Practice Guidelines

Treatment of Chronic Obstructive Pulmonary Disease: Guidelines from the American Thoracic Society


Am Fam Physician. 2021 Jul ;104(1):102-103.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• For symptomatic COPD, combination LABA/LAMA therapy is recommended over monotherapy because of reduced exacerbations and hospitalizations and improvements in dyspnea.

• Adding an ICS to LABA/LAMA therapy further reduces exacerbations but increases pneumonia risk with no change in hospitalization rate.

• Maintenance oral corticosteroid therapy does not appear to improve outcomes in COPD, but it does increase adverse events.

• Long-term oxygen therapy reduces mortality in patients with COPD who have severe hypoxia and a resting oxygen saturation of 88% or less.

From the AFP Editors

Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation from airway or alveolar abnormalities. The goal of medical treatment for COPD is to reduce exacerbation frequency, improve quality of life, and control symptoms.

The American Thoracic Society (ATS) published guidelines for pharmacologic management of COPD and long-term oxygen therapy for COPD and interstitial lung disease based on systematic reviews.

Baseline Therapy

For patients with symptoms from COPD, the ATS recommends combination therapy with a long-acting beta agonist (LABA) and a long-acting muscarinic antagonist (LAMA) based on improved outcomes over monotherapy with either agent. LABA/LAMA combination therapy results in fewer exacerbations than monotherapy, with a number needed to treat (NNT) of 12 to prevent one exacerbation (95% CI, 8 to 29). Hospitalizations are also reduced with combination therapy (NNT = 53; 95% CI, 31 to 200) compared with monotherapy. With LABA/LAMA combination therapy, patients experience a mild decrease in dyspnea and a clinically insignificant quality of life improvement without increased adverse events.

Adding Corticosteroid Therapy

If patients with COPD are symptomatic despite combination LABA/LAMA therapy, adding an inhaled corticosteroid (ICS) can be considered. Adding the ICS reduces exacerbations over LABA/LAMA therapy (NNT = 16; 95% CI, 12 to 33) without changing

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at



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