COPD
Do not use bronchitis GUO for AECOPD. No ICS if low exacerbation risk unless asthma overlap. For asthma overlap, see Asthma.
Diagnose
Spirometry- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Confirm COPD | Post-bronchodilator FEV1/FVC <0.7 Spirometry required. Confirms airflow obstruction. |
| Symptoms | mMRC ≥2 or CAT ≥10 significant mMRC 0–1 or CAT <10 is low symptom burden. |
| Exacerbation risk | ≥2 moderate or ≥1 hospitalized in past year High exacerbation risk: ≥2 moderate exacerbations or ≥1 requiring hospitalization in past year. |
How to score mMRC
mMRC (modified Medical Research Council) grades usual breathlessness from 0 to 4. Ask which one description matches typical days. Do not add grades together. INESSS treats 0–1 as low symptom burden and ≥2 as significant. MDCalc mMRC opens in a new tab.
| Grade | Usual breathlessness |
|---|---|
| 0 | I only get breathless with strenuous exercise |
| 1 | I get short of breath when hurrying on level ground or walking up a slight hill |
| 2 | On level ground, I walk slower than people of my age because of breathlessness, or I have to stop for breath when walking at my own pace on the level |
| 3 | I stop for breath after walking about 100 yards or after a few minutes on level ground |
| 4 | I am too breathless to leave the house or I am breathless when dressing/undressing |
What CAT is
CAT (COPD Assessment Test) is an 8-item questionnaire. Score 0–40. INESSS uses it with mMRC to grade symptom burden. Do not reprint the items here. Use the official CAT. CAT for clinicians opens in a new tab.
- CAT <10: few or no symptoms
- CAT 10–20: significant symptoms
- CAT >20: important symptoms
- Initial inhaler class uses CAT <10 vs ≥10, the same split as mMRC 0–1 vs ≥2
Treat
Initial inhalers- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Rescue | SABA PRN Short-acting β2-agonist for acute dyspnea.
|
| Low symptoms | LAMA or LABA (LAMA preferred) mMRC 0–1 or CAT <10.
|
| Significant symptoms | LAMA + LABA mMRC ≥2 or CAT ≥10: start LAMA + LABA dual bronchodilator. |
| High exacerbation risk | LAMA + LABA + ICS High exacerbation risk (≥2 moderate or ≥1 hospitalized in past year).
|
| Drug | Class | Dose | How often |
|---|---|---|---|
| Rescue | |||
| Salbutamol (Ventolin HFA, generics) | SABA | 100 mcg, 1–2 puffs (max 8 puffs/24 h) | PRN |
| Terbutaline (Bricanyl Turbuhaler) | SABA | 0.5 mg, 1 inhalation (max 6/24 h) | PRN |
| Ipratropium (Atrovent HFA, generics) | SAMA | 20 mcg, 2 puffs | TID–QID |
| One long-acting bronchodilator | |||
| Tiotropium (Spiriva Respimat) | LAMA | 2.5 mcg, 2 puffs | DIE |
| Tiotropium (Spiriva HandiHaler, generics) | LAMA | 18 mcg, 1 capsule inhaled (do not swallow) | DIE |
| Umeclidinium (Incruse Ellipta) | LAMA | 62.5 mcg, 1 inhalation | DIE |
| Glycopyrronium (Seebri Breezhaler) | LAMA | 50 mcg, 1 capsule inhaled (do not swallow) | DIE |
| Aclidinium (Tudorza Genuair) | LAMA | 400 mcg, 1 inhalation | BID |
| Formoterol (Oxeze Turbuhaler) | LABA | 6 or 12 mcg, 1 inhalation | BID |
| Salmeterol (Serevent Diskus) | LABA | 50 mcg, 1 inhalation | BID |
| Dual bronchodilator | |||
| Tiotropium/olodaterol (Inspiolto Respimat) | LAMA+LABA | 2.5/2.5 mcg, 2 puffs | DIE |
| Umeclidinium/vilanterol (Anoro Ellipta) | LAMA+LABA | 62.5/25 mcg, 1 inhalation | DIE |
| Indacaterol/glycopyrronium (Ultibro Breezhaler) | LAMA+LABA | 110/50 mcg, 1 capsule inhaled (do not swallow) | DIE |
| Escalation | |||
| Salmeterol/fluticasone (Advair Diskus 250 or 500) | ICS/LABA | 250/50 or 500/50 mcg, 1 inhalation | BID |
| Formoterol/budesonide (Symbicort Turbuhaler 200) | ICS/LABA | 200/6 mcg, 2 inhalations | BID |
| Vilanterol/fluticasone furoate (Breo Ellipta 100) | ICS/LABA | 100/25 mcg, 1 inhalation | DIE |
| Formoterol/budesonide/glycopyrronium (Breztri Aerosphere) | ICS/LAMA/LABA | 2 puffs of 160/7.2/5 mcg | BID |
| Vilanterol/umeclidinium/fluticasone furoate (Trelegy Ellipta) | ICS/LAMA/LABA | 100/62.5/25 mcg, 1 inhalation | DIE |
Class abbreviations
Classes match the INESSS MPOC devices and molecules table (September 2025; RAMQ list 14 August 2025). English labels are the usual clinical equivalents of the INESSS French abbreviations. INESSS devices and molecules opens in a new tab.
- SABA — short-acting β2-agonist (INESSS BACA)
- SAMA — short-acting muscarinic antagonist (INESSS AMCA)
- LAMA — long-acting muscarinic antagonist (INESSS AMLA)
- LABA — long-acting β2-agonist (INESSS BALA)
- LAMA+LABA — dual long-acting bronchodilator (INESSS BALA/AMLA)
- ICS/LABA — inhaled corticosteroid + LABA (INESSS BALA/CSI)
- ICS/LAMA/LABA — triple therapy (INESSS BALA/AMLA/CSI)
- ICS — inhaled corticosteroid (INESSS CSI)
RAMQ notes and products not covered
Match the device to inhaler technique. Doses are the Health Canada monograph start for COPD. Coverage and exception codes stay in the INESSS devices table. INESSS devices and molecules opens in a new tab.
- Anoro Ellipta and Ultibro Breezhaler: exception code RE176
- Advair Diskus: exception code RE172
- Ventolin Diskus: exception codes RE112 / RE113 (HFA is regular coverage)
- Breo Ellipta 100 is the COPD strength;
- 200 is not indicated for COPD
- Duaklir Genuair (Aclidinium/Formoterol) and Combivent Respimat (Ipratropium/Salbutamol): INESSS did not recognize therapeutic value;
- not on the public list
- Atectura, Enerzair, and Zenhale are listed for asthma, not COPD
- Oxeze monograph is asthma add-on;
- INESSS still lists both 6 and 12 mcg among COPD-evaluated devices
Exacerbations (AECOPD)
Prednisone + antibioticsAntibiotics only if presumed bacterial (purulent sputum plus increased dyspnea or volume) and moderate or severe. Change antibiotic class if another bacterial AECOPD within 3 months. Open the INESSS EAMPOC GUO for allergy. To reassess a penicillin label, see Penicillin allergy.
| Drug | Usual | Frail or other concerns | Duration |
|---|---|---|---|
| Prednisone | 50 mg PO DIE | 25 mg PO DIE | 5 days |
| Drug | Dose | Duration |
|---|---|---|
| First-line — low failure risk | ||
| Amoxicillin | 1000 mg PO TID | 5 days (5–7) |
| Azithromycin | 500 mg day 1, then 250 mg DIE | 5 days |
| Clarithromycin | 500 mg PO BID | 5 days (5–7) |
| Clarithromycin XL | 1000 mg PO DIE | 5 days (5–7) |
| Doxycycline | 100 mg PO BID | 5 days (5–7) |
| TMP-SMX | 160/800 mg PO BID | 5 days (5–7) |
| First-line — other options | ||
| Cefuroxime axetil | 500 mg PO BID | 5 days (5–7) |
| Cefprozil | 500 mg PO BID | 5 days (5–7) |
| First-line — high failure risk | ||
| Amox-clav 7:1 | 875/125 mg PO BID | 5 days (5–7) |
| First-line — Pseudomonas suspected | ||
| Levofloxacin | 750 mg PO DIE | 5 days (5–7) |
| First-line — P. aeruginosa identified | ||
| Ciprofloxacin | 750 mg PO BID | 7–10 days |
| Second-line — low failure risk | ||
| Amox-clav 7:1 | 875/125 mg PO BID | 5 days (5–7) |
| Second-line — Pseudomonas suspected | ||
| Levofloxacin | 750 mg PO DIE | 5 days (5–7) |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Inhaler review | Assess treatment adherence, verify inhalation technique, and regularly evaluate tolerance and satisfaction, particularly after therapy modifications. |
| After the start | Close follow-up (1–3 months after initiating therapy) allows monitoring of adherence, adverse effects, symptom changes, and exacerbation events.
|
| Benefits | Evaluate the benefits of pharmacological treatment and satisfaction within 6–12 months, depending on treatment type, disease severity, and comorbidities. |
| Device | Continuously reassess inhalation device selection within an interdisciplinary context, considering disease progression, overall health, the person's capabilities (e.g., dexterity, MNCD), and after any unplanned healthcare episode. |
| Worsening | If symptoms worsen 48 to 72 hours after treatment, consider medical reassessment. |
| Stable period | Verify inhalation technique and assess tolerance and satisfaction with COPD treatment during a stable period. |
Reviewed 31 August 2026 against the official sources below.
Sources
Blue square: Québec. The code names the body; each section's key gives its full name.