Obstructive

COPD: Diagnosis, Staging & Management

Added by Dr. Andrew · Last updated 2024-01-15

Overview

COPD is a common, preventable, and treatable disease characterized by persistent airflow limitation due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases (primarily cigarette smoke). GOLD 2024 guidelines provide the current framework.

Key Points

1Diagnosis: post-bronchodilator FEV1/FVC <0.70 (spirometry required)
2GOLD staging: GOLD 1 (FEV1 ≥80%), GOLD 2 (50–79%), GOLD 3 (30–49%), GOLD 4 (<30%)
3GOLD ABCD assessment: symptoms (mMRC/CAT) + exacerbation history
4Pharmacotherapy: SABA/SAMA for mild; LABA+LAMA for moderate-severe; add ICS if eos ≥300 or frequent exacerbations
5Smoking cessation: most important intervention to slow progression
6LTOT: PaO₂ ≤55 or SaO₂ ≤88% at rest (or PaO₂ 56–59 with cor pulmonale/polycythemia)

Clinical Pearls

LAMA > LABA for exacerbation prevention (SPARK trial)
Triple therapy (LABA+LAMA+ICS) reduces exacerbations and mortality in high-risk patients (IMPACT trial)
Roflumilast (PDE4 inhibitor): add for GOLD 3-4 with chronic bronchitis and frequent exacerbations
Azithromycin 250 mg daily reduces exacerbations in former smokers (Albert et al.)

Board High-Yield

Exam Focus

TORCH: salmeterol+fluticasone reduced exacerbations; mortality trend not significant
UPLIFT: tiotropium reduced exacerbations and improved QoL but did not modify FEV1 decline
IMPACT: triple therapy (FF/UMEC/VI) reduced exacerbations vs dual therapy
LTOT criteria: PaO₂ ≤55 at rest OR ≤59 with cor pulmonale/polycythemia
Acute exacerbation: BiPAP for hypercapnic RF, systemic steroids 5 days (REDUCE trial), antibiotics if purulent sputum

ABIM Exam Weight

17.5%

Obstructive Lung Disease represents approximately 17.5% of the PCCM certification exam.