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pulm.copd.core.v1

COPD (chronic GOLD ABE + exacerbation)

pulmonologychronicacuteadultoutpatientacuteinpatienttransition
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GOLD 2026 ABE CORRECTION (2026-05-24): Group E threshold lowered to ≥1 moderate OR ≥1 severe/hospitalised exacerbation (was ≥2 moderate / ≥1 hospitalisation); Groups A/B now require ZERO exacerbations in the prior 12 months. Updated across the frequent_exacerbations entry point, RISK_STRATIFICATION purpose, gold_abe_stepwise labels/applies_when/step_up_when, and the outpatient setting playbook triggers. Source: GOLD 2026 report + "Rethinking GOLD E: The Significance of a Single Moderate Exacerbation" (PMID 41690854 — live-verify in PMID pass). GOLD 2026 RECONCILIATION (2026-05-24): chapter citations converted to topic-based references (Diagnosis / Assessment / Pharmacotherapy / Follow-up & Prevention / Exacerbations / Multimorbidity); GOLD 2026 confirmed Exacerbations and Multimorbidity as distinct chapters (Healio/GOLD 2026) — exact chapter numbers not asserted pending the primary PDF. Conceptual updates: disease-activity goal added (low disease-activity state = no exacerbations, no symptom worsening, no accelerated lung-function loss); RSV vaccine age raised to 50+ (from 60+); GINA sibling/ACO references advanced to the 2026 strategy report. HFNO deliberately NOT added to exacerbation management (not found in the GOLD 2026 exacerbation chapter per Healio — anti-fabrication). PMID LIVE RE-VERIFICATION (2026-05-24): all 21 prior evidence PMIDs re-confirmed via PubMed esummary (title + journal match the claimed trial for every one — UPLIFT/FLAME/IMPACT/ETHOS/BOREAS/NOTUS/MATINEE/WISDOM/Calverley/Albert/REDUCE/Anthonisen/Austin/Plant/Seemungal/Puhan/NOTT/MRC/HOT-HMV/REACT/ENHANCE); zero wrong-article codes. Added 41690854 (Rethinking GOLD E, Arch Bronconeumol 2026) as the ABE-E change citation; last_reconciled advanced to 2026-05-24. CHRONIC DEPTH-PASS-2 (2026-05-16): additive deepening — preserved working GOLD ABE regimen_axes (A/B/E steps) and all four setting_playbooks (outpatient/ED/inpatient/ICU) incl. NIV pH 7.25–7.35 / intubation pH <7.25 thresholds; added Bayesian/differential-as-data, special-population matrix, and PMID-verified evidence. PMID AUDIT: prior evidence.pmids had 11/14 wrong-article codes (e.g. 29668288=phys-chem, 37272562=carvedilol PK, 23900119=Swaziland anaemia, 3491997=endothelial cells) + a wrong-engine POINT filler (29766750). Rebuilt to 20 PubMed-verified PMIDs (get_article_metadata 2026-05-16); POINT culled. Full audit: _briefs/pulm.copd.core.v1.depth.md §1. §5.5.2 differential as data: COPD vs asthma/ACO vs HF vs bronchiectasis vs ILD/IPF vs lung cancer (chronic) and infective vs PE vs HF vs CAP vs pneumothorax (exacerbation) — wired via severity_triggers (differential_copd_vs_mimics, differential_acute_decompensation, eos_threshold_ics_decision), DIFFERENTIAL/RISK_STRATIFICATION phase logic, copd_exacerbation workup branches_to, and 5 sibling_differentiation blocks. Cross-dossier engine_ids (7, all real): pulm.asthma.core.v1, cardio.acute-hf.core.v1, pulm.idiopathic_pulmonary_fibrosis.v1, onc.lung-cancer.core.v1, pulm.cap.core.v1, pulm.pe.core.v1, pulm.pneumothorax.core.v1. Eosinophil-threshold → ICS-benefit calculator→threshold→action chain (eos_threshold_ics_decision): ≥300 add ICS/triple + biologic-eligible (BOREAS 37272521 RR≈0.70, NOTUS 38767614 RR≈0.66, MATINEE 40305712); <100 withhold/withdraw ICS (FLAME pneumonia 4.8% vs 3.2% P=0.02 PMID 27181606; WISDOM noninferior 25196117). Regimen-builder template (project_medication_regimen_builder.md): ≥8 special-population branches as DATA (RegimenDrug.triggers + contraindication_rules) — eos-guided ICS, asthma-COPD overlap, frequent-exacerbator (roflumilast/azithromycin), renal (no inhaler adjust; comorbid abx/theophylline), cardiac (cardioselective BB NOT contraindicated — mortality benefit; non-selective caution), ICS-pneumonia-risk, ICS deprescribing (eos<100+no asthma+low exac — WISDOM), pregnancy (continue ICS/LABA, avoid roflumilast). ≥15 effect-size numbers (delivered 20) PMID-anchored in regimen rationale + monitoring + depth.md §3: FLAME RR 0.89 / pneumonia 3.2%v4.8% (27181606), IMPACT mortality (29668352), ETHOS mortality (32579807), BOREAS RR≈0.70 (37272521), NOTUS RR≈0.66 (38767614), MATINEE (40305712), Albert HR 0.73 (21864166), Calverley ~17% (19716961), UPLIFT FEV1 +47–65 mL (18836213), REDUCE noninferior (23695200), Austin RR~0.42 (20959284), Plant mortality 10%v20% (10859037), NOTT 1.94× (6776858), MRC 19/42 v 30/45 (6110912), HOT-HMV HR 0.49 (28528348), Puhan readmit OR 0.44 (27930803), Seemungal SGRQ +14.8 (9603117), WISDOM FEV1 −38 mL (25196117). mMRC/CAT/BODE calculators now wired (resolve in clinical-tools-registry by id); copd_exacerbation workup resolves via registry adapter_id. RxCUIs preserved (additive): dupilumab/mepolizumab/roflumilast/azithromycin/oxygen are correct ingredient CUIs; combination-inhaler CUIs RxNav-validated to generic SCD codes (2026-05-24): tiotropium-olodaterol 1651274, umeclidinium-vilanterol 1487527, fluticasone-umeclidinium-vilanterol 1945047, budesonide-glycopyrrolate-formoterol 2387329, budesonide-formoterol 1246304; all single ingredients (roflumilast 1091836, mepolizumab 1720597, dupilumab 1876376, azithromycin 18631, ensifentrine 2687215, tiotropium 69120, oxygen 7806) RxNav TTY=IN confirmed. SCHEMA-GAP NOTES: (1) _types.ts has no first-class Bayesian-LR / decision-threshold / conditional-dependency / special-population-matrix / effect-size field — encoded in severity_triggers, phase purpose/advance_when, calculator guideline_basis, regimen rationale/triggers/contraindication_rules, and depth.md tables; (2) RequiredCalculator.drives enum lacks diagnostic_gate — mMRC/CAT/BODE reuse severity_classification/risk_stratification. STATUS (2026-05-24 perfection pass): (1) all combination-inhaler RxCUIs RESOLVED to RxNav-validated generic SCD codes (no base-ingredient codes remain); (2) engine-specific test file still pending (currently uses tests/dossiers/dossier-contract.test.ts) — to be added with the copd-phenotype service. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template contract mirror of cardio.htn.core.v1): added (1) co-located src/lib/dossiers/pulm.copd.core.v1._research-bundle.md + ._design-brief.md per §5.5 items 1+2 (21 PubMed-verified PMIDs w/ effect sizes + 95% CI, retrieval 2026-05-16, dose-effect anchors w/ FEV1 mL + exac RR + mortality HR, RxCUI RxNav-REST log, Consensus→WebSearch/RxNav fallback log, pre-test priors w/ cohort sources, T_test≈2%/T_treat≈30% + eos chain thresholds, cross-dossier routing); design_brief: pointer repointed to the co-located brief. (2) prisma/seed/ros-and-ddx/pulm.copd.core.v1.{differentials,ros,finding-lrs}.ts (NEW, mirroring htn seed shapes exactly, ENGINE_ID pulm.copd.core.v1): 14 differentials w/ cohort-anchored priors (COPD vs asthma vs ACO vs HF vs bronchiectasis vs ILD vs PE vs deconditioning vs α1-AT vs lung cancer + 5 phenotype severities), 13 ROS, 38 LR rows (24 LR+ / 16 LR− incl. post-BD FEV1/FVC<0.70 LR+ 12, blood-eos≥300 LR+ 6 / eos<100 LR− 2.5, DLCO, NT-proBNP, BDR≥12%+200 mL, HRCT, AAT), 3 conditional-dependency rules (eos|post-BD-spirometry-confirms-COPD precondition; post-BD supersedes pre-BD FEV1/FVC; BDR|adequate-technique+washout). (3) 2nd regimen axis copd_phenotype_matrix (drug × phenotype gating as DATA: eosinophilic/frequent-exacerbator/ACO/HF-overlap/renal-hepatic/deprescribing/pregnancy/ensifentrine-add-on; 9 drugs, 7 contraindication rules, 6 monitoring). (4) Evidence refresh: MATINEE effect size corrected to verified RR 0.79 (95% CI 0.66–0.94, P=0.01) + HR 0.77 (0.64–0.93); REACT 25684586 + ENHANCE 37364283 added to evidence.pmids (→22); GOLD 2026 ABE (not ABCD) confirmed current via WebSearch; all 21 anchor PMIDs re-verified via PubMed get_article_metadata 2026-05-16; all RxCUIs RxNav-REST-confirmed valid ingredient codes (no hand-authored CUIs; combination components documented in research bundle §3/§4). DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at pulm.copd.core.v1._depth-pass-3.md.

Entry points (5)

  • symptom
    Chronic dyspnea, productive cough, chest tightness in smoker/ex-smoker (GOLD 2026 Diagnosis)
    chronic_dyspnea_cough
  • symptom
    Acute exacerbation: increased dyspnea + sputum volume + purulence (Anthonisen 1987)
    acute_exacerbation
  • lab_abnormality
    Post-bronchodilator FEV1/FVC <0.70 (GOLD 2026 diagnostic criterion)
    fev1_fvc_low_postbd
  • problem_list
    Existing COPD — annual review or post-exacerbation visit (GOLD 2026 Follow-up & Prevention)
    copd_existing
  • history
    ≥1 moderate exacerbation OR ≥1 hospitalisation in last 12 months → GOLD 2026 Group E (high exacerbation risk; 2026 threshold lowered from ≥2 moderate)
    frequent_exacerbations

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Risk factor + alpha-1 antitrypsin testing threshold (<45); GOLD 2026 Diagnosis
  • smoking_pack_yearsrequired
    history • used at CONTEXT
    Primary risk factor; exposure quantification (GOLD 2026 Diagnosis)
  • exacerbations_12morequired
    history • used at CONTEXT
    GOLD 2026 ABE classification + escalation threshold
  • mmrc_or_catrequired
    history • used at CONTEXT
    Symptom burden — drives ABE group A vs B (GOLD 2026 Assessment)
  • sputum_changerequired
    history • used at CONTEXT
    Anthonisen 1987 criteria (volume + purulence) — antibiotic decision
  • pseudomonas_riskrequired
    history • used at TREATMENT
    Recent hosp / FEV1 <50 / prior Pseudomonas / bronchiectasis / frequent abx → antipseudomonal coverage (GOLD 2026 Exacerbations)
  • blood_eosrequired
    lab • used at INITIAL_WORKUP
    Eos-guided ICS-benefit decision chain per GOLD 2026 (≥300 → add ICS/triple + biologic-eligible; <100 → withhold/withdraw ICS — pneumonia risk); dupilumab eligibility (BOREAS PMID 37272521, NOTUS PMID 38767614); mepolizumab (MATINEE PMID 40305712)
  • spirometryrequired
    imaging • used at INITIAL_WORKUP
    Post-bronchodilator FEV1/FVC <0.70 confirms diagnosis (GOLD 2026 Diagnosis); FEV1 % predicted grades severity per ATS/ERS 2004
  • last_spirometry_date
    imaging • used at RISK_STRATIFICATION
    PFT recency gate — GOLD recommends ≥annual spirometry; if post-BD spirometry is absent or >12 months old, reassess lung function BEFORE stepping therapy up or down (ABE/phenotype on stale data is low-confidence)
  • alpha1_antitrypsin
    lab • used at INITIAL_WORKUP
    AAT deficiency screen at least once per GOLD 2026 (especially <45 or family history)
  • spo2required
    vital • used at CONTEXT
    Hypoxia gating LTOT eligibility (resting SpO2 ≤88% per NOTT 1980); titration target 88–92% in exacerbation (Austin 2010)
  • rrrequired
    vital • used at CONTEXT
    Acute respiratory failure assessment; RR >25 triggers NIV per Plant 2000
  • vbg_or_abg
    lab • used at RED_FLAGS
    pH <7.35 + PaCO2 >45 → NIV indication (Plant 2000); pH <7.25 → intubation
  • cxr
    imaging • used at INITIAL_WORKUP
    Exclude alternative diagnoses + complications (pneumonia, pneumothorax, PE); GOLD 2026 Exacerbations
  • current_medsrequired
    medication • used at CONTEXT
    Current inhaler regimen for stepwise titration per GOLD 2026; flag ICS-withdrawal candidates if eos <100 + no asthma + low exac burden (WISDOM, Magnussen NEJM 2014 PMID 25196117)
  • sputum_culture
    lab • used at INITIAL_WORKUP
    Inpatient + repeat antibiotic / Pseudomonas history → guide therapy (GOLD 2026 Exacerbations)

12-phase flow (12)

  1. 1FRAME
    Confirm fixed airflow obstruction (post-BD FEV1/FVC <0.70 per GOLD 2026) + appropriate exposure history; manage toward the GOLD 2026 disease-activity goal (low disease-activity state)
    inputs: spirometry
    advance: Diagnosis confirmed
  2. 2ENTRY
    Triggered by chronic symptoms, abnormal spirometry, or acute exacerbation per GOLD 2026 Assessment
    inputs: age
    advance: Entry trigger identified
  3. 3CONTEXT
    Smoking, exposures, exacerbations 12mo, mMRC/CAT, comorbidities (CV, lung cancer, anxiety/depression, OSA, osteoporosis), inhaler technique, sputum change pattern per GOLD 2026 Assessment–3
    inputs: smoking_pack_years, exacerbations_12mo, mmrc_or_cat, spo2, rr, current_meds, sputum_change, pseudomonas_risk
    advance: Symptom burden + exposures + comorbidity sweep complete
  4. 4RED_FLAGS
    Acute respiratory failure (pH <7.35 per Plant 2000), pneumothorax, PE, ACS, decompensated cor pulmonale, AMS
    inputs: spo2, rr, vbg_or_abg
    actions: copd_exacerbation
    advance: No emergent escalation needed OR acute pathway initiated
  5. 5INITIAL_WORKUP
    Spirometry post-BD, eosinophils, AAT (once per GOLD 2026), CXR, ECG; sputum culture if inpatient + recent abx; consider DLCO + 6MWT in advanced disease
    inputs: spirometry, blood_eos, cxr, alpha1_antitrypsin
    actions: copd_exacerbation
    advance: Phenotype data complete
  6. 6BRANCHING_WORKUP
    CT chest if cancer/bronchiectasis suspected; D-dimer / CTPA if PE concern; troponin if ACS overlap; echo if cor pulmonale; rule out pneumonia and pneumothorax per GOLD 2026 Exacerbations
    advance: Mimics excluded
  7. 7DIFFERENTIAL
    §5.5.2 differential as data — COPD vs asthma/ACO (pivot: post-BD FEV1/FVC fixed <0.70 specific for COPD; BDR ≥12%+200 mL + early-onset + eosinophilia → asthma/ACO) vs HF (NT-proBNP <125 high NPV; echo EF/diastology; BNP↑↑ favors HF → cardio.acute-hf.core.v1) vs bronchiectasis (HRCT signet-ring/tram-track; chronic mucopurulent sputum; raises Pseudomonas risk) vs ILD/IPF (restrictive FEV1/FVC normal-high + ↓FVC + ↓DLCO + reticular HRCT → pulm.idiopathic_pulmonary_fibrosis.v1) vs lung cancer (CT mass/weight loss/hemoptysis → onc.lung-cancer.core.v1) per GOLD 2026 Diagnosis; alpha-1 phenotype (AAT <11 µmol/L); exacerbation phenotype (bacterial — Anthonisen purulence / viral / eosinophilic — blood eos / non-infective)
    inputs: spirometry, blood_eos, alpha1_antitrypsin
    advance: Phenotype assigned + competing dx (HF/bronchiectasis/ILD/cancer) excluded or routed
  8. 8RISK_STRATIFICATION
    GOLD 2026 ABE classification (A: low symptoms mMRC 0–1/CAT <10 + 0 exacerbations; B: high symptoms mMRC ≥2/CAT ≥10 + 0 exacerbations; E: ≥1 moderate or ≥1 severe/hospitalised exacerbation — 2026 threshold lowered from ≥2 moderate) via mMRC/CAT; BODE index for 4-yr survival in advanced disease (informs LVRS/transplant/palliative); blood eos ≥300 → ICS/biologic-eligible, <100 → ICS-deprescribe candidate; LTOT eligibility resting SpO2 ≤88% per NOTT 1980 (PMID 6776858)/MRC 1981 (PMID 6110912)
    inputs: mmrc_or_cat, exacerbations_12mo, blood_eos, spo2
    actions: calc.mmrc, calc.cat, calc.bode
    advance: ABE group + eosinophil ICS-decision + LTOT/biologic candidacy assessed
  9. 9TREATMENT
    GOLD 2026: A → bronchodilator; B → LABA-LAMA; E → LABA-LAMA-ICS triple if eos ≥300 or asthma history; biologic (dupilumab if eos ≥300, mepolizumab in eosinophilic) for refractory; smoking cessation, vaccines, pulmonary rehab, LTOT if SpO2 ≤88, NIV in chronic hypercapnia. Acute: O2 to 88–92%, neb SABA + SAMA, prednisone 40 × 5 d (REDUCE), antibiotics if Anthonisen ≥2 + purulence or mech vent, NIV if pH 7.25–7.35, intubation if pH <7.25
    inputs: blood_eos, spo2, sputum_change, pseudomonas_risk
    advance: GOLD-aligned regimen + non-pharm interventions documented
  10. 10DISPOSITION
    Acute: ED vs ward vs ICU based on respiratory failure / hypercapnia / response per GOLD 2026 Exacerbations; chronic: scheduled review cadence
    advance: Disposition set
  11. 11MONITORING
    Annual spirometry per GOLD 2026 Follow-up & Prevention, exacerbation diary, inhaler technique audit, symptom score, LTOT compliance, biologic response at 4 months; track toward the GOLD 2026 disease-activity goal (no exacerbations, no symptom worsening, no accelerated FEV1 loss). Acute: VBG q1-2h on NIV (Plant 2000); SpO2 continuous; lactate if shock
    advance: Annual review + technique audit scheduled
  12. 12FOLLOWUP
    Vaccinations (flu, pneumococcal PCV20 or PCV15+PPSV23, RSV, COVID, Tdap), smoking cessation reinforcement, pulmonary rehab within 3 weeks of discharge (Puhan 2016), advance care planning, follow-up clinic visit in 7 days post-exacerbation (Seemungal 2000)
    advance: Prevention bundle and rehab referral complete