Chronic obstructive pulmonary disease

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.

References

1.Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 Report (2025)