1. Who Is at Risk? Risk Checklist
A. Major Risk Factors
Tobacco smoking - current or past including beedis/cigars
Biomass fuel exposure - firewood, cooking, paddy drying, indoor smoke
Occupational exposure - dusts, fumes, vapours (tea, garment, construction)
Outdoor air pollution - traffic or industrial areas
Recurrent childhood respiratory infections
History of TB
Family history of chronic lung disease (asthma, COPD, bronchiectasis)
Long-standing or poorly controlled asthma
Poor response to inhaler medication (possible ACO)
B. Early Warning Symptoms
Chronic cough (≥8 weeks)
Morning or persistent sputum production
Progressive breathlessness on exertion
Reduced exercise tolerance
Repeated antibiotic/steroid courses
Wheezing in an adult smoker or biomass user
Chest tightness or progressive noisy breathing
C. Red Flags - Cough Investigation
🔴 Tuberculosis Features:
- Persistent cough ≥3 weeks
- Hemoptysis (coughing up blood)
- Night sweats
- Unexplained weight loss
- Fever (especially evening/night)
- TB contact history
- HIV positive status or immunosuppression
🔴 Malignancy Features:
- Age ≥50 years with new cough
- Heavy smoking history (≥30 pack-years)
- Hemoptysis
- Unintentional weight loss ≥5kg
- Hoarseness (vocal cord involvement)
- Chest pain
- Dyspnea (progressive breathlessness)
- Supraclavicular lymphadenopathy
- Finger clubbing
D. At-Risk Groups for Screening
- Adults ≥35 years with any risk factor above
- High-exposure workers (factory, vehicle, construction)
- Post-TB patients with ongoing respiratory symptoms
- Adults with asthma symptoms not responding to therapy
- Women with long-term biomass exposure
- Exposure to passive smoking
2. COPD Screening Questionnaire
COPD-C Screening Tool
| Question | Score (0-4) | ||||
|---|---|---|---|---|---|
| Do you often cough? | 0 | 1 | 2 | 3 | 4 |
| Do you bring up phlegm in the morning? | 0 | 1 | 2 | 3 | 4 |
| Do you get breathless walking with people your age? | 0 | 1 | 2 | 3 | 4 |
| Do you tire more easily than others? | 0 | 1 | 2 | 3 | 4 |
| Are you >40 years and a smoker/biomass user? | 0 | 1 | 2 | 3 | 4 |
Interpretation:
• Total ≥10: Suspect COPD → Perform handheld spirometry
• This is a quick screening tool; formal spirometry confirms diagnosis
• Total ≥10: Suspect COPD → Perform handheld spirometry
• This is a quick screening tool; formal spirometry confirms diagnosis
3. Diagnostic Pathway
A. Handheld Spirometry Field Screening
Record FEV₁, FEV₆, and FEV₁/FEV₆ ratio
Key Threshold: FEV₁/FEV₆ ≤0.73 = Suspect airflow obstruction → Refer for formal spirometry with BDR
B. Referral Criteria for Formal Spirometry
- FEV₁/FEV₆ ≤0.73 or borderline on handheld spirometry
- Persistent cough, sputum, or breathlessness ≥8 weeks
- Recurrent bronchitis or asthma-like episodes (age >40 years)
- Occupational or past-TB exposure with symptoms
- Abnormal CXR, crackles/wheeze on examination
- Poor or declining response to inhaler therapy
Why Formal Spirometry Matters:
Handheld devices are helpful for screening, but formal spirometry with bronchodilator response is essential for diagnosis, severity grading, and detecting reversibility
Handheld devices are helpful for screening, but formal spirometry with bronchodilator response is essential for diagnosis, severity grading, and detecting reversibility
4. Spirometry Interpretation
| Pattern | Definition/Criteria | Key Implications |
|---|---|---|
| Normal | FEV₁/FVC ≥LLN or 0.70 and FEV₁ ≥80% predicted | Normal. If symptomatic, consider pre-COPD |
| COPD | Post-BD FEV₁/FVC <0.70 and poor reversibility | Consistent with COPD - fixed obstruction |
| Asthma | FEV₁/FVC <0.70 pre-BD; post-BD increase ≥12% | Reversible obstruction. Treat as asthma or ACO |
| ACO | Persistent post-BD obstruction with partial reversibility | Mixed features - requires Type-2 targeted treatment |
| PRISm | FEV₁ ≥80% predicted with FEV₁/FVC <0.70 | Early COPD, small-airway disease |
| Pre-COPD | Normal spirometry but symptomatic or CT evidence | Risk stage - advise exposure control |
Interpretive Notes:
• Evaluate FEV₁/FVC first. If normal, look at FEV₁ to detect PRISm
• Reversibility applies only when obstruction is present (FEV₁/FVC <0.70 pre-BD)
• Marked reversibility strongly suggests asthma
• Evaluate FEV₁/FVC first. If normal, look at FEV₁ to detect PRISm
• Reversibility applies only when obstruction is present (FEV₁/FVC <0.70 pre-BD)
• Marked reversibility strongly suggests asthma
5. COPD Assessment Checklist
| Domain | Parameters to Assess | Red Flags |
|---|---|---|
| General | Weight (kg), Height (cm), BMI | BMI <18.5: poor prognosis, cachexia |
| Vitals | SpO₂ (room air), HR, BP, RR | SpO₂ <90%, RR >24: urgent review |
| Respiratory | Barrel chest, accessory muscle use | Unilateral signs: exclude TB, cancer |
| Cardiovascular | P2 loudness, right heave, edema | Suggests pulmonary hypertension |
| Extremities | Clubbing, cyanosis, tremor | Clubbing: bronchiectasis/malignancy |
| ENT/Airway | OSA signs | Consider STOP-BANG assessment |
| Gastrointestinal | GERD symptoms | GERD exacerbates cough and symptoms |
| Functional | Grip strength, 6-minute walk | Sarcopenia/frailty: poor prognosis |
| Psychological | PHQ-9 (depression), GAD-7 (anxiety) | High prevalence: address with support |
Whole-Person Assessment:
This checklist evaluates not just lung function but systemic impact. Low muscle mass is a powerful predictor of mortality in COPD.
This checklist evaluates not just lung function but systemic impact. Low muscle mass is a powerful predictor of mortality in COPD.
6. GOLD 2025 Classification System
A-B-E Classification
| Category | Symptoms (CAT/mMRC) | Exacerbations | Profile | Treatment |
|---|---|---|---|---|
| A | Low: CAT <10, mMRC 0-1 | Zero exacerbations | Mild, stable | LABA or LAMA |
| B | More: CAT ≥10, mMRC ≥2 | Zero exacerbations | Symptomatic | LABA + LAMA |
| E | Any symptom level | ≥2 moderate OR ≥1 severe | Frequent exacerbator | LABA + LAMA ± ICS |
Blood Eosinophils Guide for ICS use:
• ≥300/μL: ICS strongly indicated
• 100-300/μL: Consider ICS if repeated exacerbations
• <100/μL: Avoid routine ICS (pneumonia risk outweighs benefit)
• ≥300/μL: ICS strongly indicated
• 100-300/μL: Consider ICS if repeated exacerbations
• <100/μL: Avoid routine ICS (pneumonia risk outweighs benefit)
7. Care Escalation Checklist
| Domain | Escalation Triggers | Action |
|---|---|---|
| Symptoms | CAT ≥20 or mMRC 3 despite therapy | Review technique, refer for PR |
| Exacerbations | ≥2 moderate or ≥1 severe in 12 months | Respiratory specialist assessment |
| FEV₁ Decline | >100 mL/year or GOLD 3-4 | Specialist review; HRCT if disproportionate |
| Eosinophils | ≥300/μL with frequent exacerbations | Add ICS or triple therapy; consider biologic |
| Red Flags | Hemoptysis, weight loss, clubbing | Exclude lung cancer, bronchiectasis, post-TB |
| Oxygenation | SpO₂ <90% on room air | Refer for ABG, LTOT evaluation |
| Comorbidities | Heart failure, OSA, GERD, depression | Co-management or specialist referral |
| Rehabilitation | Reduced exercise tolerance, frailty | Pulmonary rehabilitation + nutrition |
Key Principle: Early escalation using this checklist prevents hospitalizations and improves outcomes.
8. Understanding Option 1 and Option 2
Option 1: Single-Inhaler Therapy
Principle: Simplified maintenance using a single fixed-dose combination (LABA+LAMA±ICS)
Best for: GOLD B or E patients with symptoms or exacerbations
Advantages: One device, better adherence, fewer prescribing errors
Option 2: Stepwise Add-On Therapy
Principle: Gradual escalation from monotherapy → dual → triple (separate devices)
Best for: GOLD A/early B or when fixed-dose combinations unavailable
Use when cost, availability, or patient preference limits Option 1
Comparison
| Feature | Option 1 | Option 2 |
|---|---|---|
| Device(s) | Single fixed-dose inhaler | Separate devices |
| Adherence | Better (simplicity) | Lower (multiple devices) |
| Flexibility | Limited | High |
CRITICAL: COPD requires a separate rescue inhaler (SABA). MART is NOT appropriate for COPD.
9. GOLD Management Flow
GOLD A: Low Symptom, Low Exacerbation
Initial: LABA or LAMA monotherapy
↓
Follow-Up (4-6 weeks): Assess control & technique
↓
Decision: If improved continue; if worsening escalate to dual
GOLD B: More Symptoms, Low Exacerbation
Initial: LABA + LAMA dual therapy
↓
Follow-Up (4-6 weeks): Reassess CAT, technique, SpO₂
↓
3-6 Month Review: Check exacerbations & eosinophils
GOLD E: Frequent Exacerbations
Initial: LABA + LAMA + ICS if eosinophils ≥100/μL
↓
If Eosinophils ≥300/μL: Maintain triple; consider biologic
↓
If Eosinophils <100/μL: Avoid ICS; consider roflumilast or macrolides
Non-Pharmacological Interventions
Pulmonary rehabilitation and home exercise
Nutritional and psychological support
Smoking and biomass cessation counseling
Annual influenza and pneumococcal vaccination
Early exacerbation recognition education
10. Inhaled Corticosteroid Use in COPD
When to Consider ICS
Blood eosinophils ≥300 cells/μL, OR
≥2 moderate exacerbations or ≥1 hospitalization in past year, OR
Asthma-COPD Overlap (ACO) features
Use ICS as part of TRIPLE therapy (LABA+LAMA+ICS)
When NOT to Use ICS
- Blood eosinophils <100 cells/μL
- History of recurrent pneumonia
- Active or past-TB airway disease
- Bronchiectasis or chronic Pseudomonas infection
- Current fungal colonization
Choice of ICS Molecule
| ICS Molecule | Pneumonia Risk | Preference | Comments |
|---|---|---|---|
| Budesonide | Lower | ✓ PREFERRED | Safer in elderly and post-TB airways |
| Fluticasone | Higher | ⚠ Cautious | Higher pneumonia & candidiasis risk |
| Beclomethasone | Moderate | ✓ Acceptable | Good alternative option |
Key Recommendations:
• Use lowest effective ICS dose
• Monitor for pneumonia, oral thrush, voice changes
• Can step down if no exacerbations for 1 year and eosinophils <100/μL
• Use lowest effective ICS dose
• Monitor for pneumonia, oral thrush, voice changes
• Can step down if no exacerbations for 1 year and eosinophils <100/μL
11. Advanced Therapies for Severe COPD
When patients experience ≥2 exacerbations/year despite optimized triple therapy, consider:
A. Roflumilast (PDE-4 Inhibitor)
Indication: Severe COPD (FEV₁ <50%) with chronic bronchitis and frequent exacerbations
Dose: 500 mcg once daily (oral)
Benefits: Reduces exacerbations, slight FEV₁ improvement
Side Effects: Diarrhea, nausea, weight loss (usually improve after 4-6 weeks)
Monitoring: Weight, mood, GI tolerance
B. Macrolide Prophylaxis (Azithromycin)
Indication: Former smokers with frequent exacerbations
Dose: 250-500 mg three times weekly
Duration: Minimum 6-12 months
Contraindications: Prolonged QT, hearing loss, active NTM infection
C. Nebulized Ensifentrine
Indication: Moderate-severe COPD with persistent symptoms
Dose: 3 mg twice daily via nebulizer
Benefit: Better GI tolerability; combines bronchodilation + anti-inflammation
Comparative Summary
| Therapy | Best Candidate | Key Benefit | Main Limitation |
|---|---|---|---|
| Roflumilast | Chronic bronchitis, low eosinophils | Oral, once daily | GI side effects |
| Azithromycin | Ex-smokers, frequent exacerbations | Anti-inflammatory | QT risk, hearing loss |
| Ensifentrine | Poor inhaler technique | Better tolerability | Requires nebulizer |
12. Biologic Therapy: Dupilumab
Background
GOLD 2024-2025 approved dupilumab for eosinophilic COPD, demonstrating 30-34% exacerbation reduction despite maximal inhaled therapy.
Indication Criteria (ALL Must Be Met)
Confirmed COPD (post-BD FEV₁/FVC <0.70)
Currently on LABA+LAMA+ICS (triple therapy)
≥2 moderate OR ≥1 severe exacerbation in past 12 months
Blood eosinophils ≥300 cells/μL
Age ≥40 years
Exclusions
- Dominant asthma phenotype
- Bronchiectasis-dominant disease
- ABPA or active helminth infection
Dosing & Benefits
Loading: 600 mg subcutaneous (2 × 300 mg injections)
Maintenance: 300 mg subcutaneous every 2 weeks
Expected Benefits (12 months): 30-34% exacerbation reduction, ~160 mL FEV₁ improvement, better CAT/SGRQ scores
Sri Lanka-Specific Considerations
- Include biomass-exposed women with eosinophilic COPD
- Mandatory helminth screening before initiation
- Available through MDT-approved tertiary centers
Key Message: Dupilumab is for highly selected eosinophilic COPD patients with persistent exacerbations. NOT a replacement for smoking cessation, PR, or vaccination.
13. Selecting an Inhaler Device
Principle: Match Device to Patient
Choose the inhaler device according to the patient's inspiratory capacity, hand coordination, cognition, and affordability.
The best device is the one the patient can use correctly and consistently.
Key Factors to Assess
| Domain | Key Consideration | Clinical Action |
|---|---|---|
| Inspiratory Flow | DPI requires ≥30 L/min; low flow → prefer MDI+spacer | Assess with flow meter or observe effort |
| Hand Coordination | Arthritis or weakness → avoid complex devices | Use breath-actuated MDI or SMI |
| Cognition | Memory issues → simplicity is critical | Once-daily fixed-dose combinations |
| Vision | Poor eyesight → avoid small dose counters | Simple press-and-breathe devices |
| Availability/Cost | Choose what's available locally | Match to local resources |
Device Review & Re-education
Check inhaler technique every 3 months
Use teach-back method (patient demonstrates)
Replace if resistance, leakage, or counter failure
14. Acute Exacerbation (AECOPD)
Definition
An acute worsening of dyspnea, cough, and/or sputum beyond normal day-to-day variation, requiring a change in regular therapy.
Severity Classification
| Severity | Description | Management Level |
|---|---|---|
| Mild | Symptoms managed with SABA alone | Home/OPD |
| Moderate | Requires oral corticosteroid + antibiotic | OPD/Short stay ward |
| Severe | Hospitalization, hypoxemia, respiratory failure | Hospital/HDU/ICU (±NIV) |
Early Recognition
Increased sputum volume or color change (purulent)
Increased breathlessness at rest or minimal activity
Fever (≥38°C) suggests infection
Confusion or drowsiness (hypercapnia)
Chest tightness or increased cough
Immediate Management (First Hour)
Step 1: Assess severity - Airway? SpO₂? Conscious? WOB?
↓
Step 2: Oxygen therapy - Target SpO₂ 88-92% (avoid hyperoxia)
↓
Step 3: Bronchodilators - Nebulized SABA ± SAMA every 15-20 min
↓
Step 4: Steroids + Antibiotics - Prednisolone 30-40 mg + antibiotic if purulent
15. Discharge & Post-Exacerbation
Before Discharge
SpO₂ stable ≥90% on home oxygen requirements
Able to eat, drink, mobilize independently
Pain controlled
Understand discharge medications
Follow-up appointment arranged (within 2 weeks)
Written action plan provided
Home support and contact numbers confirmed
Discharge Medications
- Oral prednisolone: Continue taper (typically 30 mg OD × 5-7 days)
- Antibiotics: Complete course (5-7 days)
- Maintenance inhalers: Continue as before or optimize
- SABA rescue: Reinforce use; avoid overuse
Post-Exacerbation Follow-Up (2-4 Weeks)
Verify recovery to baseline
Reassess inhaler technique
Reinforce medication adherence
Screen for depression, anxiety
Plan pulmonary rehabilitation referral
Prevention of Future Exacerbations
Ensure influenza and pneumococcal vaccination up-to-date
Smoking/biomass cessation support
Optimize maintenance therapy
Identify triggers and modify environment
Educate on early warning signs and action plan
16. Long-Term Follow-Up Template
Frequency of Review
- GOLD A: Annually if stable
- GOLD B: Every 3-6 months
- GOLD E: Every 1-3 months or more if unstable
Comprehensive COPD Review Checklist
| Domain | Parameters | Actions if Abnormal |
|---|---|---|
| Symptoms | CAT score, mMRC dyspnea | If CAT ≥20: review inhaler, escalate |
| Exacerbations | Frequency in past 3-12 months | If ≥2 moderate/1 severe: optimize therapy |
| Spirometry | FEV₁ trend, decline >100 mL/year | If rapid decline: check compliance, screen complications |
| Oxygenation | SpO₂ rest and exertion | If <90%: LTOT assessment |
| Weight/BMI | Weight, BMI, muscle status | If BMI <18.5: nutrition support |
| Technique | Observe patient using device | If poor: re-educate or switch device |
| Adherence | Prescription refills, patient report | If poor: identify barriers, simplify regimen |
| ICS Side Effects | Oral thrush, dysphonia, fracture risk | Manage accordingly; check for candidiasis |
| Comorbidities | HTN, DM, CAD, OSA, GERD, depression | Optimize management; refer if needed |
| Vaccinations | Influenza (annual), pneumococcal, COVID-19 | Administer if due |
| Smoking/Biomass | Current status, willingness to quit | Offer cessation support, NRT, counseling |
| Mental Health | PHQ-9 (depression), GAD-7 (anxiety) | Refer for counseling/psychology if indicated |
| Function | Exercise tolerance, ADL ability | If declining: refer for pulmonary rehabilitation |
Annual Comprehensive Assessment
Spirometry (if clinically useful)
Blood eosinophil count (if on/considering ICS changes)
Comorbidity screening and optimization
Bone density screening (DEXA) if on long-term ICS
Cognitive reassessment (if elderly)
Frailty reassessment
Goals of care discussion (especially if elderly or GOLD E)
Consider palliative care referral if appropriate
Follow-Up Philosophy:
Not every patient needs spirometry every year. Use it strategically to confirm diagnosis, detect rapid decline, or guide therapy changes. Focus on symptoms, exacerbations, and functional status at routine visits.
Not every patient needs spirometry every year. Use it strategically to confirm diagnosis, detect rapid decline, or guide therapy changes. Focus on symptoms, exacerbations, and functional status at routine visits.
17. COPD Clinical Phenotypes
Introduction
COPD is heterogeneous with multiple distinct phenotypes (emphysema-dominant, chronic bronchitis, bullous, ACO, post-TB) that guide personalized treatment and predict outcomes.
Key Concept: A phenotype is a clinically recognizable pattern of symptoms, signs, and characteristics that may respond to targeted therapy.
Major Phenotypes
- Emphysema-Predominant: Dyspnea dominant, low DLCO, hyperinflation
- Chronic Bronchitis: Productive cough, daily sputum, less dyspnea initially
- Bullous COPD: Giant bullae (>1/3 hemithorax); consider LVRS
- Asthma-COPD Overlap (ACO): Mixed features; requires ICS and biologic consideration
- Post-TB COPD: TB history with structural damage; screen for CPA and bronchiectasis
18. Treatable Traits Approach
Introduction
Treatable Traits are specific clinical problems with evidence-based solutions. Systematic identification improves outcomes regardless of FEV₁. Ideal for Sri Lanka's COPD landscape shaped by TB, biomass, CPA, and malnutrition.
Four Domains
Domain 1: Airway Traits - Airflow obstruction, eosinophilic inflammation, chronic bronchitis, exacerbation proneness
Domain 2: Structural/Parenchymal - Emphysema, bullae, post-TB, CPA, CPFE
Domain 3: Extrapulmonary - Hypercapnia, hypoxemia, sarcopenia, OSA, cardiac disease, anxiety
Domain 4: Behavioral/Environmental - Active smoking, biomass, poor technique, non-adherence, inactivity
19. LTOT, Ambulatory O₂ & NIV
Long-Term Oxygen Therapy (LTOT)
LTOT improves survival in hypoxemic COPD. Key threshold: resting SpO₂ ≤88% on room air (confirmed 2 occasions, 3 weeks apart).
Prescription: Flow 1-2 L/min (maintain SpO₂ 88-92%), ≥15 hours/day, oxygen concentrator preferred
CRITICAL: Target SpO₂ 88-92%, NOT 95-100% (hyperoxia worsens hypercapnia)
Non-Invasive Ventilation (NIV)
Acute Setting: NIV for acute respiratory acidosis (pH 7.25-7.35, PaCO₂ ≥6.0 kPa) with respiratory distress
Chronic Setting: Long-term nocturnal NIV for persistent daytime hypercapnia (PaCO₂ ≥52 mmHg) despite optimal LTOT
20. COPD in the Elderly
Introduction
COPD is predominantly a disease of older adults. Elderly patients (≥65 years) present unique diagnostic, management, and psychosocial challenges with age-related physiological changes, multimorbidity, polypharmacy, and frailty.
Key Challenges
- Underdiagnosis: Symptoms attributed to age
- Cognitive Impairment: Affects inhaler use and adherence
- Frailty & Sarcopenia: Major determinants of outcomes
- Polypharmacy: Drug interactions; increased side effects
- Multimorbidity: HTN, DM, CAD, CKD, osteoporosis, depression
- ICS Pneumonia Risk: Higher in elderly; prefer budesonide
- Fall Risk: Medication side effects, deconditioning
21. Palliative & Supportive Care
Introduction
Palliative care is NOT end-of-life care; it is patient and family-centered care aimed at relieving suffering and optimizing quality of life at any disease stage. Integrate early and throughout disease trajectory alongside disease-modifying therapies.
When to Integrate Palliative Care
- GOLD E patients with frequent exacerbations (≥2/year)
- Severe symptoms (CAT ≥20, mMRC ≥3) despite optimal therapy
- Repeated hospitalizations (≥2/year)
- Oxygen dependence or persistent hypoxemia
- Progressive functional decline and frailty
- Significant comorbidity burden
- Patient or family request for comfort-focused care
Core Components
- Symptom Management: Dyspnea, cough, fatigue, secretions, anxiety, depression
- Psychological Support: Addressing fear, loss, existential concerns
- Caregiver Support: Education, respite, burnout screening
- Advance Care Planning: Goals, preferences, surrogate decision-maker
- Spiritual Care: Chaplain, existential support
- End-of-Life Care: Comfort focus, bereavement support
Key Principle: Palliative care is complementary to disease-modifying therapy. Continue evidence-based COPD management while ADD comprehensive symptom management and psychosocial support.
📎 ANNEXURES & APPENDIX
ANNEXURE A: Self-Management Plan
Three Zones system empowers patients to recognize worsening symptoms and take appropriate action.
| 🟢 GREEN (Well) | 🟡 YELLOW (Caution) | 🔴 RED (Danger) |
|---|---|---|
| Normal breathing, Normal activity, Sleep well | More breathless, Cough increased, Poor sleep | Severe breathlessness at rest, Confusion, Blue lips |
| Action: Take maintenance inhalers | Action: Increase reliever, contact GP in 24h | Action: CALL EMERGENCY NOW |
ANNEXURE B: Home Pulmonary Rehabilitation
Duration: 8-12 weeks, 3-5 days/week, 20-30 min/session
Goal: Improve exercise capacity, reduce dyspnea, enhance QOL
Components: Walking program, strengthening, breathing techniques, energy conservation, psychosocial support
ANNEXURE C: COPD Vaccination Schedule
| Vaccine | Schedule | Key Points |
|---|---|---|
| Influenza | Annually, Sep-Nov | Reduces exacerbation risk 25-40% |
| Pneumococcal | PCV20 OR PPSV23 every 5 years | Prevents invasive disease |
| COVID-19 | Primary + annual boosters | COPD is high-risk group |
ANNEXURE D: Smoking Cessation & Biomass
The 5 As Approach
- ASK - Identify tobacco users at every visit
- ADVISE - Strongly urge all users to quit
- ASSESS - Determine willingness to quit
- ASSIST - Help develop quit plan (behavioral + NRT/varenicline)
- ARRANGE - Schedule follow-up contact
Biomass Reduction: Improved stoves, ventilation, LPG transition, occupational PPE
ANNEXURE E: Pre-COPD & PRISm Spectrum
Pre-COPD and PRISm identification allows early intervention through lifestyle modification and prevention. Close follow-up essential to prevent progression to frank COPD.
ANNEXURE F: Inhaler Device Selection
Device selection is as critical as medication choice. Considerations: inspiratory flow, hand coordination, cognition, vision, availability, cost. Best device = one patient uses correctly and consistently.
ANNEXURE G: COPD Assessment Test (CAT)
8-item questionnaire measuring COPD impact on health status and QOL.
| CAT Score | Interpretation |
|---|---|
| 0-10 | Low impact |
| 11-20 | Moderate impact |
| 21-30 | High impact |
| 31-40 | Very high impact |
📝 APPENDIX: Abbreviations
| ABG | Arterial Blood Gas |
| ACO | Asthma-COPD Overlap |
| AECOPD | Acute Exacerbation COPD |
| BDR | Bronchodilator Response |
| BMI | Body Mass Index |
| CAT | COPD Assessment Test |
| COPD | Chronic Obstructive Pulmonary Disease |
| CPAP | Continuous Positive Airway Pressure |
| CPFE | Combined Pulmonary Fibrosis Emphysema |
| CPA | Chronic Pulmonary Aspergillosis |
| CXR | Chest X-Ray |
| DPI | Dry Powder Inhaler |
| DLCO | Diffusing Capacity CO |
| ERS | European Respiratory Society |
| FEV₁ | Forced Expiratory Volume 1 sec |
| FVC | Forced Vital Capacity |
| GERD | Gastro-Esophageal Reflux Disease |
| GOLD | Global Initiative Chronic Obstructive Lung Disease |
| HRCT | High-Resolution CT |
| ICS | Inhaled Corticosteroid |
| LABA | Long-Acting Beta-2 Agonist |
| LAMA | Long-Acting Muscarinic Antagonist |
| LTOT | Long-Term Oxygen Therapy |
| MDI | Metered-Dose Inhaler |
| mMRC | Modified Medical Research Council |
| NIV | Non-Invasive Ventilation |
| NTM | Non-Tuberculous Mycobacteria |
| OSA | Obstructive Sleep Apnea |
| OPD | Out-Patient Department |
| PAL | Practical Approach to Lung Health |
| PDE-4 | Phosphodiesterase-4 Inhibitor |
| PR | Pulmonary Rehabilitation |
| PRISm | Preserved Ratio Impaired Spirometry |
| SABA | Short-Acting Beta-2 Agonist |
| SAMA | Short-Acting Muscarinic Antagonist |
| SGRQ | St George Respiratory Questionnaire |
| SLCP | Sri Lanka College of Pulmonologists |
| SMI | Soft Mist Inhaler |
| SpO₂ | Peripheral Oxygen Saturation |
| TB | Tuberculosis |
📚 Document Status:
Title: PAL 2025 - COPD Clinical Guidelines
Edition: Complete Merged Version (Sections 1-21 + Annexures A-G + Appendix)
For: Primary, Secondary, Tertiary Care in Sri Lanka
Status: ✅ FINALIZED - MOBILE & TABLET FRIENDLY
Last Updated: December 2025
Title: PAL 2025 - COPD Clinical Guidelines
Edition: Complete Merged Version (Sections 1-21 + Annexures A-G + Appendix)
For: Primary, Secondary, Tertiary Care in Sri Lanka
Status: ✅ FINALIZED - MOBILE & TABLET FRIENDLY
Last Updated: December 2025