COPD Management Guidelines (2026 Updates)
COPD management can get complicated quickly—especially when you’re seeing a patient for the first time and trying to figure out where they are in their disease process, whether their current treatment makes sense, and what you need to address today.
In this episode, I walk through a practical approach to a routine COPD visit in primary care, including updates from the GOLD guidelines and how to apply them to patient care.
We’ll talk about confirming the COPD diagnosis with spirometry, assessing disease severity and symptoms, using the GOLD ABE framework, choosing initial inhaler therapy, and knowing when additional testing or pulmonology referral may be appropriate.
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What You'll Learn in This Episode:
How to confirm a COPD diagnosis and assess severity using spirometry, GOLD classification, and symptom scores
What to assess when seeing a patient with COPD for follow-up or establishing care
How to approach initial inhaler therapy, including LABA/LAMA therapy, ICS, and blood eosinophils
Key updates including alpha-1 antitrypsin deficiency testing and the GOLD ABE framework
What to monitor over time and when to consider imaging or pulmonology referral
Key Takeaways
Don't assume the COPD diagnosis is correct just because it's on the problem list. Look for prior post-bronchodilator spirometry confirming persistent airflow obstruction.
Assess both symptoms and exacerbation history—not just the patient's FEV1. Tools like the mMRC and CAT can help you understand how COPD is affecting their daily life and guide treatment decisions.
Before escalating inhalers, check the basics. Confirm what the patient is actually taking, whether they can access it, whether they're taking it consistently, and whether they're using the inhaler correctly.
Know when you need more information or more help. Alpha-1 antitrypsin testing, blood eosinophils, lung cancer screening eligibility, and indications for pulmonology referral are important to review as part of longitudinal COPD care.
Resources mentioned in this episode:
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COPD Management Updates
Introduction
00:00
Welcome to the Real World NP podcast, where we share practical clinical education, real world practice insights, and honest conversations to help nurse practitioners feel more confident, capable, and supported in practice.
Real World NP is an ANCC accredited continuing education company supporting nurse practitioners, schools, clinics, and fellowship programs in bridging the gap between graduate education and real world practice.
Welcome to this week's episode. Today's episode, I'm going to be talking about COPD management updates. There have been some guideline changes between 2025 and 2026, so I'm going to be going over the highlights of those to keep in mind in the context of a patient visit.
So before I get too far into this episode, I want to let you know that there is a cheat sheet that goes along with it inside of the Digital NP Binder. So you can find all this cheat sheet as well as a bunch of other ones inside the binder. It's at realworldnp.com/binder.
All of these are based off of the GOLD guidelines, and you can definitely check out the GOLD Pocket Guide as well for a quick reference.
COPD Management in Primary Care
01:03
So let's get into this topic. So the context here is that I'm thinking about whether or not you're going to a new job or you're a brand new grad. A lot of times we're going to be inheriting a patient either from transferring from another practice or from another provider.
So I'm going to be talking about this from the context of seeing a patient for the first time, whether or not they are your patient, you're covering for somebody else, they're a new patient to the practice.
We're talking about general COPD management. I'm not talking about exacerbations in this episode, but I will be making another one. So stay tuned about exacerbations.
So let's give some context. So you have a patient that's there for COPD follow up or establishing care, and they have a diagnosis of COPD. So what are the things we're going to look at? And then again, I'll talk about this is how we approach COPD, how I want you to think about approaching COPD, and then I'll bring in the highlights of what has changed.
Confirming a COPD Diagnosis With Spirometry
01:53
So first things first, we want to confirm that this person actually has COPD. And so the diagnostic criteria for COPD is an FEV1 to FVC ratio of less than 0.7. And so that's a spirometry test post bronchodilator.
And what we're looking at is the forced expiratory volume in the first second compared to the total amount of forced vital capacity that they have. And physiologically, if this is helpful to understand, hopefully that'll help you remember the 0.7.
So physiologically, what we expect in the normal range is somebody to be able to exhale 80% of their total vital capacity in the first second, and then the rest of their vital capacity is after that. And I believe this is about six seconds of expiration.
So for patients who have an FEV1 to FVC ratio of less than 0.7, so less than 70%, those patients are having obstruction of their exhalations, right? They're having this air trapping. And so that's the diagnostic criteria.
You may see some other things like, you know, dyspnea or coughing with purulent cough and exacerbations, but that is the main diagnostic criteria.
Pre-COPD and PRISm
03:01
Of note, in the new guidelines, I'm not really going to get into this, but in the way that we think about pre-diabetes and diabetes, there are some places where patients can have a kind of pre-COPD situation. I'm not going to get into this. Like I said in the video, it's called PRISm.
And so if you have somebody with spirometric testing that's like kind of borderline, just know that there is some evidence now in the GOLD guidelines, there is some guidance of like, well, you want to consider maybe starting to think about COPD treatment for those patients. So again, look at the guidelines for that. We're not going to talk a ton about that in this episode.
So, okay. So first things first, we're going to confirm that they have a diagnosis, which is also going to cue us to look at their last PFTs. So pulmonary function tests, you might have something as simple as spirometry, or you might have the full pulmonary function tests. Really for COPD, we're just looking at spirometry, but it's nice to see that we have the full thing. So we're going to look at those tests.
GOLD COPD Criteria and ABE Assessment
03:53
And then the way to think about COPD, which has not changed, and it's sort of similar to heart failure in that we're looking at this status of the disease process. And we're also looking at their symptomatic experience of heart failure. Right? So with heart failure, what is their EF? And then on that New York scale, what is their dyspnea level?
So, so switching back to COPD though, when we think about COPD, there's the GOLD criteria. So that has not changed, GOLD one to four. And what the GOLD criteria is looking at is what is their FEV1 percentage going from all the way from mild to severe. So one is mild and then four is very severe.
And that's really telling us how severe their illness is and how far progressed it is, and how much leeway we have in terms of their prognosis of exacerbations and hospitalizations, et cetera.
So hold that thought. So GOLD criteria.
The next thing we're going to assess, and this has changed in the context of the new guidelines, is it used to be A, B, C, D. What we're looking at is their symptomatology kind of syndrome by looking at three categories.
So one is E, makes it easy if they had an exacerbation in the last 12 months. Anybody in that category, regardless of their symptoms, gets to be in that category.
The next two categories are A and B, and the differentiators between those is that A is less symptoms and B is more symptoms.
mMRC and CAT Scores for COPD Symptoms
05:12
So the other thing that's mentioned in the guidelines is the symptomatology scale. So I love these. It makes our job so much easier and at least streamlined. And they're tools to help us assess their symptomatology.
So these, you can find on MDCalc for free. I'm not affiliated with MDCalc in any way. I just really appreciate their services.
So the two scoring things are going to be the mMRC and the CAT. So mMRC, I can't remember what that stands for, but the CAT is the COPD assessment tool. The mMRC is a little bit easier to use. It's just a couple of questions and they're looking at the symptomatology and you're getting a score.
And similarly with the CAT score, it's just a little bit more comprehensive.
And so when it comes to those A and B categories, A is going to be an mMRC of zero to one with a CAT score of less than 10, and there's been no exacerbations.
And then that B category is the mMRC is greater. So mMRC is greater than or equal to two, and the CAT is greater than or equal to 10.
You don't have to memorize those. They're in the guidelines. They're also in the cheat sheet that I made. So just know that it's just based on their symptomatology.
And we have a new assessment tool. It's newer. I don't know how new it is, but new to me. It's in the guidelines. So it's helpful to have.
COPD History and Follow-Up Assessment
06:23
So again, you have a patient that's coming to see you for the first time or you're meeting them for the first time. We're looking at their PFTs. When were they last done? What was their FEV1 to FVC ratio? What's their GOLD category and what is their symptomatology?
So that brings us into the history and part of the visit. So hopefully you can have them do the mMRC and the CAT to see where they're at in their illness process.
We're going to ask the same things as before. This hasn't really changed a lot. So we're going to ask about their symptomatology. Have they had any exacerbations? And if so, did they have steroids, antibiotics? Did they go to the ED? Did they have hospitalization?
Because that's going to help us understand the severity of the exacerbation, which we'll talk more about in the exacerbation episode.
The other things we want to ask about are what medications are they taking? How adherent are they to the medications? What barriers are they having?
It would be ideal to be able to have them bring their meds in and observe their technique, as well as asking about side effects, if they're having any adverse side effects to their medications.
And the technique I think is really important because when it comes to needing to escalate care, we want to make sure that they're able to have their meds, they're taking them as directed and they don't have any issues with the actual administration.
We also want to ask about their smoking and vaping status, as well as cessation, if that is applicable.
We also want to just check in on their comorbidities. So do they have cardiovascular disease? Do they have sleep apnea, things like depression and anxiety that can definitely go along with COPD? And then do they have any oxygen use?
Alpha-1 Antitrypsin Deficiency Testing in COPD
07:50
So a newer thing that comes next that's tied into this history that is from the guidelines is one, testing for alpha-1 antitrypsin deficiency.
So there used to be criteria that you had to meet to be able to qualify for that testing, but now it's recommended in everybody who has COPD.
And the rationale for that is that if we detect that, then patients can get treatment and support from pulmonology.
So that is the directive for us in primary care is to make sure that they've had a one-time test for that and referring out if it is low and if it's borderline, considering rechecking and just making sure that we're not missing that.
Eosinophil Count and Inhaled Corticosteroids in COPD
08:26
The other one is looking at the eosinophil count. So if you're not familiar with eosinophils and you need support with CBC interpretation, we have the CBC interpretation course for that in the lab series.
However, eosinophils, as you may or may not know, is associated with a number of different things, but predominantly it can happen in inflammatory conditions.
So, and patients who have asthma or other sort of reactive illnesses can have elevated eosinophils. And what they found from the research is that patients who have an eosinophil count of greater than 300 may benefit from inhaled corticosteroid treatment.
So that is your kind of new directive, that is our new directive, is to make sure we've done a one-time screening for alpha-1 antitrypsin deficiency.
And then when it comes to their follow-up and management, do they, how is their eosinophil count?
There is some benefit shown for patients who have an eosinophil count of 100 to 300 of potentially considering an ICS, but we'll talk about that more in a second when I touch on treatment principles.
One note about eosinophils is that the CBC in particular can be a very finicky test in that it's very labile and it can change a lot from day to day. So you may have an eosinophil count that's a little bit borderline today and it might be elevated the next time. Just keeping that in mind, the variability and using your clinical judgment.
COPD Management: Beyond Inhalers
09:37
So let's talk about management principles. And a lot of these are unchanged, but we'll talk about the medication selection and general principles about that.
But it's not just about medications.
I want you to remember that the core of COPD management is actually like the inhaler therapies are important for symptom management. And also those are not really the things that are going to move the needle in terms of their prognosis and in terms of making an impact on their disease process.
So they are important to know, but it's also really important to touch on these other things that I'm going to talk about.
So one is smoking cessation. That is the most important thing and using those five A's of discussion. If you aren't familiar with that, you can just Google that one, but you know, asking to talk about it, advising them to quit. I'm not going to remember the rest of them off the top of my head, but that is a really helpful tool to use when having those conversations about smoking cessation and getting familiar with the smoking cessation tools that we have.
Vaccinations, those are extremely important. And so those schedules can change from the CDC, but things like influenza, COVID-19, pneumococcal, RSV as indicated, Tdap and Zoster. Again, looking at the CDC recommendations, the ACIP recommendations for vaccinations as they change.
We're going to talk about exercise, diet, and weight management. So if patients have comorbid sleep apnea, we want to make sure that we're managing that as well.
There's different kind of phenotypes of how COPD patients present. And sometimes it's about they're too breathless to eat and then they're losing muscle mass. We want to worry about sarcopenia.
And then on another side, we have like a need for weight management because it's contributing to their sleep apnea, for example. So just keeping in mind what's going on with your patient and how can we support them the best.
Pulmonary Rehabilitation and COPD Comorbidities
11:15
Pulmonary rehab does exist. It is not as accessible sometimes as like a cardiovascular rehab.
And so maybe just a kind of real world pearl of practice. If you have somebody with a cardiovascular comorbidity, you may more likely be able to send them to a cardiovascular rehab, but lots of different anecdotal experience about sending patients to pulmonary rehab.
And then again, managing their comorbidities.
COPD Medications: SABA, SAMA, LABA, LAMA, and ICS
11:37
But let's talk a little bit about the medication, the general principles.
So the main bread and butter of COPD medication therapy, again, this is more symptomatology that allows them to do the things in their daily life that they need to do, functional ADLs, as well as exercise and just take care of their basic needs and enjoy their life.
So we have SABAs, SAMAs, LABAs, LAMAs, and ICS. Those are the core pieces.
So short acting beta agonist, short acting muscarinic antagonist slash anticholinergics. Those are the SABAs and SAMAs.
LABAs and LAMAs are those long acting beta agonists, as well as long acting muscarinic antagonists.
And then the last one is inhaled corticosteroid therapy.
Initial COPD Treatment by GOLD ABE Group
12:21
So if we go back to the GOLD and the ABE assessment tool, let's just focus on ABE for a second.
So for anybody who has exacerbations should be on a LABA and a LAMA together, the dual therapy.
And so those are medications like tiotropium, and I'm going to struggle to pronounce these, my apologies. Tiotropium, aclidinium, umeclidinium, glycopyrrolate, and revefenacin. Those are examples, not comprehensive.
And then LABAs are things like salmeterol, formoterol, et cetera.
And so that is the recommended initial therapy for those patients.
For patients who also have two or more moderate exacerbations per year, their blood eosinophils are greater than 300, or they have a history of asthma and, or, um, those patients recommended to consider an ICS using your clinical judgment.
You can consider using an inhaled corticosteroid in, um, patients with one moderate exacerbation per year, and potentially if their eosinophils are between 100 and 300.
We definitely want to avoid inhaled corticosteroids for a couple of reasons, though, if patients have repeated pneumonia, eosinophils less than 100 is not shown to be beneficial, or if they have a history of mycobacterial infection.
Those are reasons not to use an ICS.
And then, so, so that's exacerbations, that's the initial treatment. And then the GOLD guidelines go into a lot of places to escalate from there.
I, I'm really just going to touch on the initial treatment for all the categories, and then you can consult the guidelines for the further medication titration from there.
Initial Treatment for GOLD Groups A and B
13:50
But in the A category, the low symptomatology, the mMRC of zero to one, and the CAT of less than 10, bronchodilators are recommended.
We always want to make sure everybody has a short acting one in addition to the long acting, but for that A category, you can have either the short acting or the long acting for those patients.
For the B category, we're still going to do the LABA and the LAMA.
So basically the E and the B are very similar, plus or minus the inhaled corticosteroid with the eosinophils, history of asthma, or those multiple exacerbations that are happening.
And again, these are all initial treatments.
And so if you have a patient who's on these medications and they're still like, their symptoms are still severe or they're worsening or they're having exacerbations, then we want to look at the guidelines to kind of look at those treatment protocol next steps.
COPD Follow-Up and Spirometry
14:35
So last thing I just want to wrap up with is what is our follow-up care for these patients?
So we want to make sure that their symptoms are well managed. And so we want to see them at least annually using your clinical judgment of do we want to do, especially if we're changing medications, is it three month follow-up? Is it six months follow-up? Do we need a shorter range of follow-up because we're teaching them how to use inhalers for the first time, et cetera.
We want to make sure that we're doing spirometry at least annually to check in on their GOLD criteria and their disease process.
Chest Imaging and Lung Cancer Screening in COPD
15:04
When it comes to CT and chest imaging, this is not a standard part of care for COPD management.
However, we want to think about low dose CT screening for patients who are in the ages of 50 to 80 and have smoked for greater than or equal to 20 pack years and they currently smoke or if they quit less than 15 years ago.
But we can consider doing more imaging if they have things like unexplained worsening of their COPD, abnormal chest X-rays, their symptoms are disproportionate to what we'd expect of their disease process.
They have these recurrent exacerbations or infections, or if you have something like suspected bronchiectasis, which a little bit of an uncommon diagnosis, but if they have recurrent superior sputum, potentially something to consider.
I can get more into that if that would be helpful, but I'll leave it at that for now.
When to Refer a Patient With COPD to Pulmonology
15:46
And then we want to collaborate with pulmonology and refer to them as needed.
If we had that alpha-1 antitrypsin deficiency suspicion, we have diagnostic uncertainty, do they have something like bronchiectasis or something else going on?
Their disease is severe or progressive. They're having frequent exacerbations despite optimizing their therapy. If they need oxygen or if there are other advanced therapies that are outside of the kind of bread and butter of what we should be doing in primary care.
Conclusion
16:14
So hopefully this is a helpful overview. Like I said, I put this all into a cheat sheet for quick reference to hopefully keep it in the front of your mind. That'll be inside the Digital NP Binder at realworldnp.com/binder.
But yeah, that's it for this episode. So stay tuned for the COPD exacerbation episode. That'll be coming up soon.
Thanks for spending this time with us on the Real World NP podcast. We're so glad you're here.
If you haven't grabbed your copy of the Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. To explore courses, resources, and more, you can also find that all at realworldnp.com.
Until next time, take care.
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