Standard of Care Recommendations

Assessment Recommendations

Screening	A clinical diagnosis of COPD should be considered in a patient who has symptoms and risk factors for the disease (Table 6).¹ The American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society (ACP/ACCP/ATS/ERS)² U.S. Preventive Services Task Force (USPSTF)³, and GOLD guidelines¹ recommend against spirometric screening in asymptomatic individuals [Level of evidence [LOE]: Strong rec, Mod evidence].
Diagnostic confirmation with spirometry	Spirometry is required to establish a diagnosis of COPD. The presence of a post-bronchodilator ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1/FVC ratio) < 0.70 confirms the diagnosis of COPD. Any single spirometry measurement that yields a value between 0.60 and 0.80 should be repeated at a later time to rule out biological variability.¹
Reversibility of airflow limitation	GOLD guidelines suggest that determining the degree of reversibility (e.g. measuring FEV₁ before and after bronchodilator or corticosteroids) has never been shown to improve the diagnosis, enhance the differentiation from asthma, or to help predict response to long-term treatment with bronchodilators or corticosteroids and is not recommended.¹
Inaccurate diagnosis	Performing spirometry in individuals without symptoms and risk factors can lead to inaccurate diagnosis. Peak expiratory flow measurement has good sensitivity to identify COPD, but has weak specificity and cannot be reliably used for diagnosis.¹
Goals of assessment	The goals of COPD assessment are to determine the severity of airflow limitation, the impact on the patient’s health status, and the risk of future events in order to guide therapy.¹
GOLD assessment	The GOLD guidelines ABCD assessment tool has not been demonstrated superior to a basic spirometric assessment.¹
Screening for other chronic conditions and complications	Patients with COPD should also be evaluated for concomitant chronic diseases and extrapulmonary complications of COPD, such as malnutrition, sleep disturbances, and depression.^1,4
Follow-up	GOLD guidelines recommend assessing symptoms (e.g., dyspnea, fatigue, limitations in activity), exacerbations (e.g., frequency, severity, likely causes), and exposure to noxious particles (e.g., tobacco smoke, occupational chemical) at every visit.¹

Treatment Recommendations

Tobacco cessation	Among interventions for COPD, tobacco cessation is most likely to alter the natural history of the disease.1 Telling the patient their estimated “lung age” may improve cessation rates.⁵
Pulmonary rehabilitation	Pulmonary rehabilitation is the most effective intervention for improving symptoms, having been shown to improve exercise capacity and quality of life across different severities of COPD [LOE: A].^1,2
Immunization	Vaccination against respiratory pathogens can reduce serious illness and death in COPD patients. Provide influenza and pneumococcal vaccinations (with both the 13-valent [PCV13] and the 23-valent [PPSV23] vaccines) according to availability and guidelines.
Pharmacotherapy benefits unknown in mild/moderate COPD	Pharmacotherapy for COPD has not been conclusively shown to alter the natural history of COPD; however, it can reduce symptoms, decrease the frequency and severity of exacerbations, and improve health status and exercise tolerance. However, since most trials enrolled patients with significant airflow limitation (i.e., FEV1 < 60%) or a history of exacerbations, little is known about the impact of chronic therapy in patients with mild-to-moderate COPD.^1,3
GOLD treatment recommendations	GOLD guidelines recommend treatment based on assessment of symptoms and risk of future exacerbations.¹
ACP treatment recommendations	The ACP/ACCP/ATS/ERS guidelines recommend that therapy should be based on FEV₁, cost, potential adverse events, and patient preferences.³ Each treatment regimen needs to be patient-specific and adequate education and training needs to be provided to those patients using inhalers.
Bronchodilator therapy	Regular and as-needed use of inhaled bronchodilators significantly improves dyspnea, reduces the risk for exacerbations, and improves health status, making them the foundation of COPD treatment.[LOE: A]¹
ICS therapy	Inhaled corticosteroids (ICS) can improve health status and reduce exacerbations when combined with a long-acting beta-agonist (LABA), but has been shown to increase the risk of pneumonia.[LOE: A]¹
Combination therapy	The GOLD guidelines generally support the use of combination therapy in an effort to increase efficacy.1 However, evidence supporting clinically significant differences in meaningful outcomes is inconsistent. In contrast, the ACP/ACCP/ATS/ERS concluded that combination therapy is not consistently superior to monotherapy.²
Inhaler technique	Observational data suggest that poor inhaler technique is associated with worse symptom control in COPD, yet two-thirds of patients make at least one error in their technique. All patients using inhaled therapy should receive device-specific instruction for each prescribed inhaler device , including demonstration of proper use.¹
Oxygen therapy	Long-term oxygen therapy (> 15 hours/day) can improve survival in patients with severe, chronic resting hypoxemia defined as either (1) a partial pressure of oxygen (PaO2) ≤ 55 mm Hg or an oxygen saturation (SaO2) ≤ 88% or (2) a PaO2 between 55-60 mm Hg in combination with right heart failure or erythrocytosis [LOE: A].¹
Referral	Consider referral to a specialist for complicated cases.¹
End-of-life care	Palliative, end-of-life, and hospice care are important considerations in all patients with a life-limiting illness such as COPD.¹
Exacerbations	Bronchodilators and systemic corticosteroids, with or without antibiotics, constitutes the foundation of management of COPD exacerbations.¹