Pulmonary · Topic 9 of 28

COPD: Diagnosis & Maintenance

Pulmonary · obstructive lung disease

COPD: Diagnosis & Maintenance

Confirm with post-bronchodilator FEV1/FVC < 0.7, classify A/B/E, start LABA + LAMA for most, stop smoking, and give oxygen for PaO₂ ≤ 55.

Key numbers

Post-bronchodilator FEV1/FVC < 0.7FEV1/FVC < 0.7

Group E: ≥ 1 exacerbation per yearE = ≥ 1 exacerbation/yr

Home oxygen for PaO₂ ≤ 55 mmHgPaO₂ ≤ 55 or SaO₂ ≤ 88%

01 · Defined byPost-bronchodilator FEV1/FVC < 0.7

COPD is confirmed by spirometry: a post-bronchodilator FEV1/FVC below 0.7 in a patient with dyspnea, chronic cough or sputum, or exposure to risk factors. Spirometry is mandatory for the diagnosis.

02 · Defined byGroup E: ≥ 1 exacerbation per year

GOLD ABE: E = ≥ 1 moderate or severe exacerbation in the past year; with none, A = mMRC 0–1 and CAAT (formerly CAT) < 10, B = mMRC ≥ 2 or CAAT ≥ 10.

03 · Defined byHome oxygen for PaO₂ ≤ 55 mmHg

Long-term oxygen improves survival when resting PaO₂ ≤ 55 mmHg or SaO₂ ≤ 88%, or PaO₂ 55–60 with pulmonary hypertension, edema or hematocrit > 55%, confirmed twice over 3 weeks.

Diagnosis & monitoring

Work-up

GOLD grades 1–4 by post-bronchodilator FEV1Airflow obstruction grade (post-bronchodilator FEV1 % predicted): GOLD 1 ≥ 80, GOLD 2 50–79, GOLD 3 30–49, GOLD 4 < 30. Grade guides prognosis, not the initial drug choice.

ICS raises pneumonia riskInhaled corticosteroids increase pneumonia risk and may cause candidiasis, osteoporosis and cataracts; withdraw the ICS after pneumonia or no response, but expect more exacerbations if eosinophils ≥ 300/µL.

Azithromycin 250 mg daily: watch QTc, hearingLong-term azithromycin (250 mg daily or 500 mg three times weekly) reduces exacerbations, less so in current smokers; it can prolong QTc, impair hearing and select resistant bacteria.

Management

Orders

LABA + LAMA for groups B and E must knowInitial therapy: group A, a bronchodilator (long-acting preferred); groups B and E, LABA + LAMA, ideally one inhaler; group E with eosinophils ≥ 300/µL, consider LABA + LAMA + ICS. All get a rescue SABA.

Smoking cessation slows decline and prolongs life must knowSmoking cessation is the single most effective intervention: it slows the decline in FEV1 and improves survival; combine counseling with pharmacotherapy (nicotine replacement, varenicline).

Exacerbating on LABA + LAMA: add ICSIf moderate or severe exacerbations occur on LABA + LAMA, escalate to LABA + LAMA + ICS when blood eosinophils are ≥ 100/µL; benefit is greatest at ≥ 300/µL.

Low eosinophils: azithromycin or roflumilastIf exacerbations continue with eosinophils < 100/µL or despite triple therapy: azithromycin for patients who no longer smoke, or roflumilast when FEV1 < 50% with chronic bronchitis and a prior severe exacerbation.

Eosinophils ≥ 300 despite triple: consider a biologicExacerbations despite LABA + LAMA + ICS with blood eosinophils ≥ 300/µL: consider dupilumab (with chronic bronchitis) or mepolizumab.

Persistent dyspnea: check technique, rehab, ensifentrineFor dyspnea despite LABA + LAMA: check inhaler technique and adherence, look for other causes, switch device or molecule, start or escalate pulmonary rehabilitation, and consider adding ensifentrine.

Refer for pulmonary rehabilitationPulmonary rehabilitation (exercise training with education) improves exercise capacity, symptoms and quality of life at every grade of severity; early rehab after hospitalization may lower readmissions and mortality.

Vaccinate: influenza, pneumococcal, RSV, COVID-19, TdapGive annual influenza, pneumococcal, RSV and COVID-19 vaccines, Tdap for those not vaccinated in adolescence, and shingles vaccine — influenza, pneumococcal and RSV vaccines reduce lower respiratory infections.

Test every COPD patient for alpha-1 antitrypsin deficiencyGOLD recommends testing all patients with COPD for alpha-1 antitrypsin deficiency once; augmentation therapy is considered for severe deficiency with FEV1 ≤ 65% predicted.

Red flags & don'ts

Avoid harm

Avoid LABA + ICS without LAMA in COPD avoidLABA + ICS alone is not encouraged in COPD without asthma; when an ICS is indicated, LABA + LAMA + ICS is superior.

More detail

Reference

Show 7 reference facts

Long-term oxygen is prescribed for more than 15 hours per day; 24-hour use did not lower hospitalization or death compared with 15 hours, and oxygen for moderate desaturation gives no survival benefit.

Long-term home NIV may help selected patients with pronounced daytime hypercapnia and a recent hospitalization.

For advanced upper-lobe emphysema refractory to medical care, consider lung volume reduction surgery or bronchoscopic valves; lung transplant for selected end-stage patients.

When asthma coexists with COPD, follow asthma guidelines: an ICS is mandatory.

Repeat spirometry at least annually without stopping bronchodilators; a normal pre-bronchodilator spirometry can exclude COPD.

Theophylline is not recommended for stable COPD because safer, more effective drugs exist; toxicity includes arrhythmias and seizures.

Screen patients with a smoking history for lung cancer with annual low-dose CT, as for the general population.

Pearl

One exacerbation is enough: under GOLD 2026, a single moderate exacerbation in the past year puts the patient in group E.

Sources · GOLD 2026 Report — Global Strategy for the Diagnosis, Management, and Prevention of COPD · GOLD 2026 Teaching Slide Set (Figures 2.10, 2.13, 3.8) · Merck Manual Professional — Treatment of Stable COPD · GOLD 2026 Key Changes Summary · GOLD 2026 Pocket Guide to COPD Diagnosis, Management, and Prevention · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).