Prevention, Management and Diagnosis of COPD

Publication Date: November 22, 2021
Last Updated: March 14, 2022

Recommendations

VACCINATION FOR STABLE COPD

Influenza vaccination reduces serious illness and death in COPD patients. ()
(Evidences)
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The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been shown to reduce the incidence of community - acquired pneumonia in COPD patients aged <65 years with an FEV1 <40% predicted and in those with comorbidities. (B)
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In the general population of adults ‚Č•65 years the 13-valent conjugated pneumococcal vaccine (PCV13) has demonstrated significant efficacy in reducing bacteremia & serious invasiye¬∑pneumococcal disease. (B)
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BRONCHODILATORS IN STABLE COPD

Inhaled bronchodilators in COPD are central to symptom management and commonly given on a regular basis to prevent or reduce symptoms. (A)
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Regular and as-needed use of SABA or SAMA improves FEV, and symptoms. (A)
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Combinations of SABA and SAMA are superior compared to either medication alone in improving FEV1 and symptoms. (A)
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LABAs and LAMAs significantly improve lung function, dyspnea, health status, and reduce exacerbation rates. (A)
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LAMAs have a greater effect on exacerbation reduction compared with LABAs (A)
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and decrease hospitalizations.
(B)
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Combination treatment with a LABA and LAMA increases FEV, and reduces symptoms compared to monotherapy. (A)
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Combination treatment with a LABA/LAMA reduces exacerbations compared to monotherapy. (B)
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Tiotropium improves the effectiveness of pulmonary rehabilitation in incrasing exercise performance. (B)
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Theophyllin exerts a small bronchodilator effect in stable COPD (A)
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and that is associated with modest symptomatic benefits.
(B)
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ANTI-INFLAMMATORY THERAPY IN STABLE COPD

Inhaled corticosteroids

An ICS combined with a LABA is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and moderate to very severe COPD. (A)
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Regular treatment with ICS increases the risk of pneumonia especially in those with severe disease. (A)
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Triple inhaled therapy of ICS/LAMA/LABA improves lung function, symptoms and health status and reduces exacerbations compared to ICS/LABA, LABA/LAMA or LAMA monotherapy. (A)
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Oral glucocorticoids

Long-term use of oral glucocorticoids has numerous side effects (A)
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with no evidence of benefit.
(C)
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PDE4 inhibitors

In patients with chronic bronchitis, severe to very severe COPD and a history of exacerbations:
  • A PDE4 inhibitor improves lung function and reduces moderate and severe exacerbations.
(A)
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  • A PDE4 inhibitor improves lung function and decreases exacerbations in patients who are on fixed-dose LABA/ICS combinations.
(A)
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ANTIBIOTICS

Long-term azithromycin and erythromycin therapy reduces exarbations over one year. (A)
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Treatment with azithromycin is associated with an increased incidence of bacterial resistance (A)
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Treatment with azithromycin is associated with an increased incidence of bacterial resistance (A)
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and hearing test impairments.
(B)
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MUCOREGULATORS AND ANTIOXIDANT AGENTS

Regular treatment with mucolytics s erdosteine, carbocysteine and NAC reduces the risk of exacerbations in select populations. (B)
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Other anti-inflmmatory agents

Simvastatin does not prevent exacerbations in COPD patients at increased risk of exacerbations and without indications for statin therapy. (A)
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However, observational studies suggest that statins may have positive effects on some outcomes in patients with COPD who receive them for cardiovascular and metabolic indications. (C)
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Leukotriene modifiers have not been tested adequately in COPD patients. ()
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OTHER PHARMACOLOGICAL TREATMENTS

Alph-1 antitrypsin augmentation therapy

Intravenous augmentation therapy may slow down the progression of emphysema. (B)
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ANTITUSSIVES

There is no conclusive evidence of a beneficial role for antitussives in patients with COPD. (C)
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Vasodilators

Vasodilators do not improve outcomes and may worsen oxygenation. (B)
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PULMONARY REHABILITATION, SELF-MANAGEMENT AND INTEGRATIVE CARE IN COPD 

Pulmonary rehabilitation

Pulmonary rehabilitation improves dyspnea, health status and exercise tolerance in stable patients. (A)
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Pulmonary rehabilitation reduces hospitalization among patients who have had a recent exacerbation (<4 weeks from prior hospitalization). (B)
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Pulmonary rehabilitation leads to a reduction in symptoms of anxiety and depression. (A)
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EDUCATION AND SELF-MANAGEMENT

Education alone has not been shown to be effective. (C)
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Self-management intervention with communication with a health care professional improves health status and decreases hospitalizations and emergency department visits. (B)
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Integrated care programs

Integrative care and telehealth have no demonstrated benefit at this time. (B)
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PALLIATIVE CARE, END OF LIFE AND HOSPICE CARE IN COPD

Opiates, neuromuscular electrical stimulation (NMES), oxygen and fans blowing air on to the face can relieve breathlessness. (C)
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In malnourished patients, nutritional supplementation may improve respiratory muscle strength and overall health status. (B)
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Fatigue can be improved by self-management education, pulmonary rehabilitation, nutritional support and mind-body interventions. (B)
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OXYGEN THERAPY AND VENTILATORY SUPPORT IN STABLE COPD

The long-term administration of oxygen increases survival in patients with severe chronic resting arterial hypoxemia. (A)
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In patients with stable COPD and moderate resting or exercise-induced arterial desaturation, prescription of long-term oxygen does not lengthen time to death or first hospitalization or provide sustained benefit in health status, lung function and 6-minute walk distance. (A)
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Resting oxygenation at sea level does not exclude the development of severe hypoxemia when traveling by air. (C)
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Ventilatory support

NPPV may improve hospitalization-free survival in selected patients after recent those with pronounced daytime persistent hypercapnia (PaC02 >52 mmHg). (B)
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INTERVENTIONAL THERAPY IN STABLE COPD

Lung volume reduction surgery

Lung volume reduction surgery improves survival in severe emphysema patients with an upper-lobe emphysema and low post-rehabilitation exercise capacity. (A)
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Bullectomy

In selected patients, bullectomy is associated with decreased dyspnea, improved lung function and exercise tolerance. (C)
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In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity. (C)
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TRANSPLANTATION

BRONCHOSCOPIC INTERVENTIONS 

In select patients with advanced emphysema, bronchoscopic interventions reduce end-expiratory lung volume and improve exercise tolerance, health status and lung function at 6-12 months following treatment:
  • Endobronchial valves
(A)
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  • Lung coils
(B)
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  • Vapor ablation
(B)
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IDENTIFY & REDUCE RISK FACTOR EXPOSURE

Smoking cessation interventions should be actively pursued in all COPD patients. (A)
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Efficient ventilation, non-polluting cooking stoves and similar interventions should be recommended. (B)
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Clinicians should advise patients to avoid continued exposures to potential irritants, if possible. (D)
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KEY POINT FOR THE USE OF BRONCHODILATORS

LABAs and LAMAs are preferred over short-acting agents except for patients with only occasional dyspnea, (A)
and for immediate relief of symptoms in patients already on long-acting bronchodilators for maintenance therapy.
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Patients may be started on single long-acting bronchodilator therapy or dual long-acting bronchodilator therapy. Patients with persistent dyspnea on one bronchodilator treatment should be escalated to two. (A)
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Inhaled bronchodilators are recommended over oral bronchodilators. (A)
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Theophylline is not recommended unless other long-term treatment bronchodilators are unavailable or unaffordable. (B)
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KEY POINTS FOR THE USE OF ANTI-INFLAMMATORY AGENTS

Long-term monotherapy with ICS is not recommended. (A)
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Long-term treatment with ICS may be considered in association with LABAs for patients with a history of exacerbations despite appropriate treatment with long-acting bronchodilators. (A)
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Long-term therapy with oral corticosteroids is not recommended. (A)
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In patients with severe to very severe airflow limitation, chronic bronchitis and exacerbations the addition of a PDE4 inhibitor to a treatment with long acting bronchodilators with/without ICS can be considered. (B)
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Preferentially, but not only in former smokers with exacerbations despite appropriate therapy, macrolides, in particular azithromycin, can be considered. (B)
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Statin therapy is not recommended for prevention of exacerbations. (A)
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Antioxidant mucolytics are recommended only in selected patients. (A)
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KEY POINTS FOR THE USE OF OTHER PHARMACOLOGICAL TREATMENTS

Patients with severe hereditary alpha-1 antitrypsin deficiency and established emphysema may be candidates for alpha-1 antitrypsin augmentation therapy. (B)
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Antitussives cannot be recommended. (C)
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Drugs approved for primary pulmonary hypertension are not recommended for patients with a pulmonary hypertension secondary to COPD. (B)
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Low-dose long-acting oral and parenteral opioids may be considered for treating dyspnea in COPD patients with severe disease. (B)
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KEY POINTS FOR THE USE OF NON-PHARMACOLOGICAL TREATMENTS

EDUCATION, SELF-MANAGEMENT AND PULMONARY REHABILITATION

Education is needed to change patient's knowledge but there is no evidence that used alone it will change patient behavior. ()
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Education self-management with the support of a case manager with or without the use of a written action plan is recommended for the prevention of exacerbation complications such as hospital admissions. (B)
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Rehabilitation is indicated in all patients with relevant symptoms and/or a high risk for exacerbation. (A)
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Physical activity is a strong predictor of mortality. (A)
Patients should be encouraged to increase the level of physical activity although we still don't know how to best insure the likelihood of success.
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VACCINATION

Influenza vaccination is recommended for all patients with COPD. (A)
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Pneumococcal vaccination: the PCV13 and PPSV23 are recommended for all patients >65 years of age, and in younger patients with significant comorbid conditions including chronic heart or lung disease. (B)
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NUTRITION

Nutritional supplementation should be considered in malnourished patients with COPD. (B)
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END-OF-LIFE AND PALLIATIVE CARE

All clinicians managing patients with COPD should be aware of the effectiveness of palliative approaches to symptom control and use these in their practice. (D)
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End of life care should include discussions with patients and their families about their views on resuscitation, advance directives and place of death preferences. (D)
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TREATMENT OF HYPOXEMIA 

In patients with severe resting hypoxemia long-term oxygen therapy is indicated. (A)
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In patients with stable COPD and resting or exercise-induced moderate desaturation, long term oxygen treatment should not be routinely prescribed. However, individual patient factors may be considered when evaluating the patient's needs for supplemental oxygen. (A)
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TREATMENT OF HYPERCAPNIA 

In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term noninvasive-ventilation may be considered. (B)
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INTERVENTION BRONCHOSCOPY AND SURGERY 

Lung volume reduction surgery should be considered in selected patients with upper-lobe emphysema. (A)
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In selected patients with a large bulla, surgical bullectomy may be considered. (C)
325320
In select patients with advanced emphysema, bronchoscopic interventions reduce end-expiratory lung volume and improve exercise tolerance, quality of life and lung function at 6-12 months following treatment.
  • Endobronchial valves
(A)
325320
  • Lung coils
(B)
325320
  • Vapor ablation
(B)
325320
In patients with very severe COPD (progressive disease, BODE score of 7 to 10, and not candidate for lung volume reduction) lung transplantation may be considered for referral with at least one of the following:
(1) history of hospitalization for exacerbation associated with acute hypercapnia (Pco2 >50 mm Hg);
(2) pulmonary hypertension and/or cor pulmonale, despite oxyqen therapy; or
{3) FEV1 <20% and either DLCO <20% or homogenous distribution of emphysema.
(C)
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KEY POINTS FOR THE MANAGEMENT OF EXACERBATIONS

Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat acute exacerbations. (C)
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Systemic corticosteroids can improve lung function {FEV1), oxygenation and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days. (A)
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Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-7 days. (B)
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Methylxanthines are not recommended due to increased side effect profiles. (B)
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Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival. (A)
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Recommendation Grading

Overview

Title

Prevention, Management and Diagnosis of COPD

Authoring Organization

Endorsing Organization

Publication Month/Year

November 22, 2021

Last Updated Month/Year

September 18, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Respiratory therapist, physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D029424 - Pulmonary Disease, Chronic Obstructive

Keywords

chronic obstructive pulmonary disease (COPD), Spirometry, emphysema, chronic bronchitis, chronic respiratory symptoms, musculoskeletal impairment, chronic airflow limitations, Oxidative stress