Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
OR
salmeterol inhaled: (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
OR
indacaterol inhaled: (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
OR
arformoterol inhaled: 15 micrograms nebulized twice daily
OR
olodaterol inhaled: (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule) twice daily; (25 micrograms/vial nebulizer inhalation solution) 25 micrograms nebulized twice daily using Magnair® nebulizer device
Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines state that all group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator.[27]
The effect of the bronchodilator should be evaluated. Depending on the response, it should be continued or stopped or another class of bronchodilator should be tried.[27]
Short-acting bronchodilators provide symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ 
]
Short-acting drugs include albuterol, levalbuterol, and ipratropium.
Long-acting drugs include salmeterol, indacaterol, arformoterol, olodaterol, tiotropium, umeclidinium,
[ ]
aclidinium, and glycopyrrolate.
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Primary options
salmeterol inhaled: (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
OR
indacaterol inhaled: (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
OR
arformoterol inhaled: 15 micrograms nebulized twice daily
OR
olodaterol inhaled: (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule) twice daily; (25 micrograms/vial nebulizer inhalation solution) 25 micrograms nebulized twice daily using Magnair® nebulizer device
Long-acting muscarinic antagonists (LAMA)
[ ]
or long-acting beta-2 agonists (LABA)[105] can be used as first-line therapy in this group of patients.[27]
According to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, long-acting inhaled bronchodilators are superior to short-acting bronchodilators when taken as needed and are, therefore, recommended in this patient group.[27][106][107]
According to GOLD guidelines, there is no evidence to recommend one class of long-acting bronchodilator over another for initial relief of symptoms in this group of patients. The choice should depend on the patient's perception of symptom relief.[27]
For patients with severe breathlessness, initial therapy with two bronchodilators may be considered.[27]
For patients with persistent breathlessness on monotherapy, GOLD guidelines recommend the use of two bronchodilators.[27]
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started early.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in significant and clinically meaningful improvements in multiple outcome areas, including dyspnea, exercise ability, health status, and healthcare utilization.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Primary options
umeclidinium/vilanterol inhaled: (62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
glycopyrrolate/formoterol fumarate inhaled: (9/4.8 micrograms/dose inhaler) 2 puffs twice daily
OR
indacaterol/glycopyrrolate inhaled: (27.5/15.6 micrograms/capsule inhaler) 1 capsule twice daily
OR
tiotropium/olodaterol inhaled: (2.5/2.5 micrograms/dose inhaler) 2 puffs once daily
For patients with persistent breathlessness on monotherapy, Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the use of two bronchodilators.[27]
If two bronchodilators do not improve symptoms, GOLD guidelines suggest stepping down again to a single bronchodilator.[27]
Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol are combinations of a long-acting beta-2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA) approved for use in COPD.[46]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started early.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in significant and clinically meaningful improvements in multiple outcome areas, including dyspnea, exercise ability, health status, and healthcare utilization.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Primary options
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule) twice daily; (25 micrograms/vial nebulizer inhalation solution) 25 micrograms nebulized twice daily using Magnair® nebulizer device
Initial treatment in group C should be a single long-acting bronchodilator.[27] In two head-to-head comparisons, the tested long-acting muscarinic antagonist (LAMA) was better than the long-acting beta-2 agonist (LABA) at preventing exacerbations.[42][43] Therefore, Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend starting with a LAMA in patient group C.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started early.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Primary options
umeclidinium/vilanterol inhaled: (62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
glycopyrrolate/formoterol fumarate inhaled: (9/4.8 micrograms/dose inhaler) 2 puffs twice daily
OR
indacaterol/glycopyrrolate inhaled: (27.5/15.6 micrograms/capsule inhaler) 1 capsule twice daily
OR
tiotropium/olodaterol inhaled: (2.5/2.5 micrograms/dose inhaler) 2 puffs once daily
Patients in group C with persistent exacerbations may benefit from dual therapy with a long-acting beta-2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA).[27]
Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol are combinations of a LABA and a LAMA approved for use in COPD.[46]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started early.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Primary options
fluticasone furoate/vilanterol inhaled: (100/25 micrograms/dose inhaler) 1 puff once daily
OR
fluticasone propionate/salmeterol inhaled: (250/50 micrograms/dose inhaler) 1 puff twice daily
OR
budesonide/formoterol inhaled: (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
OR
mometasone/formoterol inhaled: (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
Patients with persistent exacerbations may benefit from using a combination of a long-acting beta-2 agonist (LABA) and an inhaled corticosteroid (ICS). As inhaled corticosteroids increase the risk of developing pneumonia in some patients, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines prefer dual long-acting bronchodilator therapy over a LABA/ICS combination.[27]
A combination preparation of a LABA and an ICS may be used for patients who require both these agents.
[ ]
This is convenient and may help with compliance in some patients. The choice of therapy in this class is based on availability and individual response and preference. Combination therapy with a LABA and an ICS is superior to use of either agent alone.
[ ]
The combination may be provided in separate inhalers or a combination inhaler (combination formulations are detailed here).
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Discussions should be held early in the course of the disease, before acute respiratory failure develops, about the possible need for and benefits of palliative care in the future.[99]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started early.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise capacity, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Primary options
umeclidinium/vilanterol inhaled: (62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
glycopyrrolate/formoterol fumarate inhaled: (9/4.8 micrograms/dose inhaler) 2 puffs twice daily
OR
indacaterol/glycopyrrolate inhaled: (27.5/15.6 micrograms/capsule inhaler) 1 capsule twice daily
OR
tiotropium/olodaterol inhaled: (2.5/2.5 micrograms/dose inhaler) 2 puffs once daily
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend starting treatment with a long-acting beta-2 agonist (LABA) and long-acting muscarinic antagonist (LAMA) combination in group D. This is because the LABA/LAMA combinations showed superior results compared to the single drugs in studies with patient reported outcomes as the primary endpoint.[27]
In addition, a LABA/LAMA combination was superior to a LABA and an inhaled corticosteroid (ICS) combination in preventing exacerbations and other patient reported outcomes in group D patients.[27]
[ ]
Group D patients are at a higher risk of developing pneumonia when receiving treatment with ICS.[42][108]
If a single bronchodilator is chosen as initial treatment, a LAMA is preferred by GOLD guidelines over a LABA.[27]
In some patients, initial treatment with LABA/ICS combination may be the first choice.
[ ]
These patients may have a history and/or findings suggestive of asthma-COPD overlap.[27]
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Umeclidinium/vilanterol, glycopyrrolate/formoterol fumarate,[47] indacaterol/glycopyrrolate,[51] and tiotropium/olodaterol are combinations of a LABA and a LAMA approved for use in COPD.[46]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started as early as patient group B or C disease.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise capacity, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Treatment recommended for SOME patients in selected patient group
Criteria for referral for lung transplantation include: progressive disease, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy; patient is not a candidate for endoscopic or surgical lung volume reduction surgery (LVRS) (simultaneous referral of patients with COPD for both lung transplant and LVRS evaluation is appropriate); Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index of 5 to 6; PaCO₂ >50 mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8 kPa; FEV1 <25% predicted.[98]
LVRS is indicated in patients with very severe airflow limitation and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[94]
[ ]
Bullectomy is an option in COPD patients with dyspnea in whom CT reveals huge bullae occupying at least 30% of the hemithorax. Severely poor functional status and severe decrease in FEV1 (<500 mL) make these options less favorable.
Lung transplantation has been shown to improve quality of life and functional capacity.[109][110] However, lung transplantation does not appear to confer a survival benefit.[111]
Treatment recommended for SOME patients in selected patient group
For some patients with very advanced end-stage COPD, palliative care and hospice admission should be considered. 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.[99] 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.[100] 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.[101]
Primary options
fluticasone furoate/umeclidinium/vilanterol inhaled: (100/62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
fluticasone furoate/vilanterol inhaled: (100/25 micrograms/dose inhaler) 1 puff once daily
or
fluticasone propionate/salmeterol inhaled: (250/50 micrograms/dose inhaler) 1 puff twice daily
or
budesonide/formoterol inhaled: (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
or
mometasone/formoterol inhaled: (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
-- AND --
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
or
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
or
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
or
glycopyrrolate inhaled: (15.6 micrograms/capsule inhaler) 15.6 micrograms (1 capsule) twice daily; (25 micrograms/vial nebulizer inhalation solution) 25 micrograms nebulized twice daily using Magnair® nebulizer device
In group D patients who develop further exacerbations on LABA/LAMA therapy, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest two alternative pathways: escalation to LABA/LAMA/ICS or switch to LABA/ICS.[27]
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[65][66][67][68] and rate of hospitalization.[69][70]
If patients treated with LABA/LAMA/ICS (triple therapy) still have exacerbations, additional options include adding roflumilast, adding a macrolide antibiotic, and stopping the ICS.[27] Stopping the ICS may be appropriate if a lack of efficacy is reported, if there is an elevated risk of adverse events (including pneumonia), or if there would be no significant harm from withdrawal of ICS.[27]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started as early as patient group B or C disease.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise capacity, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Primary options
roflumilast: 500 micrograms orally once daily
Roflumilast may be considered in patients with an FEV1 <50% predicted and chronic bronchitis,[112] especially if they have experienced at least one hospitalization for an exacerbation in the previous year.[27][113]
Treatment recommended for SOME patients in selected patient group
Primary options
azithromycin: 250 mg orally once daily; or 500 mg orally three times weekly
OR
erythromycin base: 500 mg orally twice daily
The use of azithromycin is supported by the best available evidence.[114][115]
Decision making should take into account the potential development of resistant organisms.
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Treatment recommended for SOME patients in selected patient group
Criteria for referral for lung transplantation include: progressive disease, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy; patient is not a candidate for endoscopic or surgical lung volume reduction surgery (LVRS) (simultaneous referral of patients with COPD for both lung transplant and LVRS evaluation is appropriate); Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index of 5 to 6; PaCO₂ >50 mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8 kPa; FEV1 <25% predicted.[98]
LVRS is indicated in patients with very severe airflow limitation and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[94]
[ ]
Bullectomy is an option in COPD patients with dyspnea in whom CT reveals huge bullae occupying at least 30% of the hemithorax. Severely poor functional status and severe decrease in FEV1 (<500 mL) make these options less favorable.
Lung transplantation has been shown to improve quality of life and functional capacity.[109][110] However, lung transplantation does not appear to confer a survival benefit.[111]
Treatment recommended for SOME patients in selected patient group
For some patients with very advanced end-stage COPD, palliative care and hospice admission should be considered. 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.[99] 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.[100] 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.[101]
Primary options
fluticasone furoate/vilanterol inhaled: (100/25 micrograms/dose inhaler) 1 puff once daily
OR
fluticasone propionate/salmeterol inhaled: (250/50 micrograms/dose inhaler) 1 puff twice daily
OR
budesonide/formoterol inhaled: (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
OR
mometasone/formoterol inhaled: (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
In group D patients who develop further exacerbations while taking a combination of a LABA and a long-acting muscarinic antagonist (LAMA), the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest two alternative pathways: escalation to LABA/LAMA/ICS or switch to LABA/ICS.[27]
[ ]
There is no evidence that switching from LABA/LAMA to LABA/ICS results in better prevention of exacerbations.
[ ]
If LABA/ICS therapy does not positively impact exacerbations or symptoms, a LAMA can be added.[27]
In some patients, initial treatment with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap.[27]
Treatment recommended for ALL patients in selected patient group
Primary options
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
Provides symptomatic relief. Evidence A
Failure to respond to short-acting bronchodilator may signify an acute exacerbation.
Patients should not take short-acting anticholinergic agents if they have already been started on tiotropium.[102][103]
[ ]
Treatment recommended for ALL patients in selected patient group
Influenza and pneumococcal vaccination should be offered to every COPD patient.[27] Influenza vaccine is given annually. Pneumococcal vaccine should be given to COPD patients older than 65 years of age and to younger patients with significant comorbid conditions. This vaccine also reduces incidence of community-acquired pneumonia in patients younger than 65 with an FEV1 of <40%.[104]
Patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Physical activity is recommended for all patients with COPD.[27]
Treatment recommended for ALL patients in selected patient group
All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD. Evidence A
Nicotine-replacement therapy or other drug therapies, in conjunction with appropriate nonpharmacologic therapies, should be used.
Treatment recommended for ALL patients in selected patient group
Pulmonary rehabilitation should be started as early as patient group B or C disease.[27]
The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. Pulmonary rehabilitation can result in improvements in multiple outcome areas, including dyspnea, exercise capacity, quality of life, and emotional feelings.[27][91]
[ ]
Treatment recommended for SOME patients in selected patient group
Primary options
theophylline: 300 mg/day orally (immediate-release) initially given in divided doses every 6-8 hours, increase to 400 mg/day after 3 days, then 600 mg/day after another 3 days; adjust dose according to serum drug level and response
There is no clear recommendation about the exactly appropriate time to use theophylline, but most experts believe in its use when patients have exhausted bronchodilator and corticosteroid options.
Toxicity is dose-related. Evidence A
Treatment recommended for SOME patients in selected patient group
Criteria for long-term oxygen therapy include: PaO₂ ≤7.3 kPa (55 mmHg); or SaO₂ ≤88%, with or without hypercapnia confirmed twice over a 3-week period; or PaO₂ between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO₂ of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%).[27]
Oxygen is suggested for patients in whom the predicted PaO₂ during air travel is <6.7 kPa (<50 mmHg).[27] These patients usually have a saturation of <92% in room air at sea level. If in doubt, patients could undergo testing to be evaluated for their predicted PaO₂ during flight.
The therapeutic goal is to increase the PaO₂ to at least 5 mmHg above the patient's baseline value and to a minimum of 60 mmHg. In addition, oxygen saturation should stay above 90% during rest, exercise, and sleep.[91][96] Evidence B
Treatment recommended for SOME patients in selected patient group
Criteria for referral for lung transplantation include: progressive disease, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy; patient is not a candidate for endoscopic or surgical lung volume reduction surgery (LVRS) (simultaneous referral of patients with COPD for both lung transplant and LVRS evaluation is appropriate); Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index of 5 to 6; PaCO₂ >50 mmHg or 6.6 kPa and/or PaO₂ <60 mmHg or 8 kPa; FEV1 <25% predicted.[98]
LVRS is indicated in patients with very severe airflow limitation and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[94]
[ ]
Bullectomy is an option in COPD patients with dyspnea in whom CT reveals huge bullae occupying at least 30% of the hemithorax. Severely poor functional status and severe decrease in FEV1 (<500 mL) make these options less favorable.
Lung transplantation has been shown to improve quality of life and functional capacity.[109][110] However, lung transplantation does not appear to confer a survival benefit.[111]
Treatment recommended for SOME patients in selected patient group
For some patients with very advanced end-stage COPD, palliative care and hospice admission should be considered. 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.[99] 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.[100] 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.[101]
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