This guideline provides recommendations for the diagnosis and management of adults aged  19 years with chronic obstructive pulmonary disease (COPD).- Use spirometry to confirm airflow obstruction in all patients suspected of having COPD.  - Promote smoking cessation or reduction (even in long-term smokers) to improve symptom control and slow the progression of COPD, among other benefits.  - Refer patients with moderate to severe COPD to pulmonary rehabilitation.  - Implement pharmacologic therapy in a stepwise approach and use the lowest step that achieves optimal control based on the patient's severity of COPD.  - Develop an exacerbation action plan with the patient for pharmacologic therapies including short-acting bronchodilators, oral corticosteroids, and antibiotics.  - Use routine follow-ups to evaluate the patient's inhaler technique and adherence regularly. Evaluating inhaler technique is particularly important in patients who are older, frail, or cognitively impaired. COPD is characterized by persistent airflow limitation that is typically progressive, not fully reversible, and associated with an abnormal inflammatory response of the lungs to noxious particles or gases (e.g., exposure to cigarette smoke). The two most common conditions that contribute to COPD are emphysema (destruction of alveoli) and chronic bronchitis (inflammation of bronchioles). COPD may present with comorbidities and exacerbations which contribute to overall symptom severity affecting the patient's daily activities and quality of life. These features are most prominent in patients with moderate to severe COPD, but even patients with mild COPD can experience exacerbations. 1 Acute exacerbation of COPD (AECOPD) is characterized by an increase in dyspnea, cough and/or sputum that is beyond normal day-to-day variation. It may be acute in onset, but can also have a more indolent onset and result in a change in regular medication. 1 Patients who experience an acute exacerbation have a significantly higher mortality rate than those with stable COPD. 2 This mortality risk increases as the number of exacerbations increases.Approximately 138,500 individuals aged  45 years in BC have been diagnosed with COPD (approximately 6% of British Columbians aged  45 years). 3  Many individuals have unrecognized COPD and remain undiagnosed. 4COPD patients commonly present with comorbidities which reduce quality of life. In patients with mild to moderate COPD, cardiovascular diseases are the leading cause of hospitalizations and the second leading cause of mortality after lung cancer. In severe and very severe COPD, respiratory failure and pneumonia are the leading causes of morbidity and mortality. However, even in these patients, cardiovascular diseases remain a major concern. 5# Diagnosis
While a diagnosis is based on a combination of medical history and physical examination, it is the documentation of airflow limitation using spirometry that confirms the diagnosis.
Consider a COPD diagnosis for a patient  40 years of age who has:
1) Respiratory symptoms, including:
- dyspnea (progressive, persistent and worse with exercise); - chronic cough; and - increased sputum production.
AND 2) One of the following:
- history of exposure to cigarette smoke;
- history of environmental/occupational exposure to smoke, dust or gas/fumes; - frequent respiratory infections; or - family history of COPD.
Consider alternative diagnoses. Asthma and asthma-COPD overlap syndrome (ACOS) are the two primary differential diagnoses to rule out (see Table 1 for features). Other alternative diagnoses include:
- heart failure (e.g., older patients, when breathlessness is out of proportion to spirometry results; measuring B-type natriuretic peptide (BNP) levels may help in diagnosing heart failure); and - tuberculosis (e.g., high risk populations -aboriginal, foreign born). 

# Investigations or Tests

# Spirometry
Send ALL patients suspected of having COPD for confirmation of the diagnosis by spirometry. A COPD diagnosis is confirmed when a post-bronchodilator spirometry measurement indicates that there is airflow limitation which is not fully reversible (FEV 1 / FVC ratio < 0.7 or FEV 1 / FVC < lower limit of normal values). A FEV 1 predicted measurement is not needed for diagnosis, but is useful in the assessment of severity.
Timely access to spirometry may be a challenge in rural and remote communities, but should remain a reasonable goal.
Assuming access to spirometry can occur in a reasonable time frame, a referral to a specialist should not be done before objectively confirming the diagnosis of COPD.

# Borderline Spirometry Results
There is some controversy regarding the fixed cut-off of < 0.7 for FEV 1 / FVC ratio versus using < lower limit of normal values.
There is some evidence that a fixed ratio can lead to over diagnosis in older populations, under diagnosis in young people, and a gender difference. 6 Recent evidence also suggests that some current or former smokers may have symptoms of COPD without meeting spirometric criteria for a COPD diagnosis. 7 For borderline results, repeat spirometry after a few months.
Consider alternative diagnoses for all patients with borderline spirometry results or if breathlessness is out of proportion to spirometry results. If FEV 1 response to bronchodilator is:
-  400 mL, strongly consider asthma or ACOS.
- < 400 mL (but  200 mL and  12% of FEV 1 ), consider asthma or ACOS depending on the history and pattern of symptoms (see Table 1 above).
? Chest X-ray A chest x-ray is not helpful in diagnosing COPD. A chest x-ray that shows hyperinflation may suggest COPD, but the diagnosis requires objective confirmation with spirometry. A chest x-ray may be useful, and should be documented, if there are concerns about other significant comorbidities (e.g., heart failure, tuberculosis, pneumonia).

# ? Other Pulmonary Function Tests
Other pulmonary function tests (e.g., body plethysmography, diffusing capacity, arterial blood gas measurement) are not required for a COPD diagnosis, but may be helpful in assessing the severity of COPD or when considering alternative diagnoses. For example, a body plethysmography may help in the assessment of severity of COPD, but is not essential.
Peak flow meter readings may help rule out asthma, but their usefulness in assessing COPD remains unclear.

# Assessment of COPD Severity
Once the diagnosis is confirmed, determine the level of COPD severity (see Table 2) by using the patient's:
- current level of symptoms;
- FEV 1 predicted; - risk of exacerbation; and - presence of comorbidities.

# Assessment Tools
To assist in determining the current level of a patient's symptoms, use a tool such as the COPD Assessment Test (CAT) (website: www.catestonline.org). The MRC Breathlessness/Dyspnea Scale (website: www.mrc.ac.uk/research/facilities-and-resources-forresearchers/mrc-scales) may also be useful. 

# Management
The therapeutic goals of COPD management include: 8 - to alleviate breathlessness and other respiratory symptoms that affect daily activities;
- to prevent and reduce the frequency and severity of acute exacerbations;
- to minimize disease progression and reduce the risk of morbidity/mortality; and - to optimally manage comorbidities (if present) to reduce exacerbations and COPD symptoms related to comorbidities.
When developing the patient's therapeutic goals and a management plan, consider:
- using a shared decision-making approach with the patient, taking into account patient preferences and capabilities (e.g. cognitive ability, language barriers); - including a chronic disease and self-management approach facilitated by health professionals, as it can significantly improve health status and reduce hospital admissions for exacerbations by 40%; 9 - using non-pharmacological and pharmacological interventions based on the individual patient's level of severity, - simplifying the medication regime in the context of other conditions and treatments, particularly in the elderly; and - reviewing the treatment approach regularly to eliminate medications that are not improving symptoms or reducing exacerbations.

# Lifestyle and Self-Management
The patient's understanding of, and participation in, optimal care may improve coping skills and quality of life and reduce the likelihood of hospitalization from COPD. Educate the patient and their family or caregiver about lifestyle and self-management strategies -refer to Associated Documents: Resource Guide for Patients. 

# Smoking Cessation
Promote smoking cessation or reduction (even in long-term smokers) and avoidance of second-hand smoke. Smoking is the main cause of COPD and the main contributing factor for disease progression. Smoking cessation has immediate benefits including: 1) improving symptom control, 2) slowing progression of disease, 3) improving cardiovascular outcomes, and 4) reducing long-term risk of lung cancer.
- For assistance in quitting smoking, refer patients to QuitNow at HealthLinkBC by telephone at 8-1-1 or website: www.quitnow.ca. - For more information on effective pharmacological aids for smoking cessation, refer to the BC Smoking Cessation program website: www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/what-we-cover/drugcoverage/bc-smoking-cessation-program.

# Physical Activity
Encourage exercise and a more active lifestyle. Remaining active despite symptoms of shortness of breath must remain a priority for all patients with COPD.

# Pulmonary Rehabilitation and Respiratory Services
Moderate to severe COPD patients should be referred to a pulmonary rehabilitation program (where available) and to community respiratory services. Home and Community Care programs offered by health authorities include home visits by a respiratory therapist for COPD patients, among other things.
- To find a program in BC, contact HealthLink BC at 8-1-1, refer to the Referral Resources section below, or contact health authorities regarding local services. - A list of pulmonary rehabilitation programs in BC is available at prrl.rehab.med.ubc.ca/bc-pulmonary-rehabilitationprograms-contacts/.

# Diet Considerations
Ensure adequate diet to maintain body mass index in the "normal" range (20 to 25 kg/m 2 ), as it is essential in limiting disease progression and reducing morbidity and mortality related to COPD. Reduced body mass index (and in particular anorexia) is one of the most important risk factors for COPD progression.

# Air Quality
Encourage patients to stay indoors when air quality is poor, as air quality may have a significant effect on COPD symptoms and the risk of exacerbations.

# Oxygen Therapy
The goal of oxygen therapy is to maintain PaO 2  60 mmHg or SpO 2  90% at rest, on exertion and during sleep. (PaO 2 = partial pressure of oxygen in arterial blood, SpO 2 = % oxygen saturation). Oxygen therapy may be a useful addition to increase exercise capacity. Refer to Appendix C: BC Home Oxygen Program Medical Eligibility, or to health authorities for local criteria regarding coverage.

# Immunization
Individuals with COPD are at higher risk of complications of influenza and pneumococcal infection. While the polysaccharide pneumococcal vaccine may provide some protection against morbidity for patients with COPD, the evidence remains limited. 10 Encourage an annual influenza vaccine, which is provided free of charge in BC to adults with COPD -refer to website: www.healthlinkbc.ca/healthlinkbc-files/inactivated-influenza-vaccine.
The pneumococcal polysaccharide vaccine is recommended, and provided free of charge in BC, for adults with COPD. Some patients with specific comorbidities or undergoing certain treatments (e.g., chemotherapy) may also benefit from the pneumococcal conjugate vaccine. Some international COPD guidelines also suggest a booster of the pneumococcal polysaccharide vaccine at 5-10 years. Refer to HealthLink BC (website: www.healthlinkbc.ca/healthlinkbc-files/pneumococcalpolysaccharide-vaccine) and Immunize Canada (website: www.immunize.ca/en/diseases-vaccines/pneumococcal.aspx).

# Advance Care Planning
Initiate advance care planning discussions for all patients with a diagnosis of COPD. Advance care planning should be tailored to the needs of the patient along the disease trajectory, and should incorporate the patient's values and goals, indicate potential outcomes, and identify health care professionals involved in care. The advanced care plan is also an opportunity to identify the patient's alternate substitute decision maker or representative.
- For assistance, the Ministry of Health's advance care planning guide My Voice -Expressing My Wishes for Future Health Care Treatment is available at website: gov.bc.ca/advancecare.

# Pharmacologic Management
When developing the patient's therapeutic goals and pharmacologic management plan, individualize the plan based on the patient's symptoms, exacerbation history, response to treatment and their risk of adverse effects. For more information on specific medications, refer to Appendix A: Prescription Medication Table for COPD.

# Inhaled Medications
Many new inhaled medications, including fixed dose combinations, have been introduced in recent years. It is recommended to:
- Ensure that drug classes are not duplicated when initiating or modifying drug therapy.
- Evaluate the patient's inhaler technique and adherence regularly, as up to 90% of patients use their device incorrectly. Evaluating inhaler technique is particularly important in patients who are older, frail, or cognitively impaired. For information on how to use different inhalers, refer patients to website: www.lung.ca/lung-health/get-help/how-useyour-inhaler. - Consider prescribing a spacer for metered dose inhalers; however it should be noted that spacers require regular maintenance and cleaning to ensure optimal use.
Bronchodilator medications are central to symptom management in COPD, and should be prescribed on an as-needed or regular basis to prevent or reduce symptoms. 1
Stepwise Approach to Pharmacologic Therapy Implement pharmacologic therapy in a stepwise approach and use the lowest step that achieves optimal control based on the patient's severity of COPD (see Figure 1). When assessing for the next step, consider exertional dyspnea, functional status, history of exacerbations, complexity of medicines or devices, patient preference (e.g., cost and ability to adhere to treatment plan) and occurrence of adverse effects. Refer to Appendix A: Prescription Medication Table for COPD for information on dosing, drug costs, Pharmacare coverage, and therapeutic considerations.  

# S T E P W IS E A P P R O A C H : U s e t h e lo w e s t s t e p t h a t a c h ie v e s o p t im a l c o n t r o l b a s e d o n t h e s e v e r it y o f C O P D
Abbreviations: COPD = chronic obstructive pulmonary disease; ICS = inhaled corticosteroid; LABA = long-acting beta 2 -agonist; LAMA = long-acting antimuscarinic antagonist; SABA = short-acting beta 2 -agonist; SAMA = short-acting muscarinic antagonist.
Step 1: SAMA or SABA Therapy -For symptom relief - For all symptomatic patients, prescribe a short-acting inhaled bronchodilator (short-acting beta 2 -agonist (SABA) or shortacting muscarinic antagonist (SAMA) for acute, short-term relief of shortness of breath. 6 - For those with moderate to severe COPD, SAMA or SABA monotherapy is recommended. Limited evidence suggests that SAMA reduces the risk of AECOPD, improves quality of life and lung function, and may be better tolerated, as compared to SABA monotherapy. 10,11 - If symptoms are not well controlled with monotherapy, consider combination therapy of SAMA + SABA. 10 Step 2: Additional LAMA or LABA Therapy -For symptom relief and to prevent exacerbations
- At the next step in symptom management, consider monotherapy with a long-acting beta 2 -agonist (LABA) or a long-acting antimuscarinic antagonist (LAMA). Limited evidence suggests LAMA may reduce the number of moderate and severe exacerbations compared to LABA therapy. 12,13 Given the limited evidence, consider a substantial trial of LAMA, followed by a LABA (or vice versa), then continue with the patient's preferred therapy. 13 - If monotherapy does not provide adequate relief of symptoms, consider a combination of LABA + LAMA, which provides slightly better quality life and lung function over either therapy alone, and reduces exacerbations compared to LABA alone. 14 Fixed dose combination inhalers of LABA with a LAMA are available, 8 and have been shown to be superior to inhaled corticosteroid (ICS) + LABA combination in reducing symptoms and preventing exacerbations in COPD. 15 - Ipratropium bromide/Atrovent (a SAMA) and a LAMA should not be used concurrently. 6,10 Step 3: Triple Therapy -To prevent exacerbations
- For those with moderate to severe COPD and repeated exacerbations (e.g., FEV 1 < 50% predicted and  2 exacerbations in the past 12 months), a triple combination therapy of a LABA + ICS and LAMA is recommended. 6 - Fixed dose combination inhalers of an ICS with a LABA are available; if a combination inhaler is initiated, discontinue the use of the single agent LABA inhaler. 6 - The use of ICS with COPD remains controversial (see Controversies in Care section below). ICS monotherapy is not recommended, and if used in combination therapy, use the lowest possible dose.

# Treatment of Acute Exacerbations of COPD (AECOPD)
Acute exacerbations are characterized by sustained (e.g., 48 hours or more) worsening of shortness of breath and coughing, usually with increasing sputum volume. The most common cause of AECOPD is a viral or bacterial infection; however, there are a number of non-infectious causes of exacerbations including: pleural effusion, heart failure, pulmonary embolism, and pneumothorax.
Severe AECOPD complicated by acute respiratory failure is a medical emergency and the patient should seek immediate treatment. However, more than 80% of exacerbations can be managed on an outpatient basis with pharmacologic therapies including short-acting bronchodilators, oral corticosteroids, and antibiotics. 1 Develop an exacerbation action plan with the patient (see Associated Document: COPD Flare-up Action Plan). Note that there are some populations for which a written action plan may not be appropriate, including patients with cognitive disabilities, patients who cannot adequately follow instructions, and patients with significant comorbidities that might increase the risk of steroid-adverse effects. 16 Pharmacologic therapies may include:
1) short-acting bronchodilator for initial treatment of acute exacerbations - Adequate doses of bronchodilator (e.g., salbutamol 400 to 800 mcg ) delivered via metered dose inhaler with a spacer is equivalent to 2.5 mg by nebulizer and is as effective. Administer salbutamol frequently (up to every couple of hours) and titrate to response. 6 2) oral corticosteroids in most moderate to severe COPD patients 1 - A dose of 40 mg of prednisone per day for 5 days is an appropriate dose. 17 However, a dose of 50 mg of prednisone per day is often used in Canada because of its availability in a single tablet. Lower doses may need to be used, especially in the presence of diabetes mellitus.
- Evidence suggests that systemic corticosteroids in AECOPD shorten recovery time, improve lung function, improve arterial hypoxemia, and reduce the risk of early relapse, treatment failure, and duration of hospitalization. 1 - There is a well-powered randomized controlled trial comparing 5 versus 14 days of oral corticosteroids showing similar efficacy. 17 - For most patients, tapering of the corticosteroid dose should not be necessary. 1,6 - Systemic corticosteroids have not been shown to reduce AECOPD beyond the initial 30 days of an exacerbation and the long-term use of systemic corticosteroids is not recommended as the risk of adverse events far outweighs any potential benefits.
Bronchodilators and corticosteroids may be administered by nebulizer, metered-dose inhaler, or dry powder inhaler. While all of these devices are appropriate for treating COPD exacerbations, each has advantages and disadvantages. In choosing a drug/ device combination, take into account the patient's cognitive and physical ability, ease of use, convenience, cost, and patient preferences. 18 3) antibiotic treatment - Patients presenting with symptoms and risk factors for bacterial infection may benefit from antibiotic treatment. While studies have shown large and consistent benefit from antibiotic use among COPD patients admitted to the ICU, the evidence for their use in patients with mild to moderate exacerbations is less clear. 19 However, the totality of data suggests that for patients with moderate to severe exacerbations, antibiotics are effective in reducing relapse rates in COPD. 20 - Refer to Appendix B: Antibiotic Treatment Recommendations for Acute Exacerbations of COPD.

# Controversies in Care Cardiovascular Risk and Ipratropium
A small increase in cardiovascular events has been reported with the regular use of ipratropium in COPD patients. 1 However, this result has not been validated by a large randomized controlled trial (RCT) and further study is required. 21 

# Cardiovascular Risk and Tiotropium
One large, long-term clinical trial showed no evidence of cardiovascular risk when tiotropium was added to other standard therapies. 21 

# Mortality Risk and Tiotropium
A meta-analysis suggested that tiotropium delivered via the Respimat inhaler was associated with a significantly increased risk of mortality when compared to placebo. However, in a large RCT comparing tiotripium via Respimat to tiotropium via HandiHaler (dry powder inhaler), no differences in mortality or exacerbation rates were shown. 22 

# Use of Inhaled Corticosteroid
The effects of ICS on pulmonary and systemic inflammation in COPD remain controversial, 1 and the use of ICS in COPD management is limited to specific indications:
- ICS monotherapy has very modest effects on symptoms and exacerbations and its limited benefits are outweighed by potential adverse effects, including increased risk of pneumonia. As such, ICS monotherapy is not recommended. - Triple therapy of a LABA, ICS and a LAMA has limited evidence to suggest it improves lung function and quality of life. 1 However, triple combination may be useful for the management of patients with moderate to severe COPD who continue to experience repeated exacerbations despite use of LABA/LAMA combination therapy or who have been recently hospitalized with severe COPD exacerbation. 23 As such, triple therapy is recommended for this indication.

# Use of Methylxanthines
The exact physiologic benefits of methylxanthines (xanthine derivatives, such as theophylline) remain unknown. There is limited data on the duration of action for both conventional release and extended release xanthine preparations. In the studies that have shown efficacy of theophylline in COPD, extended release formulations were used. 1 The use of theophylline in select patients with persistent symptoms was recommended in the previous version of this guideline (2011), and continues to be recommended by a number of international guidelines. 1,6 However, a Cochrane Review recommended against the use of methylxanthines for COPD exacerbations given that the evidence of potential benefit was modest and inconsistent, while potential adverse effects were significant. 24 Use of Oral N-acetylcysteine (NAC)
The routine use of NAC in the management of COPD remains controversial due to conflicting evidence and methodological issues in the trials. 25 

# Indications for Referral
Refer patient to a specialist in cases where:
- the diagnosis is uncertain;
- a patient is < 40 years with COPD and limited smoking history, or has severe symptoms and disability which is disproportionate to their lung function; - there is evidence of an alpha-1 antitrypsin (A1AT) deficiency (e.g. early onset of emphysema or COPD, unexplained liver disease, family history); - there are signs and symptoms of hypoxemic or hypercarbic respiratory failure; - there are severe or recurrent exacerbations and treatment failure;
- the patient has severe COPD and disability requiring more intensive interventions;
- a more intensive comorbidity assessment and management is required; - a patient is frail and may benefit from multidisciplinary or comprehensive geriatric assessment, and/or - there is difficulty in assessing home oxygen or sleep disorders.
Family physicians and nurse practitioners in participating areas may consider contacting the Rapid Access to Consultative Expertise (RACE) phone line to speak directly with a specialist, including respirologists, or accessing referral services through PathwaysBC.ca. Refer to the Referral Resources section below.

# Ongoing Management
Follow-up Care Modify therapeutic goals and management plans as appropriate. Use routine follow-ups to ask about and monitor the patient's key clinical indicators, including:
- lung function;
- changes in symptoms (e.g. any improvement since starting/changing treatment; changes in level of breathlessness, activity level, sleep quality, etc.); - exacerbation history (frequency, severity) and review of the Flare-Up Action Plan (website: www2.gov.bc.ca/assets/gov/ health/practitioner-pro/bc-guidelines/copd_action_plan.pdf); - management of comorbidities (if present); and - pharmacologic therapy adherence and inhaler technique.

# Palliative Care
Making decisions about the intensity of palliative care is a highly individualized process and requires continuous review as COPD progresses. Once the decision to initiate palliative care is made, the goal of therapy is to manage symptoms, reduce treatment burden, and maximize comfort and quality of life. This may include providing support for the patient's family and caregivers. Consider referral to palliative care/hospice teams, if available.
Assess the need for home oxygen, non-pharmacologic therapies, and pharmacologic options for severe dyspnea (e.g., systemic opioids, anxiolytics).
For more information, refer to BCGuidelines.ca -Palliative Care for the Patient with Incurable Cancer or Advanced Disease and BC Pharmacare's Palliative Care Benefits Program (website: www2.gov.bc.ca/gov/content/health/practitioner-professionalresources/pharmacare/prescribers/plan-p-bc-palliative-care-benefits-program).

# Referral Resources - RACE -Rapid Access to Consultative Expertise Program
A telephone advice line from a selection of specialty services for general practitioners. - Pathways, pathwaysbc.ca An online resource that allows GPs and nurse practitioners and their office staff to quickly access current and accurate referral information, including wait times and areas of expertise, for specialists and specialty clinics. In addition, Pathways makes available hundreds of patient and physician resources that are categorized and searchable.

# Additional Resources
- BC Ministry of Health -Advance Care Planning, www.health.bc.ca In addition, each health authority also has an Advance Care Planning website.
- This guideline is based on scientific evidence current as of the effective date.
The guideline was developed by the Guidelines and Protocols Advisory Committee, approved by Doctors of BC and adopted by the Medical Services Commission.

# The principles of the Guidelines and Protocols Advisory Committee are to:
- encourage appropriate responses to common medical situations - recommend actions that are sufficient and efficient, neither excessive nor deficient - permit exceptions when justified by clinical circumstances

# Contact Information:
Guidelines and Protocols Advisory Committee PO Box 9642 STN PROV GOVT Victoria BC V8W 9P1 Email: hlth.guidelines@gov.bc.ca Website: www.BCGuidelines.ca