COPD Management Checklist
A comprehensive COPD management checklist must prioritize spirometric confirmation of diagnosis, aggressive smoking cessation, stepwise pharmacotherapy based on disease severity, and systematic assessment for complications that impact mortality and quality of life.
Initial Diagnosis and Assessment
Confirm Diagnosis with Objective Testing
- Spirometry is mandatory – diagnosis cannot be made on symptoms alone and requires post-bronchodilator FEV1 <80% predicted AND FEV1/FVC ratio <70% 1
- Perform spirometric testing rather than peak flow measurements, as serial recordings over one week are needed if using PEF 1
- Critical pitfall: A single spirometry test may be insufficient, as up to one-third of patients with baseline obstruction shift to non-obstructed status when re-tested after 1-2 years 2
- Test for reversibility: A positive response is FEV1 increase of ≥200 ml AND ≥15% from baseline 1
- Substantial bronchodilator response suggests possible asthma rather than pure COPD 1
Classify Disease Severity
- Mild COPD: FEV1 60-80% predicted, smoker's cough, minimal breathlessness, no abnormal signs 1
- Moderate COPD: FEV1 40-59% predicted, breathlessness on moderate exertion, variable abnormal signs 1
- Severe COPD: FEV1 <40% predicted, breathlessness on any exertion/at rest, lung overinflation, possible cyanosis and cor pulmonale 1
Additional Baseline Testing
- Chest radiography to exclude other pathology and identify bullae 1
- Arterial blood gas measurement in severe COPD to identify persistent hypoxemia (PaO2 <7.3 kPa) with or without hypercapnia 1
- Consider corticosteroid trial in all patients with moderate-to-severe disease 1
Smoking Cessation (Highest Priority Intervention)
- Smoking cessation is essential at all disease stages – it cannot restore lost lung function but prevents accelerated decline 1
- Participation in active smoking cessation programs with nicotine replacement therapy leads to higher sustained quit rates 1
- Assess smoking status at every visit for smokers aged 40 and over 1
Pharmacological Management Algorithm
Mild Disease (FEV1 60-80%)
- Start with short-acting β2-agonist OR inhaled anticholinergic as needed, depending on symptomatic response 1, 3
- Never use ICS monotherapy – it provides no benefit and is explicitly not recommended 3
Moderate Disease (FEV1 40-59%)
- Regular bronchodilator therapy with either short-acting β2-agonist or anticholinergic, or combination of both 1
- Consider corticosteroid trial in all patients at this stage 1
- For moderate-to-high symptoms, escalate to LAMA/LABA dual bronchodilator therapy as maintenance treatment 3
Severe Disease (FEV1 <40%)
- Combination therapy with regular β2-agonist AND anticholinergic 1
- Consider corticosteroid trial 1
- For patients with ≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalization in past year, escalate to triple therapy (ICS/LAMA/LABA) 4, 3
- Assess for home nebulizer using BTS guidelines 1
- For COPD-asthma overlap: Prefer ICS/LABA combination over LAMA/LABA 3
Inhaler Technique Optimization
- Verify proper inhaler technique at each visit – incorrect use leads to poorly controlled disease 3
- Select appropriate device to ensure efficient delivery 1
Medications with Limited Role
- Theophyllines are of limited value in routine COPD management 1
- Long-acting β2-agonists should only be considered if objective evidence of improvement is available 1
- Avoid long-term oral corticosteroids in stable COPD 3
Non-Pharmacological Management
Exercise and Nutrition
Vaccination
- Influenza vaccination recommended, especially for moderate-to-severe disease 1
Pulmonary Rehabilitation
- Pulmonary rehabilitation improves exercise performance and reduces breathlessness – consider in moderate/severe disease 1
- Outpatient-based programs have demonstrated benefits 1
Advanced Disease Management
Oxygen Therapy Assessment
- Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 1
- LTOT should only be prescribed if objectively demonstrated hypoxia (PaO2 <7.3 kPa) is present 1
- Short burst oxygen lacks evidence for reducing breathlessness 1
Surgical Considerations
- Surgery indicated for recurrent pneumothoraces and isolated bullous disease 1
- Lung volume reduction surgery may be useful in selected patients 1
Psychosocial Assessment
Travel Considerations
- Travel by land and sea possible in virtually all cases 1
- Air travel may be hazardous if PaO2 breathing air is <6.7 kPa – check oxygen availability on chosen flight 1
Specialist Referral Indications
Refer to specialist when: 1
- Suspected severe COPD requiring diagnosis confirmation and treatment optimization
- Onset of cor pulmonale
- Assessment for oxygen therapy (to measure blood gases)
- Assessment for nebulizer therapy
- Assessment for oral corticosteroids (to justify long-term treatment or supervise withdrawal)
- Bullous lung disease (to identify surgical candidates)
- COPD in patient <40 years old – to identify α1-antitrypsin deficiency, consider therapy, and screen family
- Uncertain diagnosis
- Symptoms disproportionate to lung function deficit
- Frequent infections (to exclude bronchiectasis)
- Rapid decline in FEV1
- <10 pack-year smoking history
Acute Exacerbation Management
Home Treatment Criteria 1
- Add or increase bronchodilators (verify inhaler device and technique are appropriate)
- Prescribe antibiotic if ≥2 of the following present: increased breathlessness, increased sputum volume, development of purulent sputum
- Oral corticosteroids may be prescribed in some cases (specific criteria apply)
Hospital Admission Decision
Consider admission if multiple negative answers to: 1
- Mild breathlessness?
- Good general condition?
- Not receiving LTOT?
- Good level of activity?
- Good social circumstances?
Follow-Up After Exacerbation
- If treated at home and not improved in 2 weeks: consider chest radiography and hospital referral 1
- For all patients, follow-up 4-6 weeks after discharge should include: patient's ability to cope, FEV1 measurement, inhaler technique reassessment, need for LTOT/home nebulizer in severe COPD 1
Ongoing Monitoring
Regular Follow-Up Components
- Measurement of FEV1 1
- Reassessment of inhaler technique and patient understanding of treatment regimen 1
- Emphasize lifestyle management benefits (smoking, weight, exercise) 1
- Access to spirometric tests 1
Treatment Reassessment
- Reassess patients at 3 months and consider escalation if inadequate response with continued exacerbations 4
- For patients on triple therapy with moderate-to-high symptom burden or FEV1 <80%, continue triple therapy rather than stepping down 3