Decision support only — not a substitute for the COPD-X Plan, eTG, or your respiratory team. Confirm the diagnosis with post-bronchodilator spirometry (FEV₁/FVC <0.7) before committing to lifelong therapy. Inhaler escalation is driven by symptoms, exacerbation history, and blood eosinophils. Verify all doses and PBS criteria.
1 Inhaled therapy — step up by symptoms, exacerbations & eosinophils
Reliever — everyoneas required
All patients, all steps.
SABA ± SAMA PRN for symptom relief. Not a maintenance strategy on its own.
Single long-actingGOLD Group A
Persistent symptoms, low exacerbation risk.
LAMA (preferred) or LABA. Starting LAMA delays escalation vs ICS/LABA.
Dual bronchodilatorGroup B; ongoing Sx/exac
Ongoing symptoms or exacerbations on monotherapy.
LABA + LAMA — the workhorse maintenance. Single inhaler where possible.
Triple therapyexac despite dual
Exacerbations on LABA+LAMA, and eosinophils support ICS.
LABA + LAMA + ICS. Add ICS if eos ≥100; evidence strongly favours ≥300. Direct-to-triple at diagnosis if eos ≥300 + exacerbating.
Refractory exacerbatorsdespite triple
Frequent exacerbations on optimal inhaled therapy.
Azithromycin (ex-smokers) or roflumilast (FEV₁<50% + chronic bronchitis). Dupilumab if chronic bronchitis + eos ≥300. Refer.
Eosinophil logic: on dual + exacerbating → eos ≥100 add ICS, eos <100 favour azithromycin/roflumilast. The ladder is the visible part — but smoking cessation, pulmonary rehab and vaccination sit under every rung and do more for outcomes than any inhaler choice.
2 The foundation — this is where the outcomes are
Smoking cessation
- ImpactThe only intervention that slows lung-function decline and cuts mortality. Ask every visit.
- HowCombine support with pharmacotherapy: varenicline, NRT, or bupropion.
Pulmonary rehab
- ReferAll symptomatic patients. Improves dyspnoea, exercise capacity, QoL; reduces admissions.
- AfterEspecially post-exacerbation — the highest-yield window.
Prevent & support
- VaccinateInfluenza, pneumococcal, COVID, RSV, pertussis.
- Self-mgmtWritten COPD Action Plan ± rescue pack; physical activity; nutrition; treat comorbidities.
3 Getting the ICS decision right
When ICS helps
- Add itExacerbations + eos ≥300 (strong), or ≥100 (consider). Also asthma–COPD overlap.
- Triple>dualWhen ICS is indicated, triple beats ICS/LABA for exacerbation prevention (IMPACT, ETHOS).
- MortalitySignal exists, but partly an artefact of abrupt ICS withdrawal in comparator arms — read it cautiously.
When ICS hurts — and stepping down
- HarmPneumonia risk, oral candidiasis, dysphonia. ICS is not for every COPD patient.
- Low eoseos <100 → ICS unlikely to help; favour azithromycin/roflumilast instead.
- De-escalateGOLD 2025 now supports ICS withdrawal in stable non-exacerbators, eos-guided (WISDOM, SUNSET).
- TechniqueCheck device technique & adherence every visit — a wrong inhaler beats no escalation.
4 Beyond inhalers
Long-term oxygen
- CriteriaSevere resting hypoxaemia: PaO₂ ≤55 mmHg (7.3 kPa), or ≤59 (7.8) with cor pulmonale/polycythaemia. ≥15h/day.
- BenefitSurvival in this group only (NOTT/MRC). Patient must be stable & non-smoking (fire risk).
- Not forNot for breathlessness with mild/moderate desaturation — no benefit (LOTT).
Add-on drugs
- AzithromycinFrequent exacerbators, best in ex-smokers. Baseline ECG (QTc), hearing, resistance.
- RoflumilastFEV₁<50% + chronic bronchitis + exacerbations. GI upset, weight loss.
- DupilumabNew (GOLD 2025): chronic bronchitis + eos ≥300 on triple.
Advanced / severe
- Home NIVChronic hypercapnia → reduces admission/death (HOT-HMV). Refer.
- LVREndobronchial valves or surgery for selected hyperinflated/emphysema.
- TransplantAdvanced disease, declining — refer early.
- PalliativeLow-dose opioids for refractory breathlessness; advance care planning.
5 The whole patient
Comorbidities — actively look
- CVDLeading cause of death in COPD — don't withhold cardioselective beta-blockers when indicated.
- BonesOsteoporosis — DXA, especially with repeated steroid courses.
- MoodAnxiety & depression are common and under-treated.
- CancerLung cancer risk — assess LDCT screening eligibility; investigate new symptoms.
Don't forget
- Alpha-1Test for α1-antitrypsin deficiency: early onset, minimal smoking, basal emphysema, family history.
- OverlapConsider asthma-COPD overlap, bronchiectasis, OSA.
- ReviewRegular review, yearly spirometry, inhaler technique every visit, action plan current.
- ACPAdvance care planning before the crisis, particularly in severe disease.
Sources.
COPD-X Plan — Australian & New Zealand Guidelines for the Management of COPD (Lung Foundation Australia / TSANZ), V2.78 Dec 2025 (Optimise function; Prevent deterioration; Develop self-management). GOLD 2025 report (ABE groups, eosinophil-guided escalation, ICS de-escalation, dupilumab). eTG; PBS for subsidised combinations.
Key trials: IMPACT & ETHOS (triple vs dual; mortality signal — ICS-withdrawal confounding); WISDOM/SUNSET/INSTEAD (ICS withdrawal); NOTT & MRC (LTOT survival); LOTT (no benefit for moderate desaturation); HOT-HMV (home NIV in chronic hypercapnia).
Caveats: eosinophil thresholds (≥100 consider / ≥300 strong) guide both adding and removing ICS — they are a guide, not a switch. LTOT prescription has strict gas criteria; confirm locally. PBS authority criteria govern which combinations are subsidised. Verify all doses. Companion to the acute COPD exacerbation sheet.