Dx¹

• COPD Defined as FEV₁/FVC ≤ 0.7
• Other respiratory SSx are cause for suspicion, but not diagnostic
• Screen for α-1 antitrypsin deficiency

Classification

All staging must be done when stable. Pts cannot be staged during an exacerbation

GOLD (Spirometric) Assessment

GOLD Stage	Severity	FEV1 Criteria
1	Mild	≥ 80%
2	Moderate	[50%,80)
3	Severe	[30%,50%)
4	Very Severe	< 30%

Symptomatic Assessment

mMRC Grade	SSx Description
0	SOB w/ strenuous exercise
1	SOB when hurrying or going uphill
2	Stop for breath at own pace, must walk slower than other
3	Unable to walk 100m w/o SOB
4	Cannot leave house or easily dress self w/o SOB

Group Assignment

≥ 2 exacerbations or ≥ 1 hospitalization	C	D
≤ 1 exacerbation No hospitalization	A	B
	mMRC ≤ 1 CAT < 10	mMRC ≥ 2 CAT ≥ 10

Outpatient Tx¹

• Smoking Cessation
• Vaccination
  • Influenza
  • Consider PPSV23 in pts < 65 with comorbidities or with FEV₁ < 40%
• Everyone gets a SABA inhaler
• Can add supplemental O2 as needed, target O2sat ≥ 90%

Group A

1. Bronchodilator
2. Try different bronchodilator

Group B

1. LABA or LAMA
2. LAMA + LABA

Group C

1. LAMA
2. LAMA + LABA (preferred) or LABA + ICS

Group D

1. LAMA
2. LAMA + LABA or LABA + ICS or LAMA + LABA + ICS
   • Preferred to try LAMA + LABA then LAMA + LABA + ICS
3. Add Roflumilast if continued exacerbations, FEV₁ < 50%
4. Consider macrolide Abx in former smokers

Exacerbation Tx^{1, 2}

Classification

• No respiratory Failure: RR 20-30 BPM, no accessory muscle use, improves w/ supplemental O2, no increase in PaCO2, and no changes in mental status
• Non-life Threatening Acute Respiratory Failure: Hypercarbia 50-60, accessory muscle use, no mental status changes
• Life Threatening Acute Respiratory Failure: Mental status changes, hypercabia > 60, acidosis

Tx

• Give Non-invasive ventilation for respiratory compromise
• Add / increase bronchodilators (SABA or SABA + SABA appropriate)
  • Consider Epinephrine 0.3-0.5mg SubQ Q20min x3 doses or Terbutaline 0.25mg SubQ Q20min x3 doses if not responding to or tolerating inhaled bronchodilators
• Consider GCs
  • Prednisone 40-60mg Q4-6H or equivalent
  • Methylprednisolone 1mg/kg IV is a good parenteral choice
  • Usually 5-7d course
• Consider 5-7d of Abx
  • Usually Azithromycin 500mg on day 1 then 250mg QD x4d³
  • Can consider doxycycline or Amox or Augmentin
  • Coverage of Strep pneumoniae, H. influenzae, and Moraxella catarrhalis

References