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pulm.copd.core.v1PRODUCTION
pulm.copd.core.v1

COPD (chronic GOLD ABE + exacerbation)

pulmonologychronicacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Diagnosis confirmed

Patient inputs (16)

Risk factor + alpha-1 antitrypsin testing threshold (<45); GOLD 2026 Diagnosis

Primary risk factor; exposure quantification (GOLD 2026 Diagnosis)

GOLD 2026 ABE classification + escalation threshold

Symptom burden — drives ABE group A vs B (GOLD 2026 Assessment)

Anthonisen 1987 criteria (volume + purulence) — antibiotic decision

Hypoxia gating LTOT eligibility (resting SpO2 ≤88% per NOTT 1980); titration target 88–92% in exacerbation (Austin 2010)

Acute respiratory failure assessment; RR >25 triggers NIV per Plant 2000

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)

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)

Post-bronchodilator FEV1/FVC <0.70 confirms diagnosis (GOLD 2026 Diagnosis); FEV1 % predicted grades severity per ATS/ERS 2004

Recent hosp / FEV1 <50 / prior Pseudomonas / bronchiectasis / frequent abx → antipseudomonal coverage (GOLD 2026 Exacerbations)

AAT deficiency screen at least once per GOLD 2026 (especially <45 or family history)

Exclude alternative diagnoses + complications (pneumonia, pneumothorax, PE); GOLD 2026 Exacerbations

Inpatient + repeat antibiotic / Pseudomonas history → guide therapy (GOLD 2026 Exacerbations)

pH <7.35 + PaCO2 >45 → NIV indication (Plant 2000); pH <7.25 → intubation

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)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningNIV_failure_or_pH_under_7.25
    pH <7.25 OR no improvement in pH after 1–2 h of NIV (Plant 2000)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaltered_mental_status_in_copd
    AMS in COPD exacerbation — CO2 narcosis OR hypoxic encephalopathy (GOLD 2026 Exacerbations)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretype2_respiratory_failure
    pH 7.25–7.35 + PaCO2 >45 + RR >25 + dyspnoea (Plant 2000 NIV criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredifferential_acute_decompensation
    Acute decompensation in known COPD — is it AECOPD or a mimic? §5.5.2 exacerbation differential: infective (Anthonisen ≥2 + purulence) vs PE (disproportionate hypoxia, no sputum change → D-dimer/CTPA) vs decompensated HF (orthopnea/JVD/NT-proBNP↑↑/echo) vs CAP (lobar consolidation CXR, CURB-65) vs pneumothorax (sudden pleuritic + ↓breath sounds, CXR/POCUS — bullous COPD high SSP risk) (GOLD 2026 Exacerbations)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanthonisen_2_or_more_with_purulence
    Increased dyspnoea + sputum volume + sputum purulence — ≥2 of 3 cardinal symptoms with purulence required (Anthonisen 1987)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepseudomonas_risk_pattern
    FEV1 <50% AND (recent hospitalisation OR prior Pseudomonas isolation OR bronchiectasis OR frequent antibiotics) per GOLD 2026 Exacerbations
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeos_>=300_persistent_exac
    Blood eosinophils ≥300 cells/µL with persistent exacerbations on triple therapy (GOLD 2026 Pharmacotherapy; BOREAS, Bhatt NEJM 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespo2_under_88_resting_chronic
    Resting SpO2 ≤88% on RA in stable COPD — chronic outpatient (NOTT 1980 PMID 6776858; MRC 1981 PMID 6110912)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeos_threshold_ics_decision
    Blood eosinophil count drives the ICS-benefit decision chain: ≥300 cells/µL → add ICS to LABA-LAMA (triple) + biologic-eligible; 100–299 + frequent exac → consider ICS; <100 → withhold/withdraw ICS (minimal benefit + pneumonia risk) (GOLD 2026 Pharmacotherapy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_copd_vs_mimics
    Chronic dyspnea/cough not clearly COPD — §5.5.2 pivots: post-BD FEV1/FVC <0.70 (specific for COPD, asthma reverses); BDR ≥12%+200 mL + early-onset + eosinophilia → asthma/ACO; NT-proBNP↑↑ + echo LV dysfunction → HF; HRCT signet-ring/tram-track → bronchiectasis; restrictive spirometry + ↓DLCO + reticular HRCT → ILD/IPF; CT mass + weight loss/hemoptysis → lung cancer (GOLD 2026 Diagnosis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepft_recency
    Post-bronchodilator spirometry is absent or >12 months old in a patient being assessed for a COPD therapy change (GOLD recommends at least annual spirometry)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

GOLD 2026 ABE stepwise — chronic outpatient
axis: gold_abe_stepwisestep A - GOLD 2026 Group A — low symptoms + 0 exacerbations/yr
Selected step "GOLD 2026 Group A — low symptoms + 0 exacerbations/yr" — mMRC 0–1 OR CAT <10, AND ZERO moderate or severe exacerbations in the last 12 months per GOLD 2026 ABE
  • tiotropium OR salbutamol PRN
    first line
    LAMA_or_SABA
    Tiotropium 18 µg HandiHaler OR 2.5 µg Respimat 2 puffs daily; albuterol 100 µg 2 puffs PRN • inhaled • once daily LAMA OR PRN SABA
    GOLD 2026 Group A — long-acting bronchodilator preferred (UPLIFT, Tashkin NEJM 2008); PRN SABA acceptable for occasional symptoms
    rxcui 69120

outpatient playbook — drug actions (6)

  1. 1. Group A: tiotropium OR PRN SABA
    Tiotropium 2.5 µg Respimat 2 puffs daily OR albuterol 100 µg 2 puffs PRN • inhaled • once daily / PRN
    trigger: mMRC 0–1, CAT <10, 0 exac/yr
    GOLD A
  2. 2. Group B: tiotropium-olodaterol
    5/5 µg Respimat 2 puffs • inhaled • once daily
    trigger: mMRC ≥2 OR CAT ≥10
    GOLD B — FLAME
  3. 3. Group E: triple ICS-LABA-LAMA
    Fluticasone-umeclidinium-vilanterol 100/62.5/25 µg Ellipta 1 inh daily OR budesonide-glycopyrrolate-formoterol 160/9/4.8 µg MDI 2 puffs BID • inhaled • daily / BID
    trigger: ≥1 mod exac/yr OR ≥1 hosp; eos ≥300 OR asthma history
    IMPACT + ETHOS
  4. 4. add-on biologic (dupilumab / mepolizumab)
    Dupilumab 300 mg SC q2w; mepolizumab 100 mg SC q4w • SC • q2–4 weeks
    trigger: Eos ≥300 + persistent exacerbations on triple
    BOREAS / NOTUS / MATINEE
  5. 5. add-on roflumilast OR azithromycin
    Roflumilast 500 µg PO daily; azithro 250 mg PO 3×/week • PO • daily / 3×/week
    trigger: Frequent exac despite triple ± biologic + chronic bronchitis (roflumilast) or former smoker (azithro)
    Calverley 2009 / Albert 2011
  6. 6. smoking cessation pharmacotherapy
    Varenicline 0.5 mg → 1 mg BID; bupropion SR 150 mg BID; NRT patch + lozenge • PO/transdermal • per agent
    trigger: Active smoker
    Highest impact intervention per GOLD 2026 Follow-up & Prevention; pair with behavioural counselling

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic dyspnea, productive cough, chest tightness in smoker/ex-smoker (GOLD 2026 Diagnosis); Acute exacerbation: increased dyspnea + sputum volume + purulence (Anthonisen 1987); Post-bronchodilator FEV1/FVC <0.70 (GOLD 2026 diagnostic criterion).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**COPD (chronic GOLD ABE + exacerbation)** (pulm.copd.core.v1).
Phenotype framing: §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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GOLD 2026 ABE stepwise — chronic outpatient** — step "GOLD 2026 Group A — low symptoms + 0 exacerbations/yr".
1. tiotropium OR salbutamol PRN Tiotropium 18 µg HandiHaler OR 2.5 µg Respimat 2 puffs daily; albuterol 100 µg 2 puffs PRN inhaled once daily LAMA OR PRN SABA (LAMA_or_SABA, first line) — GOLD 2026 Group A — long-acting bronchodilator preferred (UPLIFT, Tashkin NEJM 2008); PRN SABA acceptable for occasional symptoms

Setting playbook (outpatient) — Achieve and maintain symptom control; reduce future exacerbation risk via GOLD 2026 ABE-guided regimen + smoking cessation + pulmonary rehab + vaccines + LTOT/NIV in advanced disease
2. Group A: tiotropium OR PRN SABA Tiotropium 2.5 µg Respimat 2 puffs daily OR albuterol 100 µg 2 puffs PRN inhaled once daily / PRN — mMRC 0–1, CAT <10, 0 exac/yr (GOLD A)
3. Group B: tiotropium-olodaterol 5/5 µg Respimat 2 puffs inhaled once daily — mMRC ≥2 OR CAT ≥10 (GOLD B — FLAME)
4. Group E: triple ICS-LABA-LAMA Fluticasone-umeclidinium-vilanterol 100/62.5/25 µg Ellipta 1 inh daily OR budesonide-glycopyrrolate-formoterol 160/9/4.8 µg MDI 2 puffs BID inhaled daily / BID — ≥1 mod exac/yr OR ≥1 hosp; eos ≥300 OR asthma history (IMPACT + ETHOS)
5. add-on biologic (dupilumab / mepolizumab) Dupilumab 300 mg SC q2w; mepolizumab 100 mg SC q4w SC q2–4 weeks — Eos ≥300 + persistent exacerbations on triple (BOREAS / NOTUS / MATINEE)
6. add-on roflumilast OR azithromycin Roflumilast 500 µg PO daily; azithro 250 mg PO 3×/week PO daily / 3×/week — Frequent exac despite triple ± biologic + chronic bronchitis (roflumilast) or former smoker (azithro) (Calverley 2009 / Albert 2011)
7. smoking cessation pharmacotherapy Varenicline 0.5 mg → 1 mg BID; bupropion SR 150 mg BID; NRT patch + lozenge PO/transdermal per agent — Active smoker (Highest impact intervention per GOLD 2026 Follow-up & Prevention; pair with behavioural counselling)

Non-pharmacologic actions:
- Pulmonary rehabilitation referral — especially after any exacerbation; within 3 weeks (Puhan 2016)
- Long-term oxygen therapy (LTOT) ≥15 h/day if resting SpO2 ≤88% on RA (NOTT 1980; MRC 1981)
- Home NIV consideration if chronic hypercapnia PaCO2 ≥52 (GOLD 2026 Pharmacotherapy)
- Annual flu, PCV20 (or PCV15+PPSV23), RSV (≥50 — GOLD 2026 lowered from ≥60), COVID, Tdap (GOLD 2026 Follow-up & Prevention)
- Lung cancer screening — annual LDCT if 50–80, ≥20 pack-years, current smoker or quit ≤15 years (USPSTF 2021)
- Advance care planning in advanced disease (GOLD 2026 Follow-up & Prevention)

AVOID / contraindication checks:
- Cardioselective_beta_blocker_NOT_contraindicated_continue_if_CAD_or_HFrEF_indication — mortality benefit outweighs bronchospasm risk; reserve caution for NON selective beta blockers (GOLD 2026 Multimorbidity)
- Azithromycin_QTc_check_baseline_and_audiogram_and_exclude_atypical_mycobacteria (Albert NEJM 2011 PMID 21864166)
- ICS_withdraw_consideration_if_eos_lt_100_and_no_asthma_and_low_exacerbation_burden (WISDOM, Magnussen NEJM 2014 PMID 25196117)
- ICS_pneumonia_risk_weigh_vs_exacerbation_benefit_favor_eos_high (FLAME pneumonia 4.8% vs 3.2% P=0.02 PMID 27181606)
- Roflumilast_avoid_pregnancy_weight_loss_depression_titrate_from_250ug (Calverley Lancet 2009 PMID 19716961)
- Pregnancy_continue_ICS_LABA_uncontrolled_disease_worse_than_drug_avoid_roflumilast (GOLD 2026; GINA 2026 safety extrapolation)
- No_major_renal_dose_adjust_for_inhaled_COPD_drugs_renal_adjust_comorbid_abx_theophylline (KDIGO; GOLD 2026)
- Opioid_caution_chronic_dyspnoea_and_hypercapnia (GOLD 2026 Pharmacotherapy)
- Supplemental_oxygen_avoid_hyperoxia_target_88_92 (Austin BMJ 2010 PMID 20959284)

Monitoring

Regimen monitoring:
- annual spirometry (GOLD 2026 Follow-up & Prevention)
- exacerbation diary frequent exacerbator phenotype (Seemungal AJRCCM 1998 PMID 9603117 — frequent exac SGRQ +14.8, prior-yr predicts future)
- inhaler technique q visit (GOLD 2026 Follow-up & Prevention)
- mMRC or CAT q visit drives ABE (GOLD 2026 Assessment)
- eos q year to inform ICS decision >=300 add <100 withdraw (GOLD 2026 Pharmacotherapy)
- biologic response at 4 months (BOREAS Bhatt NEJM 2023 PMID 37272521; NOTUS PMID 38767614; MATINEE PMID 40305712)
- LTOT compliance >=15h day 8h overnight oximetry (NOTT 1980 PMID 6776858; MRC 1981 PMID 6110912)
- pulmonary rehab completion post exac (Puhan Cochrane 2016 PMID 27930803 — readmission OR 0.44)
- home NIV response if persistent hypercapnia post exac (HOT-HMV Murphy JAMA 2017 PMID 28528348 — readmission/death HR 0.49)

Setting (outpatient) monitoring:
- Spirometry annually (GOLD 2026 Follow-up & Prevention)
- mMRC + CAT q visit (GOLD 2026 Assessment)
- Inhaler technique q visit (GOLD 2026 Follow-up & Prevention)
- Eos at least annually (GOLD 2026 Pharmacotherapy)
- Exacerbation diary — patient-recorded (GOLD 2026)
- Daily/regular home weight + trend — gain ≥2 kg over 2–3 days suggests volume overload / HF decompensation (CHF-comorbidity surveillance); low BMI / weight loss is an adverse COPD prognostic → nutrition referral if BMI <21 (GOLD 2026 Multimorbidity)
- LTOT 8-h overnight oximetry annually (NOTT 1980)

Follow-up plan: 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)
- Close-out criterion: Prevention bundle and rehab referral complete

Monitoring phase: 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

Disposition

Current setting: outpatient — Achieve and maintain symptom control; reduce future exacerbation risk via GOLD 2026 ABE-guided regimen + smoking cessation + pulmonary rehab + vaccines + LTOT/NIV in advanced disease

Disposition criteria:
- Continue current group therapy if controlled (GOLD 2026 Follow-up & Prevention)
- Step up GOLD group if exacerbation pattern worsens (GOLD 2026 ABE)
- Refer for lung volume reduction / transplant evaluation if FEV1 <30 + severe symptoms despite max therapy (NETT 2003; GOLD 2026 Pharmacotherapy)

Escalation triggers (move to higher acuity):
- Acute exacerbation with severe symptoms or O2 requirement → ED (GOLD 2026 Exacerbations)
- Failure to thrive / unintended weight loss → MDT review (GOLD 2026 Pharmacotherapy)
- Worsening cor pulmonale / right HF → cardiology + pulmonary HTN evaluation (GOLD 2026 Multimorbidity)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] pH <7.25 OR no improvement in pH after 1–2 h of NIV (Plant 2000)
- [LIFE_THREATENING] AMS in COPD exacerbation — CO2 narcosis OR hypoxic encephalopathy (GOLD 2026 Exacerbations)
- [SEVERE] pH 7.25–7.35 + PaCO2 >45 + RR >25 + dyspnoea (Plant 2000 NIV criteria)

Citations

- GOLD 2026 Report (v1.3, 2025-12-08) + ATS/ERS 2023 COPD Exacerbation Management [PMID:18836213](https://pubmed.ncbi.nlm.nih.gov/18836213/)
- Cited evidence (PMID 27181606) [PMID:27181606](https://pubmed.ncbi.nlm.nih.gov/27181606/)
- Cited evidence (PMID 29668352) [PMID:29668352](https://pubmed.ncbi.nlm.nih.gov/29668352/)
- Cited evidence (PMID 32579807) [PMID:32579807](https://pubmed.ncbi.nlm.nih.gov/32579807/)
- Cited evidence (PMID 37272521) [PMID:37272521](https://pubmed.ncbi.nlm.nih.gov/37272521/)

Last reconciled with current guidelines: 2026-05-26.
References