Management of Chronic Stable COPD *Based on GOLD Risk Stratification 2019 Category Symptoms Risk Suggested Treatment Co- Management ALL Patients Short-acting Bronchodilator (rescue) Self-Management Education Smoking cessation Increase Exercise tolerance Influenza and Pneumococcal vaccination A Less symptomatic Mild or infrequent symptoms, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill Low Risk mMRC 0-1 or CAT <10, AND 0 to 1 exacerbations a year not leading to hospital admission Pharmacologic: First choice: LAMA or LABA Primary Care B More symptomatic: Moderate to sever symptoms (i.e. Patient has to walk more slowly that others of the same age due to breathlessness, has to stop to catch breath when walking on level ground) Pharmacologic Second Choice: LABA/ICS combination in patients eos ≥ 300 or eos ≥100 AND ≥ 2 moderate exacerbations/ 1 hospitalization Non-Pharmacologic: Pulmonary Rehab C High Risk mMRC ≥ 0-1 or CAT ≥ 10, AND ≥ 2 exacerbations a year OR ≥ 1 leading to hospitalization First choice: LAMA Consider Referral to Pulmonary Medicine for Co-Management D First choice: LAMA: Initial therapy LAMA/LABA: Preferred if highly symptomatic (i.e. CAT >20) LABA/ICS: Preferred if eos ≥300 Second choice: LAMA/LABA/ICS: Preferred as escalation of therapy if eos ≥ 100 with predominant exacerbations OR if dyspnea is not controlled by LABA/ICS Primary Care Referral to Pulmonary Medicine for Co- Management Palliative care referral for COPD Patients with more than 1 hospitalization a year for COPD Exacerbation

Hospital Follow Up and Referral Pathways for COPD Hospital Follow Up for Acute Exacerbation of COPD Phone Call within 24 hours of Discharge Office Visit within 3- 7 days with PCP Refer to Pulmonary if meets criteria Arrange for Pulmonary follow up, if established patient Refer to Palliative Care, per criteria below Referral Pathways Pulmonary to Consult and Co- Manage: Severe COPD, GOLD Stage D Pulmonary to Consult and Co- Manage: If 2 or more admissions per year for AE-COPD Palliative care consult: If ≥ 1 hospitalizations per year for COPD