COPD — the Pakistan pathway

Highest prevalence in the region, a fifth of it in people who never smoked, and a whole chapter on obstruction after tuberculosis that GOLD does not have.

The fact most likely to change a consultation. In COPD secondary to tuberculosis, only 27% have a positive bronchodilator response — against 82% in COPD alone. A poor response in a patient with a TB history is what post-TB obstruction looks like. It is not a reason to stop treating.

Every recommendation here carries a divergence badge. Same as international guideline Pakistan-adapted Local data only National guideline outdated

The pharmacology follows GOLD 2025 closely and is badged as such. What is local is the burden, the household biomass advice, the ceiling-of-care decision made on admission, and post-TB COPD.

Decision-support only. The published guideline is a scanned document with no text layer, so everything here was transcribed from rendered pages by eye. Verify doses against the original before prescribing.

Step 1 · Who gets it here

Pakistan Chest Society — Guidelines for the Management of COPD, 2026 revised edition

Pakistan-adapted Written, in the guideline's own words, to give evidence-based recommendations while maintaining simplicity for the assessment, diagnosis and management of COPD by graduates, postgraduates and general practitioners. Aligned to GOLD 2025.

Highest in the region — and not only in smokers Local data only

Pakistan's COPD prevalence	13.8% — the highest in the WHO Eastern Mediterranean Region Meta-analysis, 2018.
Global prevalence, adults 40 and over	12.6% by fixed ratio, 7.4% by lower limit of normal 2024 systematic review and meta-analysis of over 100 population-based studies across 94 countries.
Global ranking	4th leading cause of death As of 2021 — around 3.5 million deaths, roughly 5% of global mortality, and the 8th leading cause of disability-adjusted life years.

A fifth of moderate-to-severe COPD is in people who never smoked

The BOLD study looked at 4,291 never-smokers aged 40 and over: 6.6% met criteria for mild COPD and 5.6% for moderate-to-very-severe disease. Never-smokers accounted for 23.3% of all GOLD stage II+ cases — 20.5% even using the stricter lower-limit-of-normal threshold.

What that means at the desk. The risk factors behind that are advancing age, lower educational attainment particularly in women, occupational exposure, childhood respiratory disease and abnormal body mass index. In Pakistan the household exposure in step 5 belongs on that list too. "Does she smoke?" is not a screening question for COPD here.

Step 2 · Grading it

PCS 2026 — chapter 9, on GOLD 2025

Grading it — the ABE tool, not the old ABCD grid Same as international guideline

The 2023 GOLD report merged the old C and D groups into a single group E, to recognise that an exacerbation matters regardless of how symptomatic the patient is between attacks. This guideline uses that version, and separates the spirometry classification from the symptom and exacerbation assessment. For symptoms it prefers the CAT score.

Group	Symptoms	Exacerbations
A	mMRC 0–1, CAT below 10	No moderate or severe exacerbation in the previous year
B	mMRC 2 or more, CAT 10 or more	No moderate or severe exacerbation in the previous year
E	Any level of symptoms	One or more moderate or severe exacerbations in the previous year

The three numbers worth adding

Blood eosinophils

Blood eosinophil count predicts how much inhaled corticosteroid will reduce future exacerbations, and GOLD recommends using it to guide ICS. A count of 300 cells/µL or above marks the patients most likely to benefit.

DLco

Measure DLco in anyone whose breathlessness is out of proportion to their airflow obstruction. Values below 60% predicted independently predict more symptoms, less exercise capacity, worse health status and higher mortality.

BODE index

The BODE composite — body mass index, obstruction, dyspnoea, exercise — predicts survival better than any single component.

Step 3 · What to start, and how to adjust it

PCS 2026 — chapter 12, figures 12.2 and 12.4

What to start Same as international guideline

Bronchodilators are first-line. Pharmacological treatment reduces symptoms, improves exercise capacity, reduces exacerbation risk, improves health status and reduces mortality.

Group	Initial treatment
Group A	A bronchodilator
Group B	LABA + LAMA
Group E	LABA + LAMA — and consider LABA + LAMA + ICS if the blood eosinophil count is 300 cells/µL or above

Single-inhaler therapy may be more convenient and more effective than multiple inhalers.

Adjusting it — two tracks, not one ladder Same as international guideline

Follow-up therapy is chosen by which of two treatable traits persists: breathlessness, or exacerbations. They lead to different escalations, and a patient can be on either track regardless of the group they started in.

If breathlessness is the problem

LABA or LAMA, escalating to LABA + LAMA.
If breathlessness persists on dual therapy: consider switching the inhaler device or the molecule, escalate non-pharmacological treatment, consider adding ensifentrine — and investigate other causes of breathlessness.

If exacerbations are the problem

LABA or LAMA, escalating to LABA + LAMA if the blood eosinophil count is below 300.
If the eosinophil count is 300 or above, go to LABA + LAMA + ICS.
Still exacerbating on LABA + LAMA with eosinophils 100 or above: add ICS.
Still exacerbating with eosinophils below 100: roflumilast if FEV₁ is under 50% with chronic bronchitis, or azithromycin — preferentially in chronic bronchitis — or dupilumab in chronic bronchitis.

Stepping down. Consider de-escalating ICS if pneumonia or other considerable side effects occur. But note the asymmetry: with eosinophils at 300 or above, de-escalation is more likely to be followed by an exacerbation.

The management cycle is review, assess, adjust. Review symptoms, breathlessness and exacerbations; assess inhaler technique, adherence and non-pharmacological treatment; then escalate, switch device or molecule, or de-escalate.

Step 4 · The half that is not a prescription

PCS 2026 — chapter 13

Smoking cessation Pakistan-adapted

Where time and resources are genuinely dedicated to it, long-term quit rates of 14% to 27% are reported. Counselling combined with pharmacotherapy is the most effective combination in COPD.

Indicators of high nicotine dependence

Smoking within 30 minutes of waking
Smoking at night
Twenty or more cigarettes a day
A Fagerström score of 7–10, or 5–6 on the Heaviness of Smoking Index

Indoor and occupational pollution Pakistan-adapted

Indoor pollution due to burning of wood and coal to keep houses warm in winter and use of biomass fuel in stoves should be minimized and measures should be taken to reduce exposure as by cooking in open air rather than a closed kitchen, having separate cooking area, making chimneys etc.

This is the paragraph international guidance does not write, and it is household-level and actionable: move the cooking outdoors, separate the cooking area, put in a chimney. Irritant particles and gases at work should be avoided too.

Heat and cold

People with COPD are at increased risk of death from exposure to both heat and cold, with cold carrying the greater risk. In cold weather, keep bedroom temperatures above 18°C. In a heatwave, stay hydrated, keep out of the heat, and aim for living spaces below 32°C and sleeping spaces below 24°C, as WHO recommends.

Pulmonary rehabilitation and nutrition

Mild to moderate disease: walking, cycling or swimming, about 30 minutes daily, which can be split into two or three sessions or done until breathlessness stops the patient.
Severe disease: exercise aimed at the strength and endurance of respiratory, abdominal, back, neck and limb muscles.
A low body mass index is an independent risk factor for mortality in COPD — increased calorie intake should come with a regimen that has anabolic action.
Obesity brings its own breathlessness and activity limitation. A well-balanced diet is what is recommended, in both directions.

Step 5 · The exacerbation

PCS 2026 — chapter 14, table 14.1

The exacerbation — and the decision to admit Same as international guideline

Moderate. Heart rate 90 bpm or more; SaO₂ below 92% on room air or baseline oxygen, with a drop of 3% or more from a known baseline; CRP 10 mg/L or above. Blood gases, if taken, may show hypoxaemia with PaO₂ below 60 mmHg and/or hypercapnia with PaCO₂ above 45 mmHg but no acidosis.

Severe. The same clinical indicators as moderate, but with blood gases revealing worsening hypercapnia and acidosis — PaCO₂ above 45 mmHg and pH below 7.35.

Peak expiratory flow is not useful for deciding whether a COPD exacerbation needs admission. After grading severity, look for the cause — viral panels, sputum culture or other relevant tests.

Treat at home, or admit?

	Treat at home	Treat in hospital
Able to cope at home	Yes	No
Breathlessness	Mild	Severe
General condition	Good	Poor and worsening
Level of activity	Good	Poor
Cyanosis	No	Yes
Worsening peripheral oedema	No	Yes
Level of consciousness	Normal	Impaired
Already on supplemental oxygen	No	Yes
Social support	Good	Not coping, or alone
Acute confusion	No	Yes
Changes on chest X-ray	No	Yes
Rapid rate of onset	No	Yes
Arterial pH	7.35 or above	Below 7.35
PaO₂	52 mmHg or above	Below 52 mmHg

Treated at home

Add or increase the bronchodilator. Metered-dose inhalers with a spacer are preferred: salbutamol 2 puffs hourly, then 3–4 hourly. Ipratropium bromide 2 puffs four-hourly can be added.
If the response is not adequate, add sustained-release theophylline 200–400 mg twice daily.
Add an antibiotic if there is any evidence of infection. Amoxicillin, with or without clavulanate, is a good first-line option; respiratory quinolones and macrolides are alternatives.
Oral steroids are not recommended in mild exacerbations, but can be prescribed for more severe symptoms at 30 mg/day for one week.

A unit correction. The printed guideline gives the salbutamol and ipratropium doses in milligrams per puff. Those are micrograms — salbutamol 100 micrograms per actuation, ipratropium 20–40 micrograms. The typo is in the source; the doses above are the standard inhaler strengths.

Treated in hospital

Oxygen

Controlled, by Venturi mask or nasal cannula. Target SpO₂ 88–92% — not higher.

Blood gases

In the first hour, and within one hour of any change in FiO₂. Repeat after an hour of full medical management.

Bronchodilators

Salbutamol 5 mg (1 mL) diluted in 2–3 mL normal saline, with or without ipratropium bromide 500 micrograms. If no nebuliser is available, a metered-dose inhaler works: salbutamol up to 6–8 puffs every half hour, and/or ipratropium 6–8 puffs every 3–4 hours. If PEFR is around 200 L/min or FEV₁ around 500 mL, a compressor-driven nebuliser is preferred.

Steroids

Hydrocortisone 250 mg IV stat, then 100 mg IV eight-hourly. Switch to oral 30–40 mg/day, preferably as a single morning dose, once the patient can take it by mouth. Up to 14 days.

Antibiotics

A respiratory quinolone, amoxicillin-clavulanate, or a second- or third-generation cephalosporin. Gram-negative infection is more common in severe COPD, so ciprofloxacin or a third-generation cephalosporin is used there.

Theophylline

Narrow therapeutic index and major interactions, including with erythromycin — use with caution. If none in the last 24 hours, give a loading dose over 30 minutes, then maintenance at 0.5 mg/kg/hour; up to 0.9 mg/kg/hour in children, young adults and smokers; 0.25 mg/kg/hour if prior use is uncertain. Loading dose = 10 mg/L × body weight in kg × 0.5.

Everything else

Venous thromboembolism prophylaxis, and attention to fluid and nutritional balance.

Intensive care. Move to intensive care if the patient continues to deteriorate or the blood gases worsen. Haemodynamic instability, or a plan for invasive ventilation, means ICU. The guideline also says plainly that ICU admission may not be appropriate for patients with poor functional status or end-stage lung disease.

Common questions

How common is COPD in Pakistan?

A 2018 meta-analysis puts prevalence at 13.8% — the highest in the WHO Eastern Mediterranean Region. Globally COPD is the fourth leading cause of death, responsible for around 3.5 million deaths a year.

Can someone who never smoked have COPD?

Yes, and it is common. In the BOLD study never-smokers accounted for 23.3% of all GOLD stage II+ cases. Risk factors include age, lower educational attainment particularly in women, occupational exposure, childhood respiratory disease and abnormal BMI — and in Pakistan, indoor biomass and coal smoke.

What is the ABE assessment tool?

Group A is mMRC 0–1 or CAT under 10 with no exacerbation in the past year; group B is mMRC 2 or more or CAT 10 or more with no exacerbation; group E is one or more moderate or severe exacerbations in the past year regardless of symptom level. It replaced the old ABCD grid in the 2023 GOLD report, merging C and D into E.

What inhaler do I start?

Group A: a bronchodilator. Group B: LABA + LAMA. Group E: LABA + LAMA, and consider adding ICS if the blood eosinophil count is 300 cells/µL or above. Single-inhaler therapy may be more convenient and more effective than multiple inhalers.

When should I add an inhaled corticosteroid?

Follow the exacerbation track: on LABA + LAMA with continuing exacerbations and eosinophils of 100 or above, add ICS. Below 100, consider roflumilast if FEV₁ is under 50% with chronic bronchitis, or azithromycin, or dupilumab in chronic bronchitis. Consider de-escalating ICS if pneumonia occurs — but with eosinophils at 300 or above, de-escalation is more likely to be followed by an exacerbation.

What oxygen target in a COPD exacerbation?

SpO₂ 88–92%, given by Venturi mask or nasal cannula. Get blood gases in the first hour and within an hour of any change in FiO₂.

When does a COPD exacerbation need admission?

The guideline gives a 14-point comparison. Admission is indicated for severe breathlessness, a poor or worsening general condition, cyanosis, worsening peripheral oedema, impaired consciousness or acute confusion, already being on oxygen, poor social support or living alone, chest X-ray changes, rapid onset, arterial pH below 7.35, or PaO₂ below 52 mmHg. Peak expiratory flow is not useful for this decision.

Does a negative bronchodilator response rule out treatable disease after TB?

No — and this is the single most useful fact on the page. In COPD secondary to TB, only 27% have a positive bronchodilator response, against 82% in COPD alone. Post-TB patients also have lower FEV₁, higher airway resistance and more frequent exacerbations. Treatment is the same as for COPD.

What are the five treatment escalation groups?

The guideline asks that every patient be stratified on admission — particularly in resource-constrained settings — into: needing immediate intubation; suitable for NIV and for escalation to intubation; suitable for NIV but not intubation; not suitable for NIV but for full active medical management; or palliative care as the most appropriate management.

Clinically reviewed by Dr Mehdi Raza, MBBS

MBBS — FCPS Postgraduate Trainee at Combined Military Hospital (CMH) Multan. Graduated from Federal Medical & Dental College, Islamabad. Full profile →

Sources

Pakistan Chest Society — Guidelines for the Management of COPD, 2026 revised edition. 76 pages. The source of every threshold, dose, table and algorithm on this page. The published PDF is a scanned, image-only document with no text layer; content here was read from rendered pages, so verify against the original before acting on a dose.
The guideline is aligned to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 global strategy, which is the source of the ABE assessment tool, the initial and follow-up treatment algorithms and the eosinophil thresholds.
Burden figures: a 2024 systematic review and meta-analysis of over 100 population-based studies from 94 countries for global prevalence; the BOLD study for the never-smoker data; and a 2018 meta-analysis for Pakistan's 13.8% prevalence, the highest in the EMRO region.
Post-TB COPD figures — 55.3% of treated pulmonary TB patients with dyspnoea having an obstructive defect, and the 27% versus 82% bronchodilator response — are cited by the guideline in its chapter 17.
UNIT CORRECTION: the printed guideline gives home-treatment salbutamol as "100 mg/puff" and ipratropium as "20–40 mg". Both are micrograms and are written as such here. The typo is in the source.

Background reading — why a TB history changes what a bronchodilator test means, and the ceiling-of-care decision made on admission: COPD in Pakistan.

Also in this section: asthma, tuberculosis and community-acquired pneumonia, plus pre-eclampsia, hypertension, type 2 diabetes, hepatitis C and urinary tract infection. See all clinical pathways and clinical tools.