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
Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A patients are characterized by few symptoms and low risk of exacerbations.
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 occasional dyspnea.[2] LABAs and LAMAs both significantly improve lung function, dyspnea, and health status and reduce exacerbation rates.
[ 
]
LAMAs have a greater effect on exacerbation reduction than LABAs.[63][64]
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.[80]
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.
[ ]
Primary options
SABA
albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
OR
SABA
levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) every 4-6 hours when required
OR
SAMA
ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) up to four times a day when required, maximum 204 micrograms/day
OR
LABA
salmeterol inhaled: (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
OR
LABA
arformoterol inhaled: 15 micrograms nebulized twice daily
OR
LABA
olodaterol inhaled: (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
LAMA
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
LAMA
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
LAMA
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
LAMA
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
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
Global Initiative for Chronic Obstructive Lung Disease (GOLD) group B patients are characterized by more symptoms and low risk of exacerbations.
Either a long-acting muscarinic antagonist (LAMA) or a long-acting beta-2 agonist (LABA) may be prescribed. 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.[2] LABAs and LAMAs both significantly improve lung function, dyspnea, and health status and reduce exacerbation rates.
[ ]
For patients with severe breathlessness, initial treatment with two bronchodilators of different classes may be warranted.[2]
LABAs include salmeterol, arformoterol, and olodaterol. LAMAs include tiotropium, umeclidinium, aclidinium, and glycopyrrolate.
[ ]
Revefenacin is a nebulized LAMA approved for the maintenance treatment of moderate to severe COPD.
Primary options
LABA
salmeterol inhaled: (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
OR
LABA
arformoterol inhaled: 15 micrograms nebulized twice daily
OR
LABA
olodaterol inhaled: (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
LAMA
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
LAMA
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
LAMA
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
LAMA
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
OR
LAMA
revefenacin inhaled: 175 micrograms nebulized once daily
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D patients are characterized by more symptoms and high risk of exacerbations.
GOLD recommends starting therapy with a long-acting muscarinic antagonist (LAMA), a long-acting beta-2 agonist (LABA)/LAMA combination, or an inhaled corticosteroid (ICS)/LABA combination.[2]
LAMA is the first choice for most patients. A LABA/LAMA combination should be considered if the patient is highly symptomatic (COPD assessment test [CAT] score >20), especially if the patient has significant dyspnea and/or exercise limitation.[2]
An ICS/LABA combination should be considered if the patient’s blood eosinophil count is ≥300 cells/microliter or the patient has a history of asthma.[2] 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).[71][73][100] Blood eosinophil count may predict the effectiveness of adding inhaled corticosteroids to regular long-acting bronchodilator treatment to prevent exacerbations.[66][67][101] 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.[65][76] These thresholds indicate approximate cut-off values which may help clinicians predict the likelihood of a treatment benefit.[2] 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.[119] Former smokers are more corticosteroid-responsive than current smokers at any eosinophil count.[101] 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.[73][102]
Combination therapy with an inhaled corticosteroid and a LABA is superior to use of either agent alone.[117][118]
[ ]
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.
[ ]
LAMAs include tiotropium, umeclidinium, aclidinium, and glycopyrrolate.
[ ]
Umeclidinium/vilanterol, glycopyrrolate/formoterol, tiotropium/olodaterol, and aclidinium/formoterol are LABA/LAMA combinations approved for use in COPD.[100][215] Umeclidinium/vilanterol decreases the risk of exacerbations in patients with mild/moderate COPD.[94]
[ ]
LABA/ICS combinations include fluticasone furoate/vilanterol, fluticasone propionate/salmeterol, budesonide/formoterol, and mometasone/formoterol.
Primary options
LAMA
tiotropium inhaled: (18 micrograms/capsule inhaler) 18 micrograms (1 capsule) once daily; (2.5 micrograms/dose inhaler) 5 micrograms (2 sprays) once daily
OR
LAMA
umeclidinium inhaled: (62.5 micrograms/dose inhaler) 62.5 micrograms (1 puff) once daily
OR
LAMA
aclidinium bromide inhaled: (400 micrograms/dose inhaler) 400 micrograms (1 puff) twice daily
OR
LAMA
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
OR
LAMA
revefenacin inhaled: 175 micrograms nebulized once daily
OR
LABA/LAMA
umeclidinium/vilanterol inhaled: (62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
LABA/LAMA
glycopyrrolate/formoterol fumarate inhaled: (9/4.8 micrograms/dose inhaler) 2 puffs twice daily
OR
LABA/LAMA
tiotropium/olodaterol inhaled: (2.5/2.5 micrograms/dose inhaler) 2 puffs once daily
OR
LABA/LAMA
aclidinium bromide/formoterol fumarate inhaled: (400/12 micrograms/dose inhaler) 1 puff twice daily
OR
LABA/ICS
fluticasone furoate/vilanterol inhaled: (100/25 micrograms/dose inhaler) 1 puff once daily
OR
LABA/ICS
fluticasone propionate/salmeterol inhaled: (250/50 micrograms/dose inhaler) 1 puff twice daily
OR
LABA/ICS
budesonide/formoterol inhaled: (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
OR
LABA/ICS
mometasone/formoterol inhaled: (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A patients are characterized by few symptoms and low risk of exacerbations; group B by more symptoms and low risk of exacerbations; group C by few symptoms and a higher risk of exacerbations; and group D by more symptoms and high risk of exacerbations.[2]
GOLD advise that if a patient has both persistent symptoms and exacerbations after initial therapy, clinicians should follow the pathway for treating persistent exacerbations.[2]
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, the second long-acting bronchodilator should be stopped. Changing inhaler device or molecules may be considered.[2] A LABA/LAMA combination may provide a better therapeutic effect without increasing the adverse effects of each class.[88][90][91][92] Combination therapy with a LABA/LAMA reduces exacerbation rate compared with monotherapy. Once-daily LABA/LAMA delivered via a combination inhaler is more associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild/moderate COPD, compared with placebo.[94]
[ ]
Patients with persistent dyspnea/exercise limitation while on combined LABA and inhaled corticosteroid (ICS) therapy may switch to LABA/LAMA/ICS. The indication for ICS should be reviewed. If the original indication was not appropriate, or if the patient has not responded to ICS treatment or experienced significant adverse effects, ICS should be withdrawn and the patient switched to a LABA/LAMA.[2] The combination may be provided in separate inhalers or a combination inhaler.
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.
Primary options
LABA/LAMA
umeclidinium/vilanterol inhaled: (62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
LABA/LAMA
glycopyrrolate/formoterol fumarate inhaled: (9/4.8 micrograms/dose inhaler) 2 puffs twice daily
OR
LABA/LAMA
tiotropium/olodaterol inhaled: (2.5/2.5 micrograms/dose inhaler) 2 puffs once daily
OR
LABA/LAMA
aclidinium bromide/formoterol fumarate inhaled: (400/12 micrograms/dose inhaler) 1 puff twice daily
OR
LABA/LAMA/ICS
fluticasone furoate/umeclidinium/vilanterol inhaled: (100/62.5/25 micrograms/dose inhaler) 1 puff once daily
OR
LABA/LAMA/ICS
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
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
Treatment recommended for SOME patients in selected patient group
Surgical interventions (bullectomy, lung volume reduction surgery,[202][203]
[ ]
and lung transplant) are the last step in the management of COPD. They are used to improve lung dynamics, exercise adherence, and quality of life.[203] Lung volume reduction surgery is indicated in patients with very severe airflow limitation, and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[202]
[ ]
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.[204] 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. Endobronchial valve insertion can produce clinically meaningful improvements in appropriately selected patients with COPD.[204][205][206] The procedure may be most beneficial in patients whose dyspnea is primarily due to hyperinflation and air trapping in the air spaces distal to the terminal bronchioles, which manifests as emphysema with markedly increased residual volume. Contraindications include active lung infection and incomplete lobar fissures (<80%).[207] The most common adverse events associated with endobronchial valve insertion are pneumothorax and exacerbation.[204]
Criteria for referral for lung transplantation include:[208]
Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) score 5-6 with additional factor(s) present suggestive of increased risk of mortality: frequent acute exacerbations, increase in BODE score >1 over past 24 months, pulmonary artery to aorta diameter >1 on CT scan, and/or FEV1 20% to 25% predicted.
Clinical deterioration despite maximal treatment including medication, pulmonary rehabilitation, oxygen therapy, and, as appropriate, nocturnal noninvasive positive pressure ventilation.
Poor quality of life unacceptable to the patient.
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 ]
Lung transplantation has been shown to improve quality of life and functional capacity.[203] However, lung transplantation does not appear to confer a survival benefit.[209]
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.[2][3] Smoking cessation significantly reduces the rate of progression of COPD and risk of malignancies.
Depending on local guidelines, patients should be vaccinated against influenza virus, Streptococcus pneumoniae, pertussis (whooping cough), varicella-zoster virus (shingles), and coronavirus disease 2019 (COVID-19).[2][172] Vaccination against influenza is associated with fewer exacerbations of COPD.[173][174]
[ ]
The Centers for Disease Control and Prevention (CDC) also recommends the tetanus/diphtheria/pertussis vaccine in people with COPD who were not vaccinated in adolescence, and varicella-zoster virus (shingles) for adults with COPD ages 50 years and over.[172]
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.[146][147] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[149]
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 medication 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.[2]
Treatment recommended for SOME patients in selected patient group
Surgical interventions (bullectomy, lung volume reduction surgery,[202][203]
[ ]
and lung transplant) are the last step in the management of COPD. They are used to improve lung dynamics, exercise adherence, and quality of life.[203] Lung volume reduction surgery is indicated in patients with very severe airflow limitation, and especially in patients with localized upper lobe disease and lower than normal exercise capacity.[202]
[ ]
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.[204] 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. Endobronchial valve insertion can produce clinically meaningful improvements in appropriately selected patients with COPD.[204][205][206] The procedure may be most beneficial in patients whose dyspnea is primarily due to hyperinflation and air trapping in the air spaces distal to the terminal bronchioles, which manifests as emphysema with markedly increased residual volume. Contraindications include active lung infection and incomplete lobar fissures (<80%).[207] The most common adverse events associated with endobronchial valve insertion are pneumothorax and exacerbation.[204]
Criteria for referral for lung transplantation include:[208]
Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) score 5-6 with additional factor(s) present suggestive of increased risk of mortality: frequent acute exacerbations, increase in BODE score >1 over past 24 months, pulmonary artery to aorta diameter >1 on CT scan, and/or FEV1 20% to 25% predicted.
Clinical deterioration despite maximal treatment including medication, pulmonary rehabilitation, oxygen therapy, and, as appropriate, nocturnal noninvasive positive pressure ventilation.
Poor quality of life unacceptable to the patient.
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 ]
Lung transplantation has been shown to improve quality of life and functional capacity.[203] However, lung transplantation does not appear to confer a survival benefit.[209]
Choose a patient group to see our recommendations
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
Use of this content is subject to our disclaimer