💡 TLDR Primary Care - Deep Dive (#119)

In this issue:

✅ Summarized COPD guidelines

🧠 Review the common signs and symptoms of COPD

⭐ Review the updated options for treatment

📈 And more!

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DEEP DIVE

💡 Chronic Obstructive Pulmonary Disease (COPD)

This week, we'll explore the latest clinical guidelines on Chronic Obstructive Pulmonary Disease, a progressive respiratory condition characterized by persistent airflow limitation and associated with chronic inflammation of the airways and lungs. Accurate diagnosis is essential and involves a detailed patient history, focusing on symptoms such as chronic cough, sputum production, and dyspnea, as well as risk factors like smoking history or exposure to environmental pollutants. Spirometry remains the gold standard for diagnosis, with a post-bronchodilator FEV1/FVC ratio of less than 0.7 confirming the presence of persistent airflow limitation.

The initial assessment is guided by the severity of airflow limitation, symptom burden, and the frequency of exacerbations. COPD is classified into GOLD (Global Initiative for Chronic Obstructive Lung Disease) groups A through D, which inform individualized treatment approaches.

Management generally starts with smoking cessation and pulmonary rehabilitation to improve quality of life. Pharmacologic treatment is tailored to the patient’s GOLD group, with bronchodilators (long-acting beta-agonists or antimuscarinics) forming the cornerstone of therapy. Inhaled corticosteroids are considered for patients with a history of frequent exacerbations or elevated eosinophil counts. Recent guidelines emphasize a stepwise approach to treatment intensification, incorporating triple therapy (LABA, LAMA, and ICS) or roflumilast in select cases with severe disease and frequent exacerbations. 

Non-pharmacologic strategies, including oxygen therapy and lung volume reduction procedures, may be appropriate for advanced cases. Early recognition and management of exacerbations, guided by symptoms and biomarkers, are crucial to prevent disease progression and improve patient outcomes.

Guidelines on the evaluation and management of migraine are from the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2025), the European Society for Microbiology and Infectious Diseases (ESCMID 2024), and the American Thoracic Society (ATS 2023), among others.

For a full review of COPD guidelines, head over to Pathway. We’ll cover some key takeaways below (with the recommendation strength in parentheses). 

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1) Respiratory Support

• Offer long-term oxygen therapy to improve survival in patients with severe chronic resting arterial hypoxemia (PaO2 ≤ 55 mmHg or < 60 mmHg if there is cor pulmonale or secondary polycythemia). (A)
• Do not offer long-term oxygen therapy routinely in patients with stable COPD and moderate resting or exercise-induced arterial desaturation, as it does not lengthen the time to death or first hospitalization nor provides sustained benefit in health status, lung function, or 6-minute walk distance. (D)
• Recognize that resting oxygenation at sea level does not exclude the development of severe hypoxemia when traveling by air. (B)
• Consider initiating long-term noninvasive positive-pressure ventilation to improve hospitalization-free survival in patients with severe chronic hypercapnia (particularly with pronounced daytime persistent hypercapnia, PaCO2 ≥ 53 mmHg) and a history of hospitalization for acute respiratory failure. (C)

2) Medical Management:

• Initiate regular and as-needed short-acting β-agonists or SAMAs to improve FEV1 and symptoms in patients with stable COPD. Initiate combinations of short-acting β-agonists or SAMAs for better improvements in FEV1 and symptoms. (A)
• Offer LABAs and LAMAs to significantly improve lung function, dyspnea, and health status and reduce exacerbation rates in patients with stable COPD. (A)
• Prefer LABAs and LAMAs over short-acting agents, except for patients with only occasional dyspnea. (A)
• Recognize that regular treatment with ICSs increases the risk of pneumonia, especially in patients with severe disease. (A)
• Recognize that ICSs combined with LABAs are more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and moderate-to-very severe COPD. (A)
• Recognize that LABA/LAMA/ICS triple therapy improves lung function, symptoms, and health status and reduces exacerbations compared to LABA/ICS, LABA/LAMA, and LAMA monotherapy. (A)
• Offer ensifentrine to improve lung function and dyspnea in patients with COPD. (A)
• Do not use long-term oral corticosteroids in patients with COPD because of numerous side effects and lack of benefits. (D)
• Offer mucolytics, such as erdosteine, carbocysteine, or N-acetylcysteine, to reduce the risk of exacerbations in selected patients with COPD. (B)
• Consider offering azithromycin, preferably but not limited to former smokers, experiencing exacerbations despite appropriate therapy. (C)
• Offer dupilumab to reduce exacerbations and improve lung function and QoL in patients with moderate-to-severe COPD with a history of exacerbations, chronic bronchitis, and higher blood eosinophil counts (≥ 300 cells/mcL). (A)

Common prescriptions and dosing for COPD

3) Non-pharmacologic Management:

• Offer smoking cessation interventions actively in all patients. (A)
• Advise on efficient ventilation, using non-polluting cooking stoves, and offering similar interventions in patients with COPD. (B)
• Advise patients to increase their level of physical activity as it is a strong predictor of mortality. (A)
• Offer pulmonary rehabilitation in all patients with relevant symptoms and/or high risk for exacerbation to improve dyspnea, health status, and exercise tolerance in stable patients. (A)

Acknowledgments:

• Editorial Team: Jeremy Swisher, MD, Cole Phillips, MD, Khudhur Moh, MD, Hovhannes Karapetyan, MD

🧠 Ask Pathway AI:

What are treatment recommendations based on GOLD criteria for COPD?

What is the evidence for ensifentrine in COPD?

When should a patient with COPD be put on oral corticosteroids or oral antibiotics?

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