Practice Guidelines

Treatment of Chronic Obstructive Pulmonary Disease: Guidelines from the VA/DoD


Am Fam Physician. 2021 Jul ;104(1):98-99.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• For stable COPD, LAMAs are the most effective monotherapy.

• For continued symptoms despite LAMA monotherapy, consider adding a LABA, followed by an ICS.

• In COPD exacerbations, adding antibiotics to oral corticosteroids reduces treatment failure but does not reduce repeat exacerbations or mortality.

• Supplemental oxygen is only beneficial for patients with severe resting hypoxemia.

From the AFP Editors

Chronic obstructive pulmonary disease (COPD) is a devastating disease affecting more than 16 million Americans, and the third leading cause of death globally. Mortality from COPD has increased over the past 50 years, and mortality in women has surpassed that in men. The U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) published guidelines for the primary care management of COPD.


Treatment for COPD can be started based on symptoms. Spirometry can be used later for confirmation of the diagnosis.

Stable COPD Treatment

Long-acting bronchodilators are the primary maintenance therapy for stable COPD because they decrease dyspnea and exacerbations while improving quality of life. Long-acting muscarinic antagonists (LAMAs) reduce exacerbations and hospitalizations more than long-acting beta agonists (LABAs), with fewer adverse events, and are the most effective monotherapy. No LAMA formulation appears to be more effective than any other. Monotherapy with an inhaled corticosteroid (ICS) is less effective than either LABA or LAMA monotherapy and increases the risk of candidiasis, hoarseness, and pneumonia.

With continued symptoms despite treatment with a LAMA, consider adding a second medication. This is an individual decision due to a lack of criteria for adding medications. Individuals on LAMA monotherapy with continued symptoms may benefit from adding a LABA without increased harms, although improvements may not be clinically significant. In contrast, ICS/ LABA combination therapy is less effective than LAMA

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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