Red Flags
- Severe COPD exacerbation with respiratory acidosis (pH <7.35) — non-invasive ventilation; ICU if pH <7.25 or NIV-contraindicated[1]
- Acute pulmonary embolism in COPD exacerbation — incidence elevated; CT-PA threshold low if D-dimer-positive and risk factors[1]
- Frequent exacerbator phenotype (≥2 moderate or ≥1 severe per year) — escalate to triple therapy; consider azithromycin, roflumilast, dupilumab in eosinophilic[1]
- Blood eosinophils ≥0.3 ×10⁹/L — favour ICS-containing therapy; <0.1 — withdraw ICS unless asthma overlap[1]
First-line treatment
Interventions
- Smoking cessation[1]Single most effective intervention; behavioural support plus pharmacotherapy (NRT, varenicline, bupropion)
- Pulmonary rehabilitation[1]Structured supervised exercise + education + nutrition; reduces dyspnoea, exacerbation frequency, and improves QoL
- Long-term oxygen therapy[1]PaO₂ ≤7.3 kPa OR ≤8 kPa with cor pulmonale, polycythaemia; ≥15 hours/day
- Vaccination[1]Annual influenza, pneumococcal, COVID-19, RSV (≥60), pertussis booster
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| LAMA monotherapy (Group A, low symptoms, low exacerbation risk)[1] | Long-acting muscarinic antagonist | Tiotropium 18 mcg DPI once daily; alternatives: umeclidinium 62.5 mcg, glycopyrronium 50 mcg | — | Initial therapy in low-symptom low-risk patients; LABA monotherapy alternative |
| LABA + LAMA (Group B and most Group E)[1] | Combination LABA/LAMA | Indacaterol/glycopyrronium 85/43 mcg DPI once daily; umeclidinium/vilanterol 62.5/25 mcg DPI once daily | — | Initial therapy for symptomatic patients (Group B) and most exacerbator patients (Group E) |
| ICS-LABA-LAMA triple therapy[1] | Triple combination inhaler | Beclomethasone-formoterol-glycopyrronium 100/6/10 mcg pMDI 2 puffs BD; budesonide-formoterol-glycopyrronium 160/4.8/9 mcg pMDI 2 puffs BD | — | Group E with blood eosinophils ≥0.3 OR ongoing exacerbations on LABA-LAMA |
| Salbutamol[1] | Short-acting beta-agonist | 100 mcg pMDI 2 puffs PRN | — | Rescue inhaler for breakthrough symptoms |
| Azithromycin (chronic suppressive)[1] | Macrolide antibiotic | 250 mg PO daily or 500 mg three times weekly | — | Frequent exacerbator on optimal triple therapy; QTc and audiometry monitoring |
| Roflumilast[1] | Phosphodiesterase-4 inhibitor | 500 mcg PO once daily | — | Severe-very-severe COPD with chronic bronchitis phenotype and frequent exacerbations despite triple therapy |
| Dupilumab[1] | Anti-IL-4Rα monoclonal antibody | 300 mg SC every 2 weeks | — | GOLD 2025 — newly added; eosinophilic COPD (≥0.3) with frequent exacerbations on triple therapy; specialist |
LAMA monotherapy (Group A, low symptoms, low exacerbation risk)[1]
Long-acting muscarinic antagonist
- Adult
- Tiotropium 18 mcg DPI once daily; alternatives: umeclidinium 62.5 mcg, glycopyrronium 50 mcg
- Paediatric
- —
Initial therapy in low-symptom low-risk patients; LABA monotherapy alternative
LABA + LAMA (Group B and most Group E)[1]
Combination LABA/LAMA
- Adult
- Indacaterol/glycopyrronium 85/43 mcg DPI once daily; umeclidinium/vilanterol 62.5/25 mcg DPI once daily
- Paediatric
- —
Initial therapy for symptomatic patients (Group B) and most exacerbator patients (Group E)
ICS-LABA-LAMA triple therapy[1]
Triple combination inhaler
- Adult
- Beclomethasone-formoterol-glycopyrronium 100/6/10 mcg pMDI 2 puffs BD; budesonide-formoterol-glycopyrronium 160/4.8/9 mcg pMDI 2 puffs BD
- Paediatric
- —
Group E with blood eosinophils ≥0.3 OR ongoing exacerbations on LABA-LAMA
Salbutamol[1]
Short-acting beta-agonist
- Adult
- 100 mcg pMDI 2 puffs PRN
- Paediatric
- —
Rescue inhaler for breakthrough symptoms
Azithromycin (chronic suppressive)[1]
Macrolide antibiotic
- Adult
- 250 mg PO daily or 500 mg three times weekly
- Paediatric
- —
Frequent exacerbator on optimal triple therapy; QTc and audiometry monitoring
Roflumilast[1]
Phosphodiesterase-4 inhibitor
- Adult
- 500 mcg PO once daily
- Paediatric
- —
Severe-very-severe COPD with chronic bronchitis phenotype and frequent exacerbations despite triple therapy
Dupilumab[1]
Anti-IL-4Rα monoclonal antibody
- Adult
- 300 mg SC every 2 weeks
- Paediatric
- —
GOLD 2025 — newly added; eosinophilic COPD (≥0.3) with frequent exacerbations on triple therapy; specialist
Safety-net
- Take maintenance inhalers every day even when breathing well — they prevent flares[1]
- Increased breathlessness, change in sputum colour or volume, fever — start rescue plan and contact clinician same day[1]
- Sudden severe breathlessness with chest pain — call emergency services (could be PE, pneumothorax, MI)[1]
Referral criteria
- Severe acute exacerbation requiring NIV or invasive ventilationEmergency department / respiratory or ICU[1]
- Frequent exacerbations despite optimal triple therapyRespiratory medicine for phenotype-driven add-ons (azithromycin, roflumilast, dupilumab)[1]
- Suspected alpha-1 antitrypsin deficiency, lung volume reduction candidacy, or transplant assessmentRespiratory medicine specialist centre[1]
Clinical summary
Diagnosis and management of COPD per the GOLD Report — A/B/E groups drive initial inhaler choice; ICS-containing therapy when eosinophilic or exacerbator phenotype.