncbi.nlm.nih.gov/pubmed/31539602?tool=bestpractice.com

Further treatment is determined by the patient’s symptom burden (dyspnea/exercise limitation), exacerbation history, and evidence of ongoing disease activity, and is independent of the patient’s Global Initiative for Chronic Obstructive Lung Disease (GOLD) group at diagnosis. GOLD recommends different treatment pathways depending on whether the primary treatment goal is relieving dyspnea/exercise limitation symptoms or reducing exacerbations. If treatment is required for both purposes, clinicians should follow the exacerbation pathway.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

If the response to initial therapy results in low disease activity and clinical stability, initial treatment can be maintained. Patients taking a long-acting beta-2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) alone and who experience persistent exacerbations should increase therapy to LABA/LAMA. LABAs include vilanterol, formoterol, olodaterol, and salmeterol. LAMAs include umeclidinium, glycopyrrolate, tiotropium, and aclidinium.

Blood eosinophil counts can identify patients who are more likely to respond to an inhaled corticosteroid (ICS).[75]Bafadhel M, Peterson S, De Blas MA, et al. Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. Lancet Respir Med. 2018 Feb;6(2):117-26. http://www.ncbi.nlm.nih.gov/pubmed/29331313?tool=bestpractice.com [76]Harries TH, Rowland V, Corrigan CJ, et al. Blood eosinophil count, a marker of inhaled corticosteroid effectiveness in preventing COPD exacerbations in post-hoc RCT and observational studies: systematic review and meta-analysis. Respir Res. 2020 Jan 3;21(1):3. https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-1268-7 http://www.ncbi.nlm.nih.gov/pubmed/31900184?tool=bestpractice.com [77]Oshagbemi OA, Odiba JO, Daniel A, et al. Absolute blood eosinophil counts to guide inhaled corticosteroids therapy among patients with COPD: systematic review and meta-analysis. Curr Drug Targets. 2019;20(16):1670-9. http://www.ncbi.nlm.nih.gov/pubmed/31393244?tool=bestpractice.com ​​​​​​​ Use of ICS (e.g., fluticasone, budesonide, mometasone) also slows the rate of decline in lung function following an exacerbation in patients with mild to moderate COPD and elevated blood eosinophils.[133]Kerkhof M, Voorham J, Dorinsky P, et al. Association between COPD exacerbations and lung function decline during maintenance therapy. Thorax. 2020 Sep;75(9):744-53. https://thorax.bmj.com/content/75/9/744 http://www.ncbi.nlm.nih.gov/pubmed/32532852?tool=bestpractice.com Former smokers are more corticosteroid-responsive than current smokers at any eosinophil count.[78]Pascoe S, Barnes N, Brusselle G, et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. Lancet Respir Med. 2019 Sep;7(9):745-56. http://www.ncbi.nlm.nih.gov/pubmed/31281061?tool=bestpractice.com

Escalation to triple therapy with LABA/LAMA/ICS may be considered for patients on long-acting bronchodilator monotherapy if their peripheral eosinophil count is ≥300 cells/microliter. ICS is unlikely to be beneficial in patients whose blood eosinophil count is <100 cells/microliter.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Patients who take LABA/LAMA who experience persistent exacerbations and whose blood eosinophils are ≥100 cells/microliter should escalate to LABA/LAMA/ICS.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Multiple studies support triple therapy with LABA/LAMA/ICS as being superior to single- or double-agent therapy with LABA/LAMA or LABA/ICS regarding rate of moderate to severe COPD exacerbations and rate of hospitalization.[79]Cazzola M, Rogliani P, Calzetta L, et al. Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. Eur Respir J. 2018 Dec 13;52(6):1801586. https://erj.ersjournals.com/content/52/6/1801586 http://www.ncbi.nlm.nih.gov/pubmed/30309975?tool=bestpractice.com [87]Singh D, Papi A, Corradi M, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting beta2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet. 2016 Sep 3;388(10048):963-73. http://www.ncbi.nlm.nih.gov/pubmed/27598678?tool=bestpractice.com [88]Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomised controlled trial. Lancet. 2017 May 13;389(10082):1919-29. http://www.ncbi.nlm.nih.gov/pubmed/28385353?tool=bestpractice.com [89]Papi A, Vestbo J, Fabbri L, et al. Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial. Lancet. 2018 Mar 17;391(10125):1076-84. http://www.ncbi.nlm.nih.gov/pubmed/29429593?tool=bestpractice.com [90]Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: once-daily triple therapy for patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017 Aug 15;196(4):438-46. https://www.atsjournals.org/doi/full/10.1164/rccm.201703-0449OC http://www.ncbi.nlm.nih.gov/pubmed/28375647?tool=bestpractice.com [91]Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018 May 3;378(18):1671-80. https://www.nejm.org/doi/10.1056/NEJMoa1713901 http://www.ncbi.nlm.nih.gov/pubmed/29668352?tool=bestpractice.com [92]Rojas-Reyes MX, García Morales OM, Dennis RJ, et al. Combination inhaled steroid and long-acting beta₂-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Jun 6;(6):CD008532. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008532.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27271056?tool=bestpractice.com [93]Lai CC, Chen CH, Lin CYH, et al. The effects of single inhaler triple therapy vs single inhaler dual therapy or separate triple therapy for the management of chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis. 2019 Jul 11;14:1539-48. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2020 Jan 21;15:155-6.] https://www.dovepress.com/the-effects-of-single-inhaler-triple-therapy-vs-single-inhaler-dual-th-peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/31371939?tool=bestpractice.com ​​​[94]Rabe KF, Martinez FJ, Ferguson GT, et al. Triple inhaled therapy at two glucocorticoid doses in moderate-to-very-severe COPD. N Engl J Med. 2020 Jul 2;383(1):35-48. http://www.ncbi.nlm.nih.gov/pubmed/32579807?tool=bestpractice.com ​​ One randomized controlled trial has reported a reduction in all-cause mortality in patients at risk of exacerbations who take fluticasone furoate/umeclidinium/vilanterol, compared with umeclidinium/vilanterol.[134]Lipson DA, Crim C, Criner GJ, et al. Reduction in all-cause mortality with fluticasone furoate/umeclidinium/vilanterol in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2020 Jun 15;201(12):1508-16. https://www.atsjournals.org/doi/10.1164/rccm.201911-2207OC http://www.ncbi.nlm.nih.gov/pubmed/32162970?tool=bestpractice.com Another randomized controlled trial had similar findings in terms of mortality in the triple therapy arm (budesonide/glycopyrrolate/formoterol), but only at the higher dose of ICS.[94]Rabe KF, Martinez FJ, Ferguson GT, et al. Triple inhaled therapy at two glucocorticoid doses in moderate-to-very-severe COPD. N Engl J Med. 2020 Jul 2;383(1):35-48. http://www.ncbi.nlm.nih.gov/pubmed/32579807?tool=bestpractice.com [135]Martinez FJ, Rabe KF, Ferguson GT, et al. Reduced all-cause mortality in the ETHOS trial of budesonide/glycopyrrolate/formoterol for chronic obstructive pulmonary disease. A randomized, double-blind, multicenter, parallel-group study. Am J Respir Crit Care Med. 2021 Mar 1;203(5):553-64. https://www.atsjournals.org/doi/10.1164/rccm.202006-2618OC http://www.ncbi.nlm.nih.gov/pubmed/33252985?tool=bestpractice.com ​​​ For both studies, there were no differences in mortality compared with LABA/ICS.[94]Rabe KF, Martinez FJ, Ferguson GT, et al. Triple inhaled therapy at two glucocorticoid doses in moderate-to-very-severe COPD. N Engl J Med. 2020 Jul 2;383(1):35-48. http://www.ncbi.nlm.nih.gov/pubmed/32579807?tool=bestpractice.com [134]Lipson DA, Crim C, Criner GJ, et al. Reduction in all-cause mortality with fluticasone furoate/umeclidinium/vilanterol in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2020 Jun 15;201(12):1508-16. https://www.atsjournals.org/doi/10.1164/rccm.201911-2207OC http://www.ncbi.nlm.nih.gov/pubmed/32162970?tool=bestpractice.com [135]Martinez FJ, Rabe KF, Ferguson GT, et al. Reduced all-cause mortality in the ETHOS trial of budesonide/glycopyrrolate/formoterol for chronic obstructive pulmonary disease. A randomized, double-blind, multicenter, parallel-group study. Am J Respir Crit Care Med. 2021 Mar 1;203(5):553-64. https://www.atsjournals.org/doi/10.1164/rccm.202006-2618OC http://www.ncbi.nlm.nih.gov/pubmed/33252985?tool=bestpractice.com A post hoc pooled analysis of three trials of triple therapy in patients with COPD and severe airflow limitation and a history of exacerbations showed a nonsignificant trend for lower mortality with triple therapy compared with non-ICS treatments.[136]Vestbo J, Fabbri L, Papi A, et al. Inhaled corticosteroid containing combinations and mortality in COPD. Eur Respir J. 2018 Dec 13;52(6):1801230. https://erj.ersjournals.com/content/52/6/1801230 http://www.ncbi.nlm.nih.gov/pubmed/30209195?tool=bestpractice.com These results are strengthened by findings from a meta-analysis of over 200 studies: triple therapy provided a significant reduction in mortality versus dual therapy, although was associated with greater risk of pneumonia. No differences were observed between regimens in lung function or health-related quality of life.[137]Axson EL, Lewis A, Potts J, et al. Inhaled therapies for chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMJ Open. 2020 Sep 29;10(9):e036455. https://bmjopen.bmj.com/content/10/9/e036455 http://www.ncbi.nlm.nih.gov/pubmed/32994234?tool=bestpractice.com

American Thoracic Society (ATS) guidelines recommend the use of LABA/LAMA/ICS in patients who have had one or more exacerbations requiring oral corticosteroids, antibiotics, or hospitalization in the past year and who have symptoms of dyspnea or reduced exercise tolerance despite LABA/LAMA dual therapy.[95]Nici L, Mammen MJ, Charbek E, et al. Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 May 1;201(9):e56-69. https://www.atsjournals.org/doi/10.1164/rccm.202003-0625ST http://www.ncbi.nlm.nih.gov/pubmed/32283960?tool=bestpractice.com UK guidelines recommend the use of LABA/LAMA/ICS in patients who have an exacerbation requiring hospitalization, or two moderate exacerbations within a year, despite dual therapy with LABA/LAMA.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

LABA/ICS is not recommended by GOLD. However, a patient with COPD who previously had exacerbations that responded to LABA/ICS (and has no current exacerbations) may continue on LABA/ICS; high symptom load may merit escalation to LABA/LAMA/ICS in this patient population. If a patient currently receiving LABA/ICS has no relevant exacerbation history, consider switching to LABA/LAMA. Patients on LABA/ICS with current exacerbations and blood eosinophil count <100 cells/microliter may be candidates for changing to LABA/LAMA. Those with current exacerbations and blood eosinophil count ≥100 cells/microliter while using LABA/ICS should be escalated to triple therapy by addition of a LAMA.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Patients with blood eosinophils ≥300 cells/microliter are at greatest risk of exacerbations after withdrawing ICS.[80]Chapman KR, Hurst JR, Frent SM, et al. Long-term triple therapy de-escalation to indacaterol/glycopyrronium in patients with chronic obstructive pulmonary disease (SUNSET): a randomized, double-blind, triple-dummy clinical trial. Am J Respir Crit Care Med. 2018 Aug 1;198(3):329-39. https://www.atsjournals.org/doi/10.1164/rccm.201803-0405OC http://www.ncbi.nlm.nih.gov/pubmed/29779416?tool=bestpractice.com

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide  

Short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) improve lung function and breathlessness and quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com Ipratropium, a SAMA, may have a small benefit over SABAs in improving health-related quality of life.[96]Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001387. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001387.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/16625543?tool=bestpractice.com SAMAs should be discontinued if a long-acting muscarinic antagonist (LAMA) is prescribed. SABAs include albuterol and levalbuterol.

Regular use of short-acting bronchodilators is not generally recommended. Failure to respond to short-acting bronchodilator may signify an acute exacerbation.

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Smoking cessation should be encouraged in all patients, in addition to guidance on avoiding exposure to occupational or environmental tobacco smoke, or other irritants.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 ​​ Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies. See Smoking cessation.

Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), respiratory syncytial virus, and coronavirus disease 2019 (COVID-19).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [233]Centers for Disease Control and Prevention.​ Adult immunization schedule by age: ​recommendations for ages 19 years or older, United States, 2025. Jul 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​​ Vaccination against influenza is associated with fewer exacerbations of COPD.[234]Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24;(1):CD001390. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001390.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28116747?tool=bestpractice.com [235]Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26;(6):CD002733. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29943802?tool=bestpractice.com [ ] What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2235/fullMostre-me a resposta​​​ 

Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler, and incorrect inhaler use is associated with worse disease control.[166]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80. https://journal.copdfoundation.org/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com [167]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8. https://www.resmedjournal.com/article/S0954-6111(11)00009-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com ​​ Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[169]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018 Feb 26;13:695-702. [Erratum in: Int J Chron Obstruct Pulmon Dis. 2018 Jul 25;13:2253-4.] https://www.dovepress.com/factors-associated-with-appropriate-inhaler-use-in-patients-with-copd--peer-reviewed-fulltext-article-COPD http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com

All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. No drug 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. Self-management education should include provision of a written action plan. Physical activity is recommended for all patients with COPD.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Pulmonary rehabilitation comprises aerobic exercise, strength training, and education, and should be started early in the disease course.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [195]Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-26. https://www.atsjournals.org/doi/10.1164/rccm.202306-1066ST http://www.ncbi.nlm.nih.gov/pubmed/37581410?tool=bestpractice.com [196]Man W, Chaplin E, Daynes E, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(suppl 5):s2-15. https://thorax.bmj.com/content/78/Suppl_5/s2 http://www.ncbi.nlm.nih.gov/pubmed/37770084?tool=bestpractice.com ​​​ Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pulmonary rehabilitation for patient groups B and E.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function, and enhances a sense of control to a moderately large and clinically significant extent.[197]McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/25705944?tool=bestpractice.com

One large US cohort study found that initiation of pulmonary rehabilitation within 90 days of hospital discharge following an acute exacerbation of COPD was significantly associated with lower mortality risk at 1 year and fewer rehospitalizations at 1 year.[200]Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among medicare beneficiaries. JAMA. 2020 May 12;323(18):1813-23. https://jamanetwork.com/journals/jama/fullarticle/2765730 http://www.ncbi.nlm.nih.gov/pubmed/32396181?tool=bestpractice.com [201]Stefan MS, Pekow PS, Priya A, et al. Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021 Nov 1;204(9):1015-23. https://www.atsjournals.org/doi/10.1164/rccm.202012-4389OC http://www.ncbi.nlm.nih.gov/pubmed/34283694?tool=bestpractice.com ​ However, starting pulmonary rehabilitation before hospital discharge could be associated with a higher 12-month mortality, so is not recommended.[202]Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ. 2014 Jul 8;349:g4315. https://www.bmj.com/content/349/bmj.g4315 http://www.ncbi.nlm.nih.gov/pubmed/25004917?tool=bestpractice.com

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend long-term oxygen therapy in stable patients who have: partial pressure of oxygen, arterial (PaO₂) ≤7.3 kPa (55 mmHg) or arterial oxygen saturation (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 of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Guidelines from the American Thoracic Society (ATS) recommend prescribing long-term oxygen therapy for at least 15 hours per day in adults with COPD who have severe chronic resting room air hypoxemia. The ATS defines severe hypoxemia as either: PaO₂ ≤7.3 kPa (55 mmHg) or oxygen saturation as measured by pulse oximetry (SpO₂) ≤88%; or PaO₂ 7.5 to 7.9 kPa (56-59 mmHg) or SpO₂ of 89% plus one of the following: edema, hematocrit ≥55%, or P pulmonale on an ECG.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

For patients prescribed home oxygen therapy, the ATS recommends that the patient and their caregivers should receive instruction and training on the use and maintenance of all oxygen equipment and education on oxygen safety, including smoking cessation, fire prevention, and tripping hazards.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

Supplemental oxygen should be titrated to achieve SaO₂ ≥90%.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide The patient should be reassessed after 60-90 days to determine whether oxygen is still indicated and is therapeutic.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Among different therapeutic modalities in COPD, the only two factors that improve survival are smoking cessation and oxygen supplementation.

Oxygen therapy helps minimize pulmonary hypertension by decreasing pulmonary artery pressure, and improves exercise tolerance and quality of life. It has been shown to improve survival.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide ​​

The ATS suggests prescribing ambulatory oxygen (oxygen delivered during exercise or activities of daily living) in adults with COPD who have severe exertional room air hypoxemia.[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com However, the ATS suggests not prescribing long-term oxygen therapy in adults with COPD who have moderate chronic resting room air hypoxemia (SpO₂ of 89% to 93%).[210]Jacobs SS, Krishnan JA, Lederer DJ, et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020 Nov 15;202(10):e121-41. [Erratum in: Am J Respir Crit Care Med. 2021 Apr 15;203(8):1045-6.] https://www.atsjournals.org/doi/10.1164/rccm.202009-3608ST http://www.ncbi.nlm.nih.gov/pubmed/33185464?tool=bestpractice.com

For patients who have COPD and obstructive sleep apnea, ventilatory support with continuous positive airway pressure (CPAP) can improve survival and reduce hospital admissions.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [72]Marin JM, Soriano JB, Carrizo SJ, et al. Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome. Am J Respir Crit Care Med. 2010 Aug 1;182(3):325-31. https://www.atsjournals.org/doi/10.1164/rccm.200912-1869OC http://www.ncbi.nlm.nih.gov/pubmed/20378728?tool=bestpractice.com ​ Noninvasive ventilation (NIV) is occasionally used in patients with very severe but stable COPD, although the optimal timing for initiation and best selection criteria for candidates is unclear.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [214]Wilson ME, Dobler CC, Morrow AS, et al. Association of home noninvasive positive pressure ventilation with clinical outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2020 Feb 4;323(5):455-65. https://jamanetwork.com/journals/jama/fullarticle/2760390 http://www.ncbi.nlm.nih.gov/pubmed/32016309?tool=bestpractice.com [215]Raveling T, Vonk J, Struik FM, et al. Chronic non-invasive ventilation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2021 Aug 9;(8):CD002878. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002878.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/34368950?tool=bestpractice.com

Guidelines from the ATS suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD.[217]Macrea M, Oczkowski S, Rochwerg B, et al. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice fuideline. Am J Respir Crit Care Med. 2020 Aug 15;202(4):e74-87. https://www.atsjournals.org/doi/10.1164/rccm.202006-2382ST http://www.ncbi.nlm.nih.gov/pubmed/32795139?tool=bestpractice.com The European Respiratory Society (ERS) and Canadian Thoracic Society (CTS) have issued similar guidance.[218]Ergan B, Oczkowski S, Rochwerg B, et al. European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD. Eur Respir J. 2019 Sep 28;54(3):1901003. https://erj.ersjournals.com/content/54/3/1901003 http://www.ncbi.nlm.nih.gov/pubmed/31467119?tool=bestpractice.com [219]Kaminska M, Rimmer KP, McKim DA, et al. Long-term non-invasive ventilation in patients with chronic obstructive pulmonary disease (COPD): 2021 Canadian Thoracic Society clinical practice guideline update. Can J Respir Crit Care Sleep Med. 2021 May 7;5(3):160-83. https://www.tandfonline.com/doi/full/10.1080/24745332.2021.1911218

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Roflumilast, an oral phosphodiesterase-4 (PDE-4) inhibitor, may be prescribed for patients taking long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA) who have persistent exacerbations and whose blood eosinophils are <100 cells/microliter, and for patients taking LABA/LAMA/inhaled corticosteroid (ICS) who have persistent exacerbations.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide UK guidelines recommend that roflumilast should only be started by a specialist.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Roflumilast should be considered in patients with forced expiratory volume in the first second of expiration (FEV₁) <50% predicted and chronic bronchitis, particularly if they have had at least one hospitalization for an exacerbation in the last year.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Azithromycin may be prescribed for patients taking long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA) who have persistent exacerbations and whose blood eosinophils are <100 cells/microliter, and for patients taking LABA/LAMA/inhaled corticosteroid (ICS) who have persistent exacerbations.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Azithromycin increases the risk of colonization with macrolide-resistant organisms and should not be prescribed for patients with hearing impairment, resting tachycardia, or apparent risk of QTc prolongation.[148]Albert RK, Connett J, Bailey WC, et al; COPD Clinical Research Network. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011 Aug 25;365(8):689-98. https://www.nejm.org/doi/full/10.1056/NEJMoa1104623 http://www.ncbi.nlm.nih.gov/pubmed/21864166?tool=bestpractice.com Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend that azithromycin should be considered preferentially, but not only, in former smokers with persistent exacerbations despite appropriate therapy.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

British Thoracic Society (BTS) guidelines advise that prophylactic azithromycin can be considered for patients who have more than three acute exacerbations requiring corticosteroid therapy and at least one exacerbation requiring hospitalization per year.[149]Smith D, Du Rand I, Addy CL, et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax. 2020 May;75(5):370-404. https://thorax.bmj.com/content/75/5/370 http://www.ncbi.nlm.nih.gov/pubmed/32303621?tool=bestpractice.com ​ The National Institute for Health and Care Excellence (NICE) recommends that prophylactic azithromycin should only be considered for patients who do not smoke, have optimized nonpharmacologic management and inhaled therapies, and continue to have frequent or severe hospitalizations with sputum production.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Before starting prophylactic antibiotics, baseline ECG and liver function tests should be performed, a sputum sample obtained for culture and sensitivity (including tuberculosis testing), the patient's sputum clearance technique should be optimized, and bronchiectasis should be excluded with a computed tomography (CT) scan.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 [149]Smith D, Du Rand I, Addy CL, et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax. 2020 May;75(5):370-404. https://thorax.bmj.com/content/75/5/370 http://www.ncbi.nlm.nih.gov/pubmed/32303621?tool=bestpractice.com ​​ ECG and liver tests should be repeated after 1 month of treatment. Prophylactic antibiotic therapy should be reviewed at 6 and 12 months to determine whether there is a benefit in terms of exacerbation rates.[149]Smith D, Du Rand I, Addy CL, et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax. 2020 May;75(5):370-404. https://thorax.bmj.com/content/75/5/370 http://www.ncbi.nlm.nih.gov/pubmed/32303621?tool=bestpractice.com If antibiotic therapy is not effective it should be stopped.

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Dupilumab, an interleukin (IL)-4 receptor antagonist monoclonal antibody, may be considered for patients with moderate to severe COPD taking long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA)/inhaled corticosteroid (ICS) with a history of exacerbations, chronic bronchitis, and blood eosinophils ≥300 cells/microliter.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [151]Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts. N Engl J Med. 2023 Jul 20;389(3):205-14. https://www.doi.org/10.1056/NEJMoa2303951 http://www.ncbi.nlm.nih.gov/pubmed/37272521?tool=bestpractice.com [152]Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation. N Engl J Med. 2024 Jun 27;390(24):2274-83. http://www.ncbi.nlm.nih.gov/pubmed/38767614?tool=bestpractice.com ​​​ Dupilumab should not be used for relief of acute bronchospasm. Dupilumab is approved in the US and Europe for add-on maintenance treatment in adults with uncontrolled COPD characterized by elevated blood eosinophils. Adverse effects include injection site reactions.

Mepolizumab, an IL-5 receptor antagonist monoclonal antibody, may be considered for patients with moderate to severe COPD taking LABA/LAMA/ICS with a history of exacerbations, and blood eosinophils ≥300 cells/microliter. Mepolizumab should not be used for relief of acute bronchospasm.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [153]Pavord ID, Chanez P, Criner GJ, et al. Mepolizumab for eosinophilic chronic obstructive pulmonary disease. N Engl J Med. 2017 Oct 26;377(17):1613-29. https://www.nejm.org/doi/10.1056/NEJMoa1708208 http://www.ncbi.nlm.nih.gov/pubmed/28893134?tool=bestpractice.com [154]Sciurba FC, Criner GJ, Christenson SA, et al. Mepolizumab to prevent exacerbations of COPD with an eosinophilic phenotype. N Engl J Med. 2025 May 1;392(17):1710-20. http://www.ncbi.nlm.nih.gov/pubmed/40305712?tool=bestpractice.com ​ Mepolizumab is approved in the US and Europe for add-on maintenance treatment in adults with uncontrolled COPD characterized by elevated blood eosinophils. 

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Patients with the chronic bronchitis phenotype of COPD often produce thick sputum on a frequent basis. Oral mucolytic agents (erdosteine, carbocysteine, and acetylcysteine) result in a small reduction in the frequency of acute exacerbations and in days of disability per month, but do not improve lung function or quality of life.[192]Poole P, Sathananthan K, Fortescue R. Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 May 20;(5):CD001287. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001287.pub6/full http://www.ncbi.nlm.nih.gov/pubmed/31107966?tool=bestpractice.com [193]Rogliani P, Matera MG, Page C, et al. Efficacy and safety profile of mucolytic/antioxidant agents in chronic obstructive pulmonary disease: a comparative analysis across erdosteine, carbocysteine, and N-acetylcysteine. Respir Res. 2019 May 27;20(1):104. https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-1078-y http://www.ncbi.nlm.nih.gov/pubmed/31133026?tool=bestpractice.com [194]Wei J, Pang CS, Han J, et al. Effect of orally administered N-acetylcysteine on chronic bronchitis: a meta-analysis. Adv Ther. 2019 Dec;36(12):3356-67. http://www.ncbi.nlm.nih.gov/pubmed/31598901?tool=bestpractice.com ​​​ Treatment with mucolytic agents such as carbocysteine and acetylcysteine may reduce exacerbations and modestly improve health status in patients not receiving inhaled corticosteroid (ICS).[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide However, erdosteine may have a significant effect on mild exacerbations whether or not the patient is taking ICS.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide Erdosteine and carbocysteine are not available in the US. 

UK guidelines recommend that mucolytic drugs should not be routinely used to prevent exacerbations in patients with stable COPD, and should only be continued if there is symptomatic improvement.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Theophylline (a methylxanthine agent) is not commonly used because of limited potency, narrow therapeutic window, high-risk profile, and frequent drug-drug interactions. Theophylline has modest effects on lung function in moderate to severe COPD.[155]Ram FSF, Jones P, Jardim J, et al. Oral theophylline for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002;(4):CD003902. https://pmc.ncbi.nlm.nih.gov/articles/PMC7047557 http://www.ncbi.nlm.nih.gov/pubmed/12519617?tool=bestpractice.com One large randomized controlled trial found no effect of oral theophylline alone or with prednisone on exacerbations of severe COPD.[156]Jenkins CR, Wen FQ, Martin A, et al; TASCS study investigators. The effect of low-dose corticosteroids and theophylline on the risk of acute exacerbations of COPD: the TASCS randomised controlled trial. Eur Respir J. 2021 Jun 10;57(6):2003338. https://erj.ersjournals.com/content/57/6/2003338 http://www.ncbi.nlm.nih.gov/pubmed/33334939?tool=bestpractice.com Toxicity is dose-related. UK guidelines recommend that oral theophylline is only used if a patient has already trialed short-acting and long-acting bronchodilator therapy or is unable to use inhaled therapies.[2]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Surgical interventions are the last step in the management of COPD, and include bullectomy, lung volume reduction, and lung transplantation.[220]van Agteren JE, Hnin K, Grosser D, et al. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb 23;(2):CD012158. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012158.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/28230230?tool=bestpractice.com [221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com [ ] How does bronchoscopic lung volume reduction compare with medical therapy in people with chronic obstructive pulmonary disease?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1680/fullMostre-me a resposta​​​ They are used to improve lung dynamics, exercise adherence, and quality of life.[221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com Severely poor functional status and severe decrease in forced expiratory volume in the first second of expiration (FEV₁) (<500 mL) make these options less favorable.

Bullectomy is an option in COPD patients with dyspnea in whom computed tomography (CT) reveals huge bullae occupying at least 30% of the hemithorax.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Lung volume reduction may be most beneficial in patients with emphysema whose dyspnea is primarily due to hyperinflation and air trapping distal to the terminal bronchioles. It is indicated in patients with very severe airflow limitation, and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [220]van Agteren JE, Hnin K, Grosser D, et al. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb 23;(2):CD012158. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012158.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/28230230?tool=bestpractice.com [ ] How does bronchoscopic lung volume reduction compare with medical therapy in people with chronic obstructive pulmonary disease?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1680/fullMostre-me a resposta​​​ One meta-analysis found an increased risk of early mortality in patients who underwent lung volume reduction surgery compared to standard care; however, no significant difference was observed in overall mortality.[223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com

Bronchoscopic approaches to lung volume reduction, such as endobronchial valve insertion can produce clinically meaningful improvements in appropriately selected patients with COPD.[223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com [224]Klooster K, Slebos DJ, Zoumot Z, et al. Endobronchial valves for emphysema: an individual patient-level reanalysis of randomised controlled trials. BMJ Open Respir Res. 2017 Nov 2;4(1):e000214. https://bmjopenrespres.bmj.com/content/4/1/e000214 http://www.ncbi.nlm.nih.gov/pubmed/29441206?tool=bestpractice.com [225]Labarca G, Uribe JP, Pacheco C, et al. Bronchoscopic lung volume reduction with endobronchial zephyr valves for severe emphysema: a systematic review and meta-analysis. Respiration. 2019 May 22;98(3):268-78. http://www.ncbi.nlm.nih.gov/pubmed/31117102?tool=bestpractice.com ​​​ Contraindications include active lung infection and incomplete lobar fissures (<80%).[226]Abia-Trujillo D, Johnson MM, Patel NM, et al. Bronchoscopic lung volume reduction: a new hope for patients with severe emphysema and air trapping. Mayo Clin Proc. 2021 Feb;96(2):464-72. http://www.ncbi.nlm.nih.gov/pubmed/32829903?tool=bestpractice.com The most common adverse events associated with endobronchial valve insertion are pneumothorax and exacerbation.[223]van Geffen WH, Slebos DJ, Herth FJ, et al. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313-24. http://www.ncbi.nlm.nih.gov/pubmed/30744937?tool=bestpractice.com

Lung transplantation has been shown to improve quality of life and functional capacity.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [221]van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14;(10):CD001001. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001001.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27739074?tool=bestpractice.com ​ However, lung transplantation does not appear to confer a survival benefit for most patients.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide

Patients may benefit from referral for lung transplantation if they have a Body mass index, airflow Obstruction, Dyspnea and Exercise (BODE) score of 5-6 with additional factors which are suggestive of increased mortality risk.[227]Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021 Nov;40(11):1349-79. https://www.jhltonline.org/article/S1053-2498(21)02407-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34419372?tool=bestpractice.com ​ These factors are: frequent acute exacerbations; increase in BODE score >1 over the past 2 years; pulmonary artery to aorta diameter >1 on CT scan; and FEV₁ 20% to 25% predicted.

Patients may also benefit from referral if they clinically deteriorate despite maximal treatment (including pharmacotherapy, pulmonary rehabilitation, oxygen therapy, and if appropriate, nocturnal noninvasive positive pressure ventilation) or deem their quality of life to be unacceptable.[227]Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021 Nov;40(11):1349-79. https://www.jhltonline.org/article/S1053-2498(21)02407-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34419372?tool=bestpractice.com

For a patient who is a candidate for bronchoscopic or surgical lung volume reduction (LVR), simultaneous referral for both lung transplant and LVR evaluation is appropriate.

[ BODE Index for COPD Survival Prediction Opens in new window ]

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Palliative therapies to improve symptoms of dyspnea, offer nutritional support, address anxiety and depression, and reduce fatigue may benefit patients with COPD who experience these despite optimal medical therapy. End-of-life care and hospice admission should be considered for patients with very advanced disease. Patient and family should be well educated about the process, and it is suggested that discussions should be held early in the course of the disease before acute respiratory failure develops.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide [228]Janssen DJA, Bajwah S, Boon MH, et al. European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease. Eur Respir J. 2023 Aug;62(2):2202014. https://erj.ersjournals.com/content/62/2/2202014 http://www.ncbi.nlm.nih.gov/pubmed/37290789?tool=bestpractice.com ​ Opioid analgesics, fans, neuromuscular electrical stimulation, and chest wall vibration can relieve dyspnea.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report. 2026 [internet publication]. https://goldcopd.org/2026-gold-report-and-pocket-guide One study has suggested that low doses of an opioid analgesic and a benzodiazepine are safe and are not associated with increased hospital admissions or mortality.[229]Ekström MP, Bornefalk-Hermansson A, Abernethy AP, et al. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014 Jan 30;348:g445. https://www.bmj.com/content/348/bmj.g445.long http://www.ncbi.nlm.nih.gov/pubmed/24482539?tool=bestpractice.com Another study found that regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD and refractory breathlessness.[230]Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, et al. Effect of sustained-release morphine for refractory breathlessness in chronic obstructive pulmonary disease on health status: a randomized clinical trial. JAMA Intern Med. 2020 Oct 1;180(10):1306-14. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769373 http://www.ncbi.nlm.nih.gov/pubmed/32804188?tool=bestpractice.com

One Cochrane review concluded that there is no evidence for or against benzodiazepines for the relief of breathlessness in people with advanced cancer and COPD.[231]Simon ST, Higginson IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2016 Oct 20;(10):CD007354. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007354.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27764523?tool=bestpractice.com

Acupuncture and acupressure may also improve breathlessness and quality of life in patients with advanced COPD.[232]von Trott P, Oei SL, Ramsenthaler C. Acupuncture for breathlessness in advanced diseases: a systematic review and meta-analysis. J Pain Symptom Manage. 2020 Feb;59(2):327-38.e3. http://www.ncbi.nlm.nih.gov/pubmed/31539602?tool=bestpractice.com