• Jean Bourbeau, Mohit Bhutani, Paul Hernandez, Shawn D Aaron, Marie-France Beauchesne, Sophie B Kermelly, Anthony D'Urzo, Avtar Lal, François Maltais, Jeffrey D Marciniuk, Sunita Mulpuru, Erika Penz, Don D Sin, Anne Van Dam, Joshua Wald, Brandie L Walker, and Darcy D Marciniuk.
• Department of Medicine, McGill University Health Centre, McGill University, Montréal, QC, Canada. Electronic address: jean.bourbeau@mcgill.ca.
• Chest. 2023 Nov 1; 164 (5): 115911831159-1183.

AbstractChronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.Copyright © 2023 Canadian Thoracic Society and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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