Today, I review, link to, and excerpt from The Curbsiders‘ #500: COPD Update with Cyrus Askin*.
*Wurtz P, Askin C, Williams PN, Watto MF. “500 COPD Update with Cyrus Askin”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast October 06, 2025.
All that follows is from the above resource.
Transcript available via YouTube
GOLD Updates, Novel Treatments, and Managing Comorbidities in COPD Care
Level up your COPD care with practical, evidence-based strategies. Learn how to confirm airflow obstruction with spirometry (and use LLN/Z-scores thoughtfully), stage patients with the A/B/E framework, and build treatment around long-acting bronchodilation—adding ICS selectively based on exacerbations and eosinophils. We’ll highlight the nonpharmacologic moves that change outcomes (smoking cessation, vaccination, pulmonary rehab, oxygen when indicated), when to reach for add-ons (azithromycin, roflumilast), how to approach chronic hypercapnia with home NIV, and what’s new (hello, ensifentrine). Pulmonologist and longtime Curbsiders member Dr. Cyrus Askin (@Askins_Razor ) returns to share real-world pearls for diagnosing, treating, and managing comorbidities in COPD.
Claim CME for this episode at curbsiders.vcuhealth.org!
Show Segments
- Intro
- Case 1
- Diagnostic Workup
- Understanding the Ratio, LLN/Z-Scores, and Equity
- Symptom abd Risk Staging (A/B/E)
- Case 2
- Foundational Care
- Initial Inhaler Strategy
- Progression & Hypercapnia: NIV & Adherence Counseling
- Add-On Pharmacologic Options for Frequent Exacerbators
- What’s New and Emerging
- Comorbidities and When to Refer
- Take-Home Points Recap
- Plugs, CME, and Credits
Pearls
- Confirm COPD with spirometry. Use post-bronchodilator FEV₁/FVC <0.70; if near the cutoff, consider lower limit of normal/Z-scores. Screen everyone with COPD for alpha-1 antitrypsin deficiency at least once.
- Stage by symptoms and risk, not just FEV₁. Use mMRC or CAT to sort A vs B; any patient with ≥2 moderate exacerbations or ≥1 hospitalization in the past year is Group E.
- Start with long-acting bronchodilation. LABA/LAMA is preferred first-line for most symptomatic patients. Don’t lead with ICS in COPD.
- LABA/LAMA: Google Search Results.
- Add ICS (i.e., move to triple therapy) only when the phenotype fits. Think ICS when eosinophils are higher and/or exacerbations persist on LABA/LAMA; avoid routine ICS when eos are low. Teach rinse/spit and watch for pneumonia.
- Non-pharmacologic management moves the mortality needle. Prioritize smoking cessation, vaccination, pulmonary rehab, and long-term oxygen only for severe resting hypoxemia. Pair exercise with protein-forward nutrition to fight sarcopenia.
- Consider azithromycin for frequent exacerbators (especially ex-smokers) and roflumilast for the chronic-bronchitis phenotype; monitor QT/hearing (macrolide) and weight/GI/mood (roflumilast).
- Chronic hypercapnia? Think home noninvasive ventilation (NIV). Reassess PaCO₂ after the flare; if still elevated, use nightly NIV (6–8 h). Fit and comfort matter; screen/treat OSA. Acclimation tip: wear the mask while relaxing in the evening.
- Ensifentrine is a new maintenance option. A nebulized PDE3/4 inhibitor to consider when symptoms or exacerbations persist despite standard therapy.
- Comorbidities change outcomes. Aggressively manage cardiovascular disease, screen for pulmonary hypertension (echo in advanced disease), address anxiety/depression, protect bone health, manage diabetes/metabolic syndrome, and look for OSA and bronchiectasis (add airway-clearance when present).
- Mind the practicals—and know when to refer. Re-teach inhaler technique, simplify devices/regimens, and use cost-conscious “open triple” when needed. Refer for frequent exacerbations despite therapy, chronic hypercapnia/NIV issues, suspected pulmonary hypertension, bronchiectasis, alpha-1 deficiency, or diagnostic uncertainty.
