Recommendations for the Management of COPD 1
PROfessiOnal aRtiCle
1 University clinic of 
respiratory and allergic 
diseases Golnik, Slovenia
2 Dispanzer za pljučne 
bolezni in tuberkulozo, 
Community health centre 
Murska Sobota, Slovenia
3 Health institution 
Zdravje Ljubljana, 
Slovenia
4 Community health 
centre Nova Gorica, 
Slovenia
5 Clinic of pulmonary 
diseases and allergy 
Trebnje, Slovenia
6 Clinic of internal 
medicine, Community 
health centre Idrija, 
Slovenia
7 Clinic of pulmonary 
diseases and allergy, 
Community health centre 
Jesenice, Slovenia
8 Hospital Topolšica, 
Slovenia
9 Pulmonary department, 
General hospital Novo 
mesto, Slovenia
Recommendations for 
the Management of 
COPD
Metabolic and hormonal disordersProfessional article Zdrav Vestn | januar – februar 2017 | letnik 86
Recommendations for the management of 
patients with chronic obstructive pulmonary 
disease (COPD) at primary and specialist 
pulmonary levels in Slovenia
Priporočila za obravnavo bolnika s kronično obstruktivno pljučno 
boleznijo na primarni in specialistični pulmološki ravni v Sloveniji
sabina Škrgat,1 nadja triller,2 Mitja Košnik,1 tonka Poplas susič,16 Davorina Petek,3 
Vlasta Vodopivec Jamšek,4 irena Hudoklin,5 ana Ogrič lapajne,6 saša letonja,7 Jure 
Šorli,8 irma Rozman sinur,9 Marjan Koterle,10 natalija edelbaher,11 Jurij Regvat,11 
Damjan Birtič,12 simona slaček,13 Mihaela Zidarn,1 Katja triller,14 Matjaž turel,15 
Katarina Osolnik,1 Robert Marčun,1 Matjaž fležar1
Abstract
The purpose of this paper is to implement the guidelines proposed by GOLD in the Slovenian health-
care system, and to describe the cornerstones of the management of this disease. The document is 
meant to serve as an agreed approach to the management of COPD patients.
Izvleček
Z dokumentom želimo smernice, ki jih predlaga GOLD, umestiti v slovenski prostor in opisati te-
melje obravnave te bolezni. Dokument naj bi služil čim bolj enotnemu oz. dogovorjenemu pristopu 
k obravnavi teh bolnikov.
1. Introduction and the purpose of this paper
Chronic obstructive pulmonary di-
sease (COPD) is a common condition 
dealt with by physicians at all levels of 
health care. Making differentional di-
agnosis and/or accurate definitive dia-
gnosis within the scope of obstructive 
pulmonary diseases is often challenging. 
The purpose of this paper is to imple-
ment the GOLD guidelines into the Slo-
venian health care system, and to descri-
be the basic COPD treatment options 
(1,2). Moreover, these recommendations 
should serve as a reference point for a 
unified and agreed-upon approach to 
the management of COPD patients (3). 
The paper focuses on the cooperation 
between health providers at different le-
vels of patient treatment.
The organization of patient treatment 
and the level of cooperation between 
health providers at different levels of 
patient care in Slovenia differ from one 
region to another, mirroring the overall 
functioning of the regional health care 
system. Specialists in secondary care 
should have a role in developing pneu-
monology in the region and should be 
involved in the training of general physi-
2 Zdrav Vestn | januar – februar 2017 | letnik 86
MetaBOliC anD HORMOnal DisORDeRs
10 Pulmomed, private 
health institution Koper, 
Slovenia
11 Department of 
pulmonary diseases, 
division of internal 
medicine, University 
Medical Centre Maribor, 
Slovenia
12 Department of 
pulmonary diseases, 
General hospital »Dr. 
Franca Derganca« Nova 
Gorica, Slovenia
13 Department of 
pulmonary diseases, 
General hospital Murska 
Sobota, Slovenia
14 Division of internal 
medicine, General 
hospital Izola, Slovenia
15 Department of 
pulmonary diseases 
and allergy, Division 
of internal medicine 
University medical centre 
Ljubljana, Slovenia
16 Community health 
centre Ljubljana, 
Slovenia
Korespondenca/
Correspondence:
doc. dr. sabina Škrgat, 
dr. med.
e: sabina.skrgat@klinika-
golnik.si
Ključne besede:
kronična obstruktivna 
pljučna bolezen (KOPB); 
priporočila; zdravljenje; 
diagnoza; poslabšanje 
KOPB
Key words:
chronic obstructive 
pulmonary 
disease (COPD); 
recommendations; 
treatment; diagnosis; 
COPD exacerbation
Citirajte kot/Cite as:
Zdrav Vestn. 2017;  
86(1–2):65–75
Received: 12. 12. 2016 
accepted: 16. 1. 2017
cians (GPs). They should be responsible 
for the accessibility and quality of dia-
gnostic tests. Also, they should be in con-
tact with primary care specialists regar-
ding the referral of emergency patients 
to appropriate health care centres where 
they can get the treatment they need, but 
is unavailable in their region.
Epidemiology
COPD is characterized by an irrever-
sible and progressive obstructive airway 
disorder, leading to premature death. 
The condition is common. In recent ye-
ars approximately 50 persons in Slovenia 
have died due to the consequences of 
COPD each year. According to WHO, 
COPD is the fourth leading cause of de-
ath worldwide (4).
COPD most often affects smokers 
(1). The most characteristic clinical ma-
nifestations of COPD include chronic 
cough, exertional dyspnea and reduced 
exercise performance. Each smoker who 
coughs does not necessarily have COPD. 
Approximately 20 % of smokers develop 
COPD. The disease is accompanied by 
exacerbations (aeCOPD). Severe forms of 
the disease are characterized by frequent, 
severe and life-threatening aeCOPD.
The GP who first sees a patient with 
dyspnea and chronic cough should con-
sider COPD in the differential diagno-
sis, because COPD is one of the most 
frequent causes of chronic exertional 
dyspnea. Obstructive airway disorder in 
patients with COPD is checked by spiro-
metry. Lung function does not normalize 
after the application of a bronchodilator.
GPs should provide initial diagnostic 
tests, diagnosis and treatment and are 
responsible for coordinating the COPD 
patient’s care. Because of a wide variety 
of conditions that can be considered in 
the differential diagnosis of obstructive 
airway disorder, and because these pati-
ents usually present with comorbidities, 
it is recommended that patients with an 
obstructive airway disorder be referred 
to a health care provider at a secondary 
or tertiary level of health care (1).
3. Diagnosis
Recommendation 1 D
Patients with an undiagnosed COPD 
are sought among ex- and/or active 
smokers, as well as among indivi-
duals older than 40 years who have 
been exposed to unfavourable envi-
ronmental conditions.
Recommendation 2 A
Spirometry is the basic diagnostic 
test. We must not diagnose COPD 
without performing spirometry.
The following factors should always 
be checked (1,2,3,5,6) when treating a 
patient with a suspected COPD:
The patient is a long-time smoker (at 
least ten packs of cigarettes/year) or an 
ex-smoker.
• The patient has worked, or is working, 
in an environment massively exposed 
to dust or chemicals (vapours, irri-
tants, smoke).
• The patient is older than 40 years.
It is of equal importance to identify 
patients with mild symptoms who smo-
ke and have been diagnosed with early-
-stage COPD, because the cessation of 
smoking stops the progression of the 
disease.
The basic test in diagnosing COPD 
is spirometry (1,2,6). GPs should per-
form spirometry in long-time smokers 
or refer them to a secondary level health 
care center for testing, particularly those 
with signs of chronic bronchitis and/or 
Recommendations 
for the Management 
of COPD
Recommendations for the Management of COPD 3
PROfessiOnal aRtiCle
Confirmation: these 
recommendations were 
compiled at coordination 
meetings of a working 
group of specialists 
treating pulmonary 
diseases at the secondary 
and tertiary levels, and 
general practitioners. 
Recommendations 
were presented at the 
annual meeting of the 
slovenian Respiratory 
society on november 27, 
2015. after consideration 
of corrections and 
suggestions, the 
recommendations for the 
management of COPD 
were confirmed at the 
slovenian Respiratory 
society Management 
Board and Member 
Meeting, held on March 
30, 2016 in ljubljana.
dyspnea on exertion. Perfectly normal 
spirometry results exclude COPD. On 
the other hand, it is recommended that 
all patients with abnormal test results 
(compatible with obstructive or restric-
tive disease) be referred to pulmonary 
outpatient units at the secondary or ter-
tiary levels for lung function testing.
3.1 Evaluation of spirometry results
Recommendation 3 A
A positive bronchodilator test does 
not exclude COPD. The disease can 
only be excluded with normal spi-
rometry results after bronchodilator 
administration (normalized TI, and 
an increase in FEV1 to normal pre-
dicted value).
In a healthy individual, the difference 
between the measured SVC (slow vital 
capacity) and FVC (forced vital capaci-
ty) should not exceed 10 %. With greater 
differences, we suspect that dynamic ob-
struction is caused by forced exhalation. 
With NHANES III reference values, FEV6 
(forced expiratory volume in 6 seconds) 
may also be used instead of FVC. Spiro-
metry should be technically sound (7,8).
Obstructions are assessed by the Tif-
feneau index (TI). FEV1 (forced expira-
tory volume in the first second) is divi-
ded by the vital capacity. This index is an 
indicator of obstruction when reduced 
by more than 12 % below the reference 
value. Airway obstruction as defined by 
the GOLD guidelines is diagnosed at 
a TI value below 0.70. Using this thre-
shold, the results should be interpreted 
with caution, particularly in elderly pa-
tients (1,9). According to norms, a TI va-
lue under 0.70 may be normal and not 
pathological in this age group, therefore 
misdiagnosis of COPD is possible in el-
derly patients with dyspnea (9,10,11).
ti = feV1/(VC, fVC ali feV6)*
* – The greater value is inserted as the deno-
minator.
When spirometry reveals an ob-
struction, we should always perform a 
bronchodilator test, using four inhala-
tions (0.4 mg) of salbutamol, prefera-
bly through a long extension (12) for 
adult patients. The medicine from the 
inhalator should be administered by a 
nurse. Additionally, the patients should 
be reminded of the instructions (te-
chnique) for proper dosing. Spiromet-
ry should be repeated 15 minutes after 
administering the medicine. The test 
is positive if the FEV1 values have inc-
reased by at least 12 % from the output 
value, and at least 200 ml. A borderli-
ne or barely positive bronchodilator 
test is applicable both in asthma and 
COPD. A positive bronchodilator test 
does not exclude COPD; it is ruled out 
only by spirometry normalization after 
the bronchodilator test (normalization 
of TI and an increase of FEV1 to the 
normal range). In COPD, the FEV1 and 
TI values cannot be normalized with a 
bronchodilator.
In an obstruction that does not re-
spond significantly to the bronchodila-
tor test, it is recommended to conduct 
further diagnostic testing at the specia-
list level. A GP, who reasonably suspects 
COPD can further evaluate the patient 
using the available examinations. Defi-
nitive clarification of the cause of an ir-
reversible obstruction should be in the 
domain of a secondary- or tertiary- care 
specialist. An irreversible obstruction 
may also be a sign of other less common 
pulmonary diseases, such as bronchi-
ectasis, bronchiolitis, bronchomalacia, 
some forms of asthma and tracheal ste-
nosis.
Recommendations 
for the Management 
of COPD
4 Zdrav Vestn | januar – februar 2017 | letnik 86
MetaBOliC anD HORMOnal DisORDeRs
4. Disease classification
Recommendation 4 D
The overall assessment of a patient 
with COPD includes lung function 
testing, assessment of the impact of 
dyspnea on exercise performance 
(the MRC Medical Research Council 
dyspnea scale), assessment of the im-
pact of the disease on the quality of 
life (the CAT COPD assessment sca-
le), and determination of the number 
of exacerbations per year. Also, we 
look for associated chronic diseases 
and define the disease phenotype.
4.1 Assessment of patients 
with COPD (1,11)
When assessing a patient with COPD 
we consider:
a. the degree of airway obstruction 
(post-bronchodilator FEV1),
b. the presence of symptoms: CAT que-
stionnaire (COPD assessment test),
c. the MRC scale to assess the degree of 
dyspnea during physical activity (Me-
dical Research Council),
d. the number of COPD exacerbations 
per year,
e. the associated diseases (diseases of 
the cardiovascular system (13), osteo-
porosis, depression (14), anxiety, mu-
sculoskeletal diseases, metabolic syn-
drome, lung cancer).
The points a, b, c, and d are summari-
zed in Table 2.
The patient requires antibiotic or sy-
stemic glucocorticoid treatment.
Group A: Patients with early-sta-
ge disease who can be treated by a GP. 
Cessation of smoking is a key part of 
treatment, since the decline in lung 
function in this group is faster than in 
advanced forms of the disease (C and 
D).
Group B: Patients presenting with a 
more rapid decline in lung function and 
with significant comorbidities, such as 
cancer and cardiovascular diseases, or 
patients with significant hyperinflation 
(emphysema), which makes them more 
symptomatic than expected in view of 
the FEV1 reduction.
Group C: Mildly symptomatic pa-
tients, but with FEV1 below 50 %. These 
patients represent the smallest group of 
COPD patients.
Group D: Patients who are both at 
respiratory and cardiovascular risk and 
have several disease exacerbations.
Only patients in Group A can be tre-
ated by a GP, the others should be mana-
ged jointly by a secondary- or tertiary-
-care specialist and a GP.
Table 1: assessment according to post-
bronchodilator feV1
GOLD Spirometric 
stage
All Stages: 
FEV 1 /FVC < 70 %
GOlD 1: mild feV1 > 80 % normal
GOlD 2: moderate feV1 > 50–80 % normal
GOlD 3: severe feV1 > 30–50 % normal
GOlD 4: very severe feV1 < 30 % normal
Recommendations 
for the Management 
of COPD
Table 2: assessment of disease severity (1).
Patient Groups Exacerbations/
Year
C D 1 hospital,*
≥2 outpatient*
A B 0–1 outpatient*
MRC: 0–1,
CAT <10
MRC >1,
CAT >10
* – Potreba po antibiotiku ali sistemskem 
glukokortikoidu.
Recommendations for the Management of COPD 5
PROfessiOnal aRtiCle
Patients with COPD clinically differ 
from each other in terms of the disease 
course and their response to treatment. 
Table 3 describes the basic features of cli-
nical phenotypes of COPD and the prin-
ciples of treatment of these patients.
5. Principles for treating 
stable disease
Recommendation 5 A
Non-pharmacological treatment in-
cludes advice on smoking cessation, 
and vaccination, as well as rehabilita-
tion and nutritional intervention.
The cornerstone of initial pharma-
cological treatment of COPD is the 
use of long-acting bronchodilators 
as monotherapy or in combinations. 
Short-acting bronchodilators are 
prescribed if necessary.
The objectives of treatment are redu-
cing symptoms, decelerating the natural 
course of the disease, improving the qua-
lity of life and exercise capacity, reducing 
Table 3: Definition of stable COPD by clinical phenotypes of the disease (15,16,17).
Clinical phenotype Basic characteristics
Prevailing chronic bronchitis Productive cough for more than 3 months a year, for 2 or more 
consecutive years.
Prevailing emphysema 
(hyperinflation)
no productive cough; clinical, radiological, functional signs of 
emphysema.
asthma/COPD overlap 
syndrome (aCOs)
asthma and COPD characteristics. aCOs is considered in the 
following cases:
• Highly positive bronchodilator test (feV1 above 15 % and 
400 ml), but without normal lung function;
• increased nO in the exhaled air > 45–50 ppb and/or 
eosinophilia in an induced sputum (> 3 %);
• Previous diagnosis or history of asthma.
important, but less conclusive, are the following criteria:
• Positive bronchodilator test (feV1 above 12 % and > 200 ml) 
without normal lung function;
• increased total ige;
• atopy;
• Previous diagnosis of COPD.
the disease is usually accompanied by frequent exacerbations 
and decreased lung function. specialist pulmonary treatment is 
required.
COPD/bronchiectasis overlap 
syndrome
Cough is present on a nearly daily basis, bronchiectasis confirmed 
by chest X-ray.
COPD with frequent 
exacerbations
two or more exacerbations a year, or hospitalization once a year.
COPD with obesity and sleep-
related breathing disorder
Confirmed diagnosis of COPD, and sleep related breathing disorder 
confirmed by a polygraph.
COPD with cachexia BMi < 21 kg/m2 without any other reason (ffMi < 16/m2 for men or 
< 15 kg/m2 for women).
Legend: BMI: body mass index, FFMI: fat free mass index measured by bioelectrical impedance.z 
bioelektrično impedanco.
Recommendations 
for the Management 
of COPD
6 Zdrav Vestn | januar – februar 2017 | letnik 86
MetaBOliC anD HORMOnal DisORDeRs
the frequency of disease exacerbations 
and decreasing COPD mortality (1).
1. Step:
We recommend the cessation of 
smoking to all patients regardless of the 
Table 5: treatment recommended according to the disease phenotype
Clinical phenotype Method of treatment
Predominant chronic bronchitis Pulmonary physiotherapy, roflumilast, antibiogram-based 
antibiotic therapy, otherwise a therapy following guidelines.
Predominant emphysema 
(hyperinflation)
Bronchoscopic and/or surgical lung volume reduction methods 
(reduction of disturbances in breathing mechanics), theophylline, 
otherwise a therapy following guidelines.
asthma-COPD overlap (aCOs) la anticholinergic + la beta-agonist + iGC (regardless of feV1);
COPD and bronchiectasis 
overlap
learning expectoration techniques, an antibiogram-based 
antibiotic therapy; consider the introduction of azithromycin 
250 mg 3 times per week for several months in a row **
COPD with frequent 
exacerbations
la anticholinergic + la beta-2-agonist + iGC, option of adding 
roflumilast, antibiogram-based antibiotic therapy; consider the 
introduction of azithromycin 250 mg 3 times per week for several 
months in a row **
COPD with obesity and sleep 
breathing disorder
CPaP or BiPaP +/- oxygen and pharmacological treatment of 
COPD, body weight reduction, treatment of metabolic syndrome, 
if present
COPD with cachexia nutritional supplements, pulmonary rehabilitation patient 
(hospital), other therapy guidelines .
**–Only in centres with expertise. The treatment is repeated in the event of a reduction in the frequency of 
exacerbations and the absence of side effects.
Table 4: Pharmacological treatment of stable COPD (3,20-23)
Group Initial treatment Options of treatment intensification, if necessary
a Bronchodilators
short-acting
in the case of favourable effects, continue the 
treatment; long-acting bronchodilators may be added 
in symptomatic individuals
B laBa or laMa laBa + laMa
C laMa laBa+laMa, laBa+iGC*
D laBa+laMa, laBa+iGC** laBa/laBa/iGC
aZitHROMYCin***
ROflUMilast***
*–For group C: IGC (inhaled glucocorticoid) and LABA (long-acting beta-agonist) in frequent 
exacerbations and ACOS (asthma-COPD overlap syndrome), otherwise the first choice is LABA and LAMA 
(long-acting muscarinic antagonist/anticholinergic).
**-For group D: initial combination LABA+LAMA; if there is a possibility of ACOS, the LABA+IGC 
combination is preferred
***FOR AZITHROMYCIN: phenotype of frequent disease exacerbations despite maximal inhalation 
therapy
***FOR ROFLUMILAST: persistence of chronic bronchitis despite maximal inhalation therapy and FEV1 
under 50 %.
Key: LA: long-acting; IGC: inhaled glucocorticoid
Recommendations 
for the Management 
of COPD
Recommendations for the Management of COPD 7
PROfessiOnal aRtiCle
stage of the disease. It is by far the most 
effective treatment for COPD as it slows 
down the decline in lung function (1,18). 
Continued smoking accelerates the pro-
gression of the disease regardless of its 
stage (19).
The measures undertaken by a GP 
and a pulmonologist include: rapid in-
tervention (determining the smoking 
status, advice on how to quit, offering 
assistance) and individual counselling in 
accordance with the principles of moti-
vational interviewing and behavioural 
therapy.
2. Step:
a. Non-pharmacological advice: physi-
cal activity, rehabilitation and educa-
tion about the disease, and learning 
the prescribed inhalation therapy.
b. Treatment of associated diseases.
c. Pharmacological measures (mainly 
inhaled medication and vaccination 
against influenza and pneumococcal 
infections, home oxygen therapy for 
chronic respiratory failure, dietary in-
tervention).
The selection of medicines in each 
group depends on their accessibility and 
on the patient’s response to them (Table 
4).
6. Diagnostic methods 
and treatment in family 
medicine practice 
Recommendation 6 D
In family medicine clinics, symptoms 
of COPD are actively sought among 
smokers and ex-smokers older than 
40 years. Patients known to have 
COPD are treated yearly by a family 
medicine clinic team.
The patient’s GP can raise a reasona-
ble suspicion of COPD, but definitive 
differential diagnostic clarification and 
confirmation of the diagnosis should be 
in the domain of a pulmonologist.
The so-called “reference clinics” re-
present a new form of organization of 
family medicine services at the primary 
level (24). By the end of 2017, the organi-
zational changes will be gradually adop-
ted in all family medicine clinics. The 
essential novelty is that the team will be 
extended to include a nurse working at 
least half-time. The purposes of this re-
organization are effective management 
of chronic patients and early detection 
of common chronic diseases. In accor-
dance with recommendations, family 
medicine reference clinics also conduct 
the screening of patients/smokers for 
COPD.
If COPD is suspected, the patient un-
dergoes spirometry, and in the case of 
obstructive airway disorders, a broncho-
dilator test is performed. It is recommen-
ded that a bronchodilator test be carried 
out only when spirometry is technically 
sound (8), otherwise the test has no dia-
gnostic value.
When there is a reasonable suspicion 
of COPD, the GP should refer the patient 
to a secondary- or tertiary-care specialist 
for definitive clarification and confirma-
tion of the diagnosis.. The patient’s GP 
prescribes a short-term bronchodilator 
(SABA), or a combination of SAMA and 
SABA (in symptomatic patients until the 
diagnosis is confirmed at the secondary 
or tertiary levels. In smokers, it is man-
datory to include measures for the cessa-
tion of smoking.
In a family medicine clinic a patient 
with COPD is treated by a team fol-
lowing the treatment protocol (Appen-
dix 1). There a COPD patient registry is 
established. The patients who are newly 
diagnosed with COPD in the screening 
Recommendations 
for the Management 
of COPD
8 Zdrav Vestn | januar – februar 2017 | letnik 86
MetaBOliC anD HORMOnal DisORDeRs
program, or are discovered incidentally, 
are entered in the COPD registry. The 
registry includes patients with COPD 
diagnosed or confirmed by a seconda-
ry- or tertiary-care specialist. Newly di-
agnosed patients and those already in-
cluded in the COPD registry, are invited 
to attend for assessment of the disease 
state by a RN at least once a year. The 
results are reported to the doctor (GP), 
with whom the family medicine clinic 
cooperates. At least once a year, the pa-
tient is treated by his GP.
In the case of suspected 
COPD, we recommend:
• Spirometry;
• Chest X-ray;
• ECG;
• Blood oxygen saturation measure-
ment;
• Assessment of the associated diseases;
• Treatment of the patient by a secon-
dary- or tertiary- care specialist, who 
either confirms or refutes the wor-
king diagnosis;
• Urgent treatment of “fragile” patients 
(known hypercapnia, frequent exa-
cerbations with hospitalization, long-
-term home oxygen therapy (LTOT), 
non-invasive mechanic ventilation or 
a history of intubation and mecha-
nical ventilation, pulmonary heart 
disease) at the secondary or tertiary 
levels.
Management of stable COPD
• Verification of smoking status;
• Examination of inhaled medicine use;
• CAT score once per year, in sympto-
matic patients at every examination;
• Spirometry;
• Cooperation with a secondary- or 
tertiary-care specialist.
6.1 Recommended frequency of 
treatment based on disease severity
Group A: Treatment by a GP once 
per year.
Group B: The diagnosis should be 
provided by a secondary- or tertiary- 
care specialist, recommended annual 
treatment by a secondary- or tertiary-ca-
re specialist (more or less often depen-
ding on the clinical status), and annual 
treatment by a GP (more often if requi-
red by the clinical status).
Group C: The diagnosis should be 
provided by a secondary- or tertiary-ca-
re specialist, recommended annual treat-
ment by a specialist in secondary or ter-
tiary care (more or less often depending 
on the clinical status), annual treatment 
by a GP(more often if required by the 
clinical status).
Group D: The diagnosis should be 
provided by a secondary- or tertiary-
-care specialist, recommended bi-annual 
treatment by a secondary- or tertiary-ca-
re specialist (more or less often depen-
ding on the clinical status), and annual 
treatment by a GP (more often if requi-
red by the clinical status).
Because of a multitude of possible 
medicines for COPD, the selection of 
appropriate combinations may be chal-
lenging. The treatment of COPD in-
cludes non-pharmacological therapy 
(rehabilitation) (25,26). It is therefore 
appropriate that COPD patients in gro-
ups B, C, and D are managed and have 
their treatment optimized by a seconda-
ry- or tertiary-care specialist.
“Fragile” patients are identified by in 
secondary or tertiary specialist services, 
or by a GP. For these patients, the type 
of treatment should be determined in 
advance, in cooperation with their GP. 
The patients should bring their previous 
Recommendations 
for the Management 
of COPD
Recommendations for the Management of COPD 9
PROfessiOnal aRtiCle
medical records every appointment with 
any doctor.
7. Treatment in clinics with 
specialistpulmonology 
programs
Recommendation 7 D
The COPD diagnosis is made by ru-
ling out other possible reasons for 
irreversible obstruction; therefore a 
pulmonologist should either confirm 
or refute the diagnosis of COPD .
1. Treatment of COPD at the secondary 
level (note: all the examinations listed 
are not necessarily carried out in each 
patient)
a. Medical history (dyspnea, 
chronic cough, risk factors: 
smoking, working and living 
environment, family medical 
history);
b. Clinical examination (BMI, RR, 
pulse oximetry, heart rate, re-
spiratory rate);
c. Spirometry – bronchodilator 
test → FEV1/FVC < 70;
d. Diffusion capacity*, plethysmo-
graphy*;
e. Image diagnostics: chest X-ray*, 
high-definition CT* (consulta-
tion with a radiologist);
f. Laboratory diagnostics (basic 
biochemistry, hemogram)*;
g. ECG;
h. Six- minute walk test*;
i. CAT test, mMRC;
j. Determining a f alpha-1-an-
titrypsin deficiency (measu-
rement of alpha-1-antitrypsin 
blood concentration)*.
* These tests are not contained in the minimum set 
of specialist services provided in pneumonology clini-
cs; the patient should be referred to institutions where 
they are available.
2. Differential diagnosis
a. Asthma
b. Heart failure
c. Bronchiectasis
d. Tuberculosis – post-effects
e. Bronchiolitis
f. Tracheal stenosis, tracheobron-
chomalacia
g. Vocal cord dysfunction
3. Treatment of patients with COPD
A. Stable COPD:
a. Group A:
• Cessation of smoking (and 
other non-pharmacological 
measures).
b. Groups B, C, D: introduction 
of therapy (personalized treat-
ment, therapy modification):
• CAT, smoking cessation, a 
six-minute walk test or as-
sessment of exercise capaci-
ty;
• Selection of pharmacothe-
rapy according to guideli-
nes and with respect to the 
GOLD groups;
• Comorbidity assessment: 
cardiovascular disease, de-
pression, anxiety, osteoporo-
sis, skeletal muscle dysfunc-
tion, metabolic syndrome, 
lung cancer, cachexia, sleep 
breathing disorder;
• Testing and learning the 
correct use of inhalators;
• Assessment of the need for 
LTOT;
• Assessment of pulmonary 
hypertension, especially in 
patients who are potential 
candidates for LTOT, and 
those with a disproportio-
nately severe dyspnea accor-
ding to the results of pulmo-
nary function;
Recommendations 
for the Management 
of COPD
10 Zdrav Vestn | januar – februar 2017 | letnik 86
MetaBOliC anD HORMOnal DisORDeRs
Recommendations 
for the Management 
of COPD
• COPD school;
• Health education and reha-
bilitation;
• Vaccination against influen-
za and pneumococcal pneu-
monia.
B. In the case of exacerbation–exa-
cerbation assessment:
• Medical history and clinical 
examination;
• Arterial blood gas analysis, 
chest X-ray in two projecti-
ons;
• Standard hematological and 
biochemical blood tests;
• Introduction of an empirical 
antibiotic therapy and/or sy-
stemic glucocorticoid, when 
indicated;
• Spirometry not indicated at 
deterioration;
• Repeated outpatient treat-
ment within 3 days from the 
start of exacerbation;
• Outpatient treatment betwe-
en 3 and 6 weeks after hospi-
talization.
8. Treatment of patients 
with COPB exacerbation
Recommendation 8 D
Patients with respiratory failure, a hi-
story of invasive and/or non-invasive 
mechanical ventilation, occurrence 
of right-sided heart failure, negati-
ve initial response to treatment, and 
significant comorbidities should be 
referred to a hospital.
9. Identification and evaluation of evidence
The recommendations are set forth in 
accordance with the GINA (Global Initi-
ative for Asthma) guidelines. Individual 
recommendations are scalable depen-
ding on the available studies or expert 
group opinion (Table 7).
Table 6: indications for an urgent hospital referral due to a COPD exacerbation (3,27-29).
– Respiratory failure or exacerbation of chronic respiratory failure in ltOt at home;
– severe worsening of symptoms, such as sudden dyspnea at rest;
– exacerbation of the disease in patients with severe COPD (history of iCU treatments);
– Worsening of chronic hypercapnic respiratory failure;
– Occurence of new symptoms (e.g. cyanosis, peripheral oedema);
– Poor response to the current outpatient treatment;
– significant comorbidities;
– newly occurred cardiac arrhythmia;
– Uncertain diagnosis;
– inconvenient situation at home.
Recommendations for the Management of COPD 11
PROfessiOnal aRtiCle
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