Clinical suspicion. Risk factors of exposure to smoking (≥10 pack-years) or inhalation irritants. Chronic cough, sputum production, or dyspnea. (See symptoms and signs in Table 2 in the original guideline document.)
Pulmonary function test. Required for diagnosis. Post-bronchodilator FEV1/FVC <0.70 is required to demonstrate airflow obstruction that is not fully reversible.
Alternative diagnoses. If pulmonary function testing is negative or equivocal, consider alternative diagnoses (see Tables 3 & 4 in the original guideline document) or consider referral to pulmonary specialist.
Alpha-1 antitrypsin level. Assess for deficiency in settings of clinical suspicion: age 45 or less, absence of other risk factors or severity of disease out of proportion to risk factors, prominent basilar lucency, family history, or bronchiectasis.
Initial Assessment, Patient Education, Prevention, and Treatment
COPD severity staging. Post-bronchodilator FEV1 determines stage (see Table 5 in the original guideline document).
- For patients with severe disease (FEV1 <50%), obtain oximetry on room air. Respiratory failure (O2 saturation ≤88%) indicates very severe disease (see Table 11 in the original guideline document).
- For marginal resting room air oxygen saturation (89–93%), perform 6 minute walk test to assess for ambulatory desaturation (see Table 11 in the original guideline document).
- BODE index assessment (see Table 6 in the original guideline document) may be used to determine prognosis for severe disease, but is usually deferred to referral specialists. (BODE = Body-mass index, Airflow obstruction [% of predicted FEV1], Dyspnea using the modified Medical Research Council dyspnea scale [see Table 7 in the original guideline document], and Exercise capacity [distance walked in 6 minutes].)
Patient education. Provide educational overview of COPD pathology, causes, diagnosis, staging, exacerbation triggers, and treatment options (see Table 8 in the original guideline document).
Smoking cessation. Encourage all smokers to quit, and assist them in quitting. (See the University of Michigan Health System [UMHS] guideline, Smoking Cessation.)
Inhaled irritant control. Identify and review how to avoid triggers and exposures known to cause/aggravate COPD: smoking, second hand smoke, occupational fumes and chemicals, indoor air pollution (e.g., cooking with biomass fuels), outdoor air pollution, infection.
Medical therapy. Select bronchodilator and consider inhaled corticosteroid therapy based on COPD severity by stage and by current frequency of exacerbations (see Table 9 in the original guideline document). Table 10 in the original guideline document provides dose and cost information for medications.
Oxygen therapy. Initiate long term oxygen for patients with oxygen saturation ≤88% (see Table 11 in the original guideline document).
Chronic Disease Management
Vaccinate against influenza and pneumococcus. Provide annual flu shots for all COPD patients. Provide pneumococcal vaccination. Provide a booster pneumococcal vaccine for patients age 65 and older if they received their first dose before age 65 and if more than five years have passed.
Pulmonary rehabilitation. Refer patients with functional limitations to pulmonary rehabilitation.
Medical therapy. Monitor patient adherence and correct usage. Prescribe long-acting bronchodilators for patients with frequent symptoms. For patients with exacerbations requiring systemic steroids or antibiotics within the past year and FEV1 ≤50% predicted, consider adding inhaled corticosteroid therapy (see Table 9 in the original guideline document). Table 10 in the original guideline document provides dose and cost information.
Oxygen therapy. Titrate long-term oxygen for patients with oxygen saturation ≤88% to achieve resting and exercise oxygen saturation ≥90% (see Table 11 in the original guideline document).
Inhaled irritant control. Provide ongoing smoking cessation counseling and irritant control counseling. (See the UMHS guideline Smoking Cessation.)
Monitor comorbidities. Consider increased risk for cardiovascular disease, depression, anxiety, and other smoking related diseases such as osteoporosis and cancer. Monitor blood sugar control for diabetic patients on inhaled corticosteroids. Monitor for glaucoma and cataracts for patients on inhaled corticosteroids.
Refer to COPD specialist. For patients with alpha-1-antitrypsin deficiency, severe disease (FEV1 ≤50%), supplemental oxygen dependence, severe exacerbation and/or frequent exacerbations, consider referral for co-management and consideration of surgical options.
Advanced care planning. Engage patients in shared decision making regarding goals of therapy and advanced directives.
Acute Exacerbation Management
Assess exacerbation severity. Determine severity based on history, physical, and pulse oximetry.
Consider etiology. Assess clinically for risk of pneumonia, congestive heart failure, pulmonary embolism, or other causes of respiratory decline. Consider chest radiograph if clinically indicated.
Determine care setting. Consider hospitalization for patients with marked symptoms, severe underlying disease, significant complicating comorbidities, respiratory failure, uncertain diagnosis, or insufficient outpatient supports.
Medical therapy. Select bronchodilators, antibiotics, and corticosteroid therapy based on clinical indications with the goal of reducing the frequency of future exacerbations (see Table 12 in the original guideline document).
Oxygen therapy. Titrate oxygen for patients with oxygen saturation ≤88% to achieve resting and exercise oxygen saturation ≥90% (see Table 11 in the original guideline document).
Follow-up. Consider repeat spirometry 4-6 weeks following exacerbation if symptoms have not returned to baseline. Re-evaluate necessity of oxygen therapy.