COPD
Diagnosis: post-BD FEV1/FVC <0.7 (or <LLN) + symptoms. Grade 1–4 by FEV1%; Group A/B/E by symptoms and exacerbations.
Definition and staging
COPD is heterogeneous: persistent symptoms from airway disease and/or emphysema causing persistent airflow obstruction ().
- 1
Is it COPD?
Symptoms plus post-bronchodilator FEV1/FVC <0.70 (or <LLN).
- 2
How obstructed? GOLD 1–4
FEV1 % predicted. Prognosis and non-drug therapy (O2, valves, transplant) live here.
- 3
How sick in real life? GOLD A / B / E
Symptoms (mMRC, CAT) and exacerbations. This chooses the inhaler.
- 4
What else?
Lung volumes, DLCO (<60% tracks symptoms and mortality), 6MWT, α1-antitrypsin.
GOLD 2025. Rescue SABA for everyone.
| Group | Who | Start with |
|---|---|---|
| GOLD A | Few symptoms, 0–1 moderate exacerbations, no hospitalization | A bronchodilator — LABA or LAMA |
| GOLD B | More symptoms, still rare exacerbations | LABA + LAMA |
| GOLD E | ≥2 moderate or ≥1 hospitalized exacerbation | LABA + LAMA; add ICS if eos >300 or concomitant asthma |
Neighbors, not COPD: pre-COPD (structure or physiology without obstruction), PRISm (normal ratio, FEV1 <80%), chronic bronchitis (cough + sputum 3 months/year × 2 ), asthma, bronchiectasis, obliterative bronchiolitis after transplant (mosaic / air trapping), diffuse panbronchiolitis.
Stable disease
- Long-acting beats short-acting unless dyspnea is only occasional.
- LABA + LAMA beats monotherapy (). Tiotropium may slow FEV1 decline early ().
- Triple therapy (, TRIBUTE, ETHOS) cuts exacerbations vs LABA/LAMA but raises pneumonia. Do not stop ICS if eos >300.
- Escalate exacerbations: eos >100 → add ICS; eos <100 and FEV1 <50% with bronchitis → roflumilast (); former smokers → azithromycin; eos >300 → mepolizumab (); dupilumab ().
Non-drug therapy that actually moves mortality
- Smoking cessation ().
- Vaccines: influenza, COVID, PCV21, Tdap, zoster, RSV.
- Lung-cancer screening: annual LDCT, age 50–80, ≥20 pack-, smoked within 15 (USPSTF 2021).
- Pulmonary rehab for GOLD B/E (Cochrane 2015; ).
- Home oxygen if PaO2 ≤55 or SpO2 ≤88% (or ≤59 / 89% with PH, Hct >55, or CHF). Recheck in 60–90 days.
- Nocturnal NIPPV if daytime PaCO2 >53 with nocturnal desat or after an acidotic exacerbation ().
Exacerbation
A COPD exacerbation is ↑ dyspnea, sputum volume/purulence, or cough for <14 days. Ask about prior steroids, intubations, and antibiotics. DDx: pneumonia, CHF, VTE (PE in ~25% of severe unexplained flares; ).
- Target SpO2 88–92%. Hyperoxia kills via Haldane + lost HPV ().
- Stacked DuoNebs, then space.
- NIPPV for pH <7.35 and PaCO2 >45, or high work of breathing — it cuts death and intubation (Cochrane 2004).
- Antibiotics if all 3 cardinal symptoms, or 2/3 including purulence, or need for NIV/intubation. CRP can help (). Duration 5–7 days inpatient.