AUTHORS

Philippine College of Chest Physicians Council on COPD & Pulmonary

Rehabilitation, 2018-2021

Main Authors:

Lenora Fernandez, MD, FPCCP

Ralph Elvi Villalobos, MD, FPCCP
Bernice Ong-dela Cruz, MD, FPCCP
Tim Trinidad, MD, FPCCP
Teresita de Guia, MD, FPCCP
Rommel Tipones, MD, FPCCP
Celeste Mae Campomanes, MD, FPCCP
Stefanni Nonna Paraguas, MD, FPCCP
Precillano Zamora, MD, FPCCP
Tito Atienza, MD, FPCCP
Rodolfo Pagcatipunan, MD, FPCCP
Johnson See, MD, FPCCP
Mary Andy delos Reyes, MD, FPCCP
Guinevere D. Agra, MD, FPCCP
Israeli Roque, MD, FPCCP
Eloisa de Guia, MD, FPCCP
Dennis Santos, MD, FPCCP
Cristine Untalan, MD, FPCCP
Babyleen Macaraig, MD, FPCCP
Jenet Lim, MD, FPCCP
Hazel Tolentino, MD, FPCCP
Roland Panaligan, MD, FPCCP
Luisito Idolor, MD, FPCCP

Philippine Academy of Family Physicians Co-authors:

Policarpio Joves, Jr, MD, FPAFP

Limuel Anthony Abrogena, MD, FPAFP
 BOARD OF DIRECTORS 2021-2022

GREGORIO P. OCAMPO, MD, FPCCP

President

IMELDA M. MATEO, MD, FPCCP

Vice President

EILEEN G. ANICETO, MD, FPCCP

Secretary

MA. JANETH T. SAMSON, MD, FPCCP

Treasurer

Board Members:

JUBERT P. BENEDICTO, MD, FPCCP

VIRGINIA S. DE LOS REYES, MD, FPCCP

JUDE P. GUIANG, MD, FPCCP

ALBERT L. RAFANAN, MD, FPCCP

LIZA LLANES-GARCIA, MD, FPCCP

IVAN N. VILLESPIN, MD, FPCCP

Immediate Past President
TABLE OF CONTENTS

Introduction

I. Diagnosis of COPD
Diagnosis of COPD in a Primary Care Facility
Key Points
Diagnosis of COPD in a Level 2 or 3 Health Facility
Key Points

II. Management of Stable COPD

Management of Stable COPD in a Primary Care Facility
Key Points
Management of Stable COPD in a Level 2 or 3 Health Facility
Key Points

III. Management of COPD Exacerbations

General Key Points
Management of ECOPD in the Primary Care Facility
Key Points
Management of ECOPD in Level 2 or 3 Health Facility
Key Points

IV. Monitoring and Non-pharmacologic Management of Stable COPD

General Key Points
Monitoring and Non-pharmacologic Management of Stable COPD in Primary Care Facilities
Monitoring and Non-pharmacologic Management of Stable COPD in Level 2 and Facilities

V. Appendices
Modified Medical Research Council Dyspnea Scale (English and Tagalog Version)
How to determine the peak expiratory flow rate using a mini-Wright peak flow meter
The COPD Assessment Test (CAT) – English and Tagalog Version
Computing for the Blood Eosinophil Count
Pharmacologic Medications Available in the Philippines for COPD
Patient Educational Booklets
Sample Patient Exercise Diary and Action Plan
Pulmonary Rehabilitation Programs in the Philippines
SUMMARY OF CONSENSUS STATEMENTS ON THE DIAGNOSIS AND MANAGEMENT
OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN THE PHILIPPINES

INTRODUCTION:

COPD, as a chronic airway disease, continues to be part of the top 10 causes of morbidity in the Philippines1. The
international group of COPD experts updates the Global Initiative for Obstructive Lung Diseases (GOLD) guidelines for
COPD on a regular and annual basis2. The Philippine College of Chest Physicians Council on COPD and Pulmonary
Rehabilitation last published the guidelines for COPD management in the Philippines last 2009 which was revised
in 20143. This document contains consensus statements on the diagnosis and management of COPD that aims to
provide a simple guide to all health care workers who manage possible COPD patients within the universal health care
framework of the Philippines and the presence of COVID-19 infection.

The process of the update formulation included working committees on diagnosis, pharmacologic and non-
pharmacologic treatment reviewing international guidelines and relevant literature on the sections and formulating the
algorithms. The Philippine Academy of Family Physicians participated as active members in the working committees
in the whole process. The Global Initiative on Obstructive Lung Diseases (GOLD) is the guideline that has served as
the major reference.

PART I. DIAGNOSIS OF COPD

Section A. Diagnosis of COPD in a Primary Care Facility (see Algorithm 1)

Key points:

• In a patient presenting with chronic cough (at least 8 weeks duration)4, sputum production, difficulty
of breathing, chest tightness, and/or wheezing, we recommend the following further points in the
history be asked:
a. Acute onset or acute worsening of symptoms
b. Any systemic signs such as fever, malaise, headache, nasal congestion, weakness or myalgia
c. History of exposure to a contact with a probable infectious disease (COVID, tuberculosis, pneumonia)5

1
If the patient has any of these symptoms or findings, it is prudent to consider an infectious disease (especially
COVID-19) or/and an exacerbation of a chronic lung disease. If an infectious disease is entertained, please
manage as per local regulations; if an exacerbation of COPD is entertained, please refer to the algorithms on
the management of COPD exacerbation (Algorithms 5 and 6).

• After a potential infectious disease or exacerbation is ruled out, we suggest asking the following
questions to rule out asthma6-11:
a. Personal or family history of asthma or allergic rhinitis
b. Personal or family history of any atopic diseases, including known or suspected allergies
c. Significant variability in symptoms, especially with exposure to dusts, fumes or other noxious particles
d. Previous prescription with anti-asthma medications

If any of these is present, the patient may more likely have a diagnosis of asthma, rather than COPD.

• If none of the above features in the history are present, we recommend these additional points in the history
be taken as any of these may strengthen the suspicion of a diagnosis of COPD:
a. Symptoms started in middle age (> 40 years old)12
b. Previous diagnosis of COPD, or previous prescription with COPD medications6
c. Long history of daily or frequent cough and sputum production
d. Current or previous heavy tobacco use (i.e >10 packs years, but not necessarily limited to this amount)6
e. History of heavy and prolonged exposure to burning fossil fuels (charcoal, firewood, sawdust, animal
manure or crop residue)13-16, 19
f. Work: farmer, construction/factory worker, traffic enforcer, or any occupation with prolonged exposure to
noxious particles17-19
g. History of pulmonary tuberculosis 19

1
 h. With x-ray/CT scan finding suggestive of “emphysema”

If none of these points in the history are present, then the diagnosis of COPD is not likely. We recommend that
other diagnosis be considered.

• Once the history and physical examination of a patient is compatible with COPD, the patient is now
a “PROBABLE COPD” case.

• The only confirmatory test for the diagnosis of COPD is spirometry (FEV1/FVC <0.70)2. Until spirometry is
performed and confirms the diagnosis of COPD, the patient with a compatible history, physical examination
and other laboratory findings will remain a “probable COPD” case.

• We recommend that spirometry be performed within 3 months after the patient’s first consultation.

• If the patient’s vital signs are clinically stable, with no signs and symptoms of a current infection, or any point
that may suggest an exacerbation, then the next step will be to perform a peak expiratory flow rate (PEFR)
determination in the clinic or health center.

• Peak Expiratory Flow Rate (PEFR) measurement must then be performed on a stable probable COPD patient
by a trained health worker. A PEFR measurement of < 350 L/min for males or < 250 L/min for females is highly
suggestive of COPD. A PEFR consistently above such values suggests other diagnoses other than COPD, and
other diagnostic tests must be performed. 20-22

• Once the diagnosis of COPD is suggested by history, physical examination and PEFR, the health worker
or clinician must then determine the level of symptoms by the patient by asking the question “I get short of
breath when hurrying on the level ground or walking slightly uphill” or “Naglalakad nang mas mabagal sa patag
kaysa sa mga taong kasing-edad dahil sa pangangapos ng hininga o kailangang huminto para sa paghinga
kapag naglalakad sa sariling bilis sa patag”. This question corresponds to modified Medical Research Council
dyspnea score (mMRC score) of 2 or more. 2

• Once the level of symptoms is determined, the risk of exacerbations must then be determined by asking the
patient how many times in the past year did he/she experience an exacerbation and/or was he/she hospitalized
due to an exacerbation.2

• Once these questions have been asked, the patient must be categorized using this classification table (adapted
from GOLD)6:

GOLD A GOLD B
• mMRC <2 • mMRC >2 and
• <1 exacerba on and no • no hospitaliza on or <1
hospitaliza on exacerba on

GOLD C GOLD D
• mmRC <2 and • mmRC >2 and
• >1 hospitaliza on or >2 • >1 hospitaliza on or >2
exacerba on exacerba on

• These categories will guide the health worker or clinician in the initial management of the patient.

2
ALGORITHM 1. DIAGNOSIS OF COPD IN A PRIMARY CARE FACILITY
Pa ent presen ng with chronic cough (at least 8 weeks dura on), sputum produc on,
difficulty breathing, ght chest and/or wheezing

1. Inves gate for COVID-19

and for other infec ous
Are any of the following present?
disease as per local
a. Acute onset or acute worsening of symptoms?
guidelines and
b. Any systemic signs such as: fever, malaise, headache, nasal conges on,
YES 2. Consider an exacerba on
weakness, or myalgia
of COPD (please see
c. History of exposure to a contact with a probable
algorithm 5 & 6 on
infec ous disease (COVID, tuberculosis,
ECOPD management)
pneumonia)

NO

Are any of the following present?

a. Personal or family history of asthma or allergic rhini s
b. Personal or family history of any atopic diseases, including known or A diagnosis of bronchial
suspected allergies asthma is more likely,
YES please see guidelines
c. Significant variability in symptoms, especially with exposure to dusts, fumes or
other noxious par cles on asthma
d. Previous prescrip on with
an -asthma medica ons

NO

Are any of the following also present?

a. Symptoms started in middle age (> 40 years old)
b. Previous diagnosis of COPD, or previous prescrip on with
COPD medica ons
c. Long history of daily or frequent cough and sputum produc on
d. Current or previous heavy tobacco use (i.e >10 packs years, but not necessarily Consider other diagnosis
limited to this amount) Cardiovascular disease,
e. History of heavy and prolonged exposure to burning fossil fuels NO
lung infec ons,
(charcoal, firewood, sawdust, animal manure or crop residue) bronchiectasis, etc
f. Work: farmer, construc on/factory worker, traffic enforcer, or any
occupa on with prolonged exposure to noxious par cles
g. History of pulmonary tuberculosis
h. With x-ray/CT scan finding
sugges ve of “emphysema”

YES
PROBABLE COPD

Consider other diagnosis:

Perform PEFR in health center or clinic.Is the PEFR consistently
Chronic lung diseases,
< 350 L/min for male & < 250 L/min for female? NO
tuberculosis,
In all pa ents, perform spirometry within
cardiovascular disease, etc
3 months of ini al consult

YES
• Ask the ques on: “I get short of breath when hurrying on the level ground or walking slightly uphill” or “Naglalakad nang mas
mabagal sa patag kaysa sa mga taong kasing-edad dahil sa pangangapos ng hininga o kailangang huminto para sa paghinga
kapag naglalakad sa sariling bilis sa patag”(mmRC=2); and
• Assess history of exacerba on for the past one year

GOLD A GOLD B GOLD C GOLD D

•mMRC <2 and •mMRC >2 and •mmRC <2 and •mmRC >2 and
no hospitaliza on or <1 no hospitaliza on or <1 >1 hospitaliza on or >2 >1 hospitaliza on or >2
exacerba on exacerba on exacerba ons exacerba ons

3
Section 2. Diagnosis of COPD in a Level 2 or Level 3 Facility (Algorithm 2)

Key points:
• The main difference between a level 1 facility and level 2 or level 3 facility is the availability of the spirometry,
which is considered to be the gold standard for the diagnosis of COPD.

• In level 2 or level 3 facilities, there are also available personnel and specialists who are trained specifically in
the interpretation of spirometry and management of COPD, including exacerbations.

• The same screening points in initial history taking in the algorithm for level 1 will apply for level 2 and 3 facilities,
except that there will be no more “probable COPD” case, since spirometry will rule in or rule out the diagnosis
of COPD.

• In a patient with a compatible history of COPD, the initial test of choice will be spirometry.2

• Spirometry should be performed in all patients who are suspected to have COPD, who are clinically stable,
with no active infection or exacerbation, and who have not taken medications that might interfere with the
spirometry’s result (e.g. short-acting bronchodilator in the previous 6 hours, long-acting Beta-2-agonist (LABA)
in the previous 12 hours or sustained release theophylline in the previous hours).2, 22

• A post-bronchodilator FEV1/FVC value of less than 0.70 ( FEV1/FVC < 0.70) confirms the diagnosis of COPD.2

• An FEV1/FVC value consistently > 0.70 excludes the diagnosis of COPD and other diagnosis for the symptoms
must be entertained. 2

• Soon after the diagnosis of COPD is confirmed, categorization into GOLD A-D will be undertaken using the
same steps as with the recommendations for a level 1 facility. 2

4
ALGORITHM 2. DIAGNOSIS OF COPD IN A LEVEL 2 OR LEVEL 3 FACILITY
Pa ent presen ng with chronic cough (at least 8 weeks dura on), sputum produc on,
difficulty breathing, ght chest and/or wheezing

1. Inves gate for COVID-19

and for other infec ous
Are any of the following present? disease as per local
a. Acute onset or acute worsening of symptoms? guidelines and
b. Any systemic signs such as: fever, malaise, headache, nasal conges on, weakness or myalgia YES 2. Consider an exacerba on
c. History of exposure to a contact with a probable infec ous of COPD (please see
disease (COVID, tuberculosis, pneumonia) algorithms 5 & 6 on
ECOPD management)

NO

Are any of the following present?

a. Personal or family history of asthma or allergic rhini s
A diagnosis of bronchial
b. Personal or family history of any atopic diseases, including known or suspected allergies asthma is more likely,
c. Significant variability in symptoms, especially with exposure YES please see guidelines
to dusts, fumes or other noxious par cles on asthma
d. Previous prescrip on with an -asthma medica ons

NO

Are any of the following also present?

a. Symptoms started in middle age (> 40 years old)
b. Previous diagnosis of COPD, or previous prescrip on with COPD medica ons Consider other diagnosis
c. Long history of daily or frequent cough and sputum produc on Cardiovascular disease,
d. Current or previous heavy tobacco use (i.e >10 packs years, but not necessarily limited to this amount) NO lung infec ons,
e. History of heavy and prolonged exposure to burning fossil fuels (charcoal, firewood, sawdust, bronchiectasis, etc
animal manure or crop residue)
f. Work: farmer, construc on/factory worker, traffic enforcer,
or any occupa on with prolonged
exposure to noxious par cles

YES

PROBABLE COPD

NOT COPD
Perform spirometry.FEV1/FVC >0.70? YES Consider other chronic
lung diseases
NO

CONFIRMED COPD

• Ask the ques on: “I get short of breath when hurrying on the level ground or walking slightly uphill” or “Naglalakad nang mas
mabagal sa patag kaysa sa mga taong kasing-edad dahil sa pangangapos ng hininga o kailangang huminto para sa paghinga
kapag naglalakad sa sariling bilis sa patag”(mmRC=2); and
• Assess history of exacerba on for the past one year

GOLD A GOLD B GOLD C GOLD D

•mMRC <2 and •mMRC >2 and •mmRC <2 and •mmRC >2 and
no hospitaliza on or <1 no hospitaliza on or <1 >1 hospitaliza on or >2 >1 hospitaliza on or >2
exacerba on exacerba on exacerba ons exacerba ons

5
PART II. MANAGEMENT OF STABLE COPD
Section 1. Management of Stable COPD in a Primary Care Facility (Algorithm 3)

Key points:

• In the primary care facility, both treatment naïve patients and patients on medications will be encountered.

• Patients who have signs and symptoms of infection, or an exacerbation shall be given emergency care as
needed by the health worker or clinician and should be referred to a level 2 or 3 facility for proper management.

• Because level 1 facilities need not have a spirometry as part of the equipment, depending on the urgency of
the case, patients who are deemed as “probable COPD” can be managed accordingly by the health worker
and/or clinician.

• Regardless if the patient was given initial management or not by the primary health facility, all patients still
need to undergo spirometry within 3 months from initial consult.

• For patients who are less symptomatic with low risk of exacerbation (i.e. GOLD Group A), we recommend as
needed (prn) inhaled short-acting beta-agonist (SABA) as initial treatment of choice. 2, 23

• An alternative to prn inhaled SABA are oral methylxanthines in the GOLD Group A patients.2, 24-25

• For patients who are either more symptomatic, with increased risk of exacerbations, or both (i.e. GOLD Groups
B, C and D), we suggest that these patients be referred to a pulmonary specialist, when available. 2

• However, if the specialist is not available and the patient needs medication urgently, the health worker and the
primary health clinician can opt to give these patients appropriate medications, on a case to case basis.

• For GOLD Groups B, C and D, we recommend inhaled long-acting muscarinic antagonists (LAMA) as the initial
medication of choice.2, 26-29

• An alternative to LAMA in Groups B, C and D patients are combined inhaled long-acting muscarinic antagonist
with long-acting beta-2-agonist (LAMA+LABA) or oral methylxanthines.2, 24-25, 30-32

• Monitoring and follow-up of patients shall be done every three months, in the minimum. More symptomatic
patients may warrant more frequent follow-ups and closer monitoring.

6
ALGORITHM 3. MANAGEMENT OF STABLE COPD IN A PRIMARY CARE FACILITY
Confirmed or Probable COPD pa ent

ANY of the following present: 1. Inves gate for COVID-19 and for other
1. Unstable vital signs or signs of respiratory distress infec ous disease as per local guidelines
2. Increase in dyspnea over a few days/weeks YES 2. Consider an exacerba on of COPD
3. Increase in amount or change in character of sputum (please see algorithms 5 & 6 on ECOPD
4. Signs/symptoms of infec on management)

NO

Ini al Management
Refer to Level II or III for spirometry
within three months of first consult

Dyspnea mMRC > 2 or with > 2

exacerba ons or
> 1 hospitaliza on past year?

NO YES

COPD GOLD Class A (COPD GOLD B, C or D)

Less symptoms, More symptoms or
low exacerba on risk high exacerba on risk

Is a specialist available? YES Refer to Specialist

NO

Preferred ini al medica on*:

Preferred ini al medica on:
• Inhaled LAMA
• prn inhaled SABA or SAMA
• Inhaled LABA+LAMA (for more symptoma c
Alterna ve op on:
pa ents or with repeated exacerba ons)
• Oral Methylxanthine
Alterna ve op on:

• Oral methylxanthine

7
Section 2. Management of Stable COPD in a Level 2 or Level 3 Health Facility (Algorithm 4)

Key points:

• Level 2 or Level 3 Health facilities must be able to confirm the diagnosis of COPD in every patient coming in
with history findings compatible with COPD, except those patients whose initial consultation is for a possible
exacerbation of COPD.

• Patients with signs and symptoms of infection and/or COPD exacerbation must be managed as an exacerbation
(see Section on Exacerbation)

• Generally, in Level 2 or Level 3 facilities, specialists with experience in handling COPD patients are present
and are familiar with the various COPD medications, including their adverse effects; and we suggest that these
COPD patients be seen by specialists, when possible.

• For GOLD Group A, we recommend an inhaled bronchodilator (either prn SABA or SAMA) as the preferred
initial medication. 2

• For GOLD Group B, we recommend a long-acting bronchodilator (either a LABA or a LAMA) as preferred initial
medication.2

• For GOLD Group C, we recommend a LAMA as preferred initial medication.2, 26-29

• For GOLD Group D, we recommend a LAMA or a LABA+LAMA as preferred initial medication. Inhaled
corticosteroid may be added to the regimen for patients who continue to have frequent exacerbations (> 2
exacerbations or > 1 hospitalization) for the past year or blood eosinophils > 300/uL). If inhaled bronchodilators
are not available, oral methylxanthines may be used as an alternative.2, 33-35

• Monitoring of these patients should be in 1-3 months, depending on the level of symptoms and risk of
exacerbations.

• If these patients in Level 2 or Level 3 facilities have stable symptoms, and free of exacerbations for at least 1
year, they may be referred back to a Level 1 facility for continuity of care. Otherwise, we recommend that they
continue to be monitored by specialists at a level 2 or level 3 facility.

8
ALGORITHM 4. MANAGEMENT OF STABLE COPD IN LEVEL 2 OR LEVEL 3 HEALTH FACILITIES
Confirmed COPD Pa ent
(All pa ents in Level II and III should have undergone spirometry tes ng)

Any of the following present:
• Unstable vital signs or signs of respiratory distress
• Increase in dyspnea over a few days/weeks
• Increase in amount or change in character of sputum
• Signs/symptoms of infec on
1. Inves gate for COVID-19 and for other
infec ous disease as per local guidelines
YES 2. Consider an exacerba on of COPD
(please see algorithms 5 & 6 on ECOPD
management)

NO

Ini al Management

GOLD Class A GOLD Class B GOLD Class C GOLD Class D

Preferred ini al medica on:
Any inhaled bronchodilator:
• SABA or SAMA
Preferred ini al medica on:
An inhaled long-ac ng
bronchodilator:
• LAMA or LABA
Preferred ini al medica on: Preferred ini al medica on:
• LAMA • LAMA
• LABA + LAMA (for more severe dyspnea)
• LABA + ICS (for blood eosinophil >300/uL)**
** may increase risk of pneumonia

Follow-up and
monitor every 1-3 months

Symptoms are stable Con nue to monitor and follow-up at

and no exacerba on within one year? NO level 2 or level 3;
Adjust medica ons as necessary

YES

May refer back to Level 1 Health Facility for con nuity of care

9
PART III. MANAGEMENT OF COPD EXACERBATIONS

General Key points:

• An exacerbation of COPD (ECOPD) is defined as an acute event characterized by worsening of the patient’s
respiratory symptoms that is beyond the normal day by day variation and leads to a change in medication.2,
36-37

• It is very important to rule out COVID-19 or other infectious diseases in all patients presenting as a probable
COPD exacerbation. When COVID-19 infection is entertained, we recommend that the patient be managed
according to local guidelines. 2, 5, 39
• An exacerbation is determined by any of the following points in the patient’s history. The greater the change
from the baseline or the more severe the change in the symptoms are more indicative of an exacerbation: 2, 38
o Change in sputum character or purulence
o Increase in sputum production
o Increase in dyspnea

• ECOPD are to be treated with urgency because it accelerates lung decline, decreases quality of life, increases
level of symptoms and is associated with increased mortality.

• The goals of ECOPD management are to lessen the impact of the current exacerbation and prevent the
development of further future exacerbations.

• We suggest that ECOPD are graded by severity as follows:2

o Mild: Requires only a temporary bronchodilator therapy change
o Moderate: Requires the use of either systemic steroids or antibiotics
o Severe: Requires hospitalization

• We suggest that these choices of site of care be used as a guide in the management of ECOPD:2
o Mild: Outpatient clinic
o Moderate: Outpatient clinic or Level 2 health facility
o Severe: Level 2 or Level 3 health facility

Section 1. Management of COPD Exacerbations in the Primary Care Facility (ALGORITHM 5)

Key points:

• We recommend that all health workers and primary health physicians must be able to identify signs and
symptoms of an exacerbation.

• We recommend that all health workers and primary health physicians must be able to stratify the severity of
the ECOPD.

• We suggest that health networks and referral systems between the Primary Health Facility to Level 2 or Level
3 hospitals be established.

• Proper emergency care measures must be instituted at the Primary Health Care Facility before arranging
transfer to Level 2 or 3 facilities.

• We recommend that the first-line medications to be used for ECOPD in the primary care facility are:

o Inhaled SABA+SAMA (via nebulizer or metered dose inhaler). The use of nebulization is not
recommended when COVID-19 infection is considered.
o Systemic corticosteroids (oral or intravenous), for moderate to severe COPD
o Antibiotics (oral or intravenous), for moderate to severe COPD.

• We recommend that all ECOPD patients must be referred to a level 2 or level 3 health facility. For mild cases,
we recommend that referral to a specialist with experience in handling COPD patients still be secured.

10
ALGORITHM 5. MANAGEMENT OF COPD EXACERBATIONS IN THE PRIMARY HEALTH FACILITY
Confirmed or Probable COPD Pa ent presen ng with
Acute worsening of symptoms
(increased cough/dyspnea/sputum purulence)

Are any of the following present?

a.Any systemic signs such as: fever, malaise, Inves gate for COVID-19 and for other
headache, nasal conges on, weakness or myalgia infec ous disease as per local guidelines &
b.History of exposure to a contact with a probable infec ous diseases YES proceed with ECOPD severity assessment
(COVID, tuberculosis, pneumonia) below

NO

Does the pa ent have the following SEVERE ECOPD.

signs of severe ECOPD? • Resuscitate hemodynamically
a.Use of accessory muscles • Give oxygen if peripheral satura ons <88%
b.Paradoxical chest wall movement • Give SABA + SAMA via metered-dose inhaler
YES
c.Worsening or new onset cyanosis (preferably with spacer) or nebuliza on
d.New peripheral edema (nebuliza on avoided if with COVID19 illness)
e.Hemodynamically unstable • Immediately transfer to at least a Level
f.Mental status changes 2 health facility, preferably with an ICU

NO

Is a specialist available? YES Refer to Specialist

NO

• Give SABA + SAMA via metered-dose inhaler with spacer or

nebuliza on (nebuliza on avoided if with COVID-19 illness)
• Con nue previous COPD medica ons
• Refer to Level 2 or Level 3 health facility

11
Section 2. Management of ECOPD in Level 2 or Level 3 Health Facility (Algorithm 6)

• We suggest that all COPD exacerbations be seen by a specialist who has experience in handling COPD
patients (i.e. Internist or Pulmonologist)
• It is very important to rule out COVID-19 or other infectious diseases in all patients presenting as a probable
COPD exacerbation. When COVID-19 infection is entertained, we recommend that the patient be managed
according to local guidelines2,5,39.
• We suggest that all severe ECOPD patients be managed by a Pulmonologist.

• We suggest that all ECOPD patients be triaged by a specialist regarding their site of care.2

• We recommend that all patients with ECOPD be given inhaled SABA + SAMA as the bronchodilator of choice.2,40

• We recommend that all patients with moderate to severe exacerbations of COPD be given oral or intravenous
corticosteroids (oral corticosteroids are preferred, with doses of 40mg prednisolone equivalents per day for
five days)2, 41-44

• We recommend that antibiotics be given to ECOPD patients who have increased sputum purulence as a
cardinal symptom, accompanied by either increase in sputum volume or increase in dyspnea.

• We recommend that the initial empiric antibiotic therapy be guided by the following parameters: 2, 38
o Severity of exacerbation
o Presence of comorbidities
o Severity of airflow limitation (FEV1 < 30% of predicted)
o Previous use of antimicrobial therapy within the past 3 months
o Frequency of exacerbations (>3/year)

• We recommend antibiotics targeted against Pseudomonas be given as empiric treatment for patients who
have:2, 45
o Severe exacerbations
o Need for mechanical ventilation
o Hemodynamically unstable
o With antibiotic use within the previous 3 months
o Presence of bronchiectasis

• We recommend that non-invasive ventilation (NIV) be considered in patients who meet the inclusion criteria
and none of the exclusion criteria for NIV:2, 46-47

Inclusion criteria Exclusion criteria

• Moderate to severe dyspnea with use of accessory • Respiratory arrest� Cardiovascular instability
muscles and paradoxical abdominal mo on ( hypotension, arrhythmias, myocardial infarc on)

• Moderate to severe acidosis (pH 7.35) and/ or
hypercapnia
• Respiratory frequency> 25 breaths per minute
• Change in mental status; uncoopera ve pa ent
• High aspira on ris�� Viscous or copious secre ons
Recent facial or gastroesophageal surgery
Craniofacial trauma� �ixed nasopharyngeal
abnormali es� �urns

• Extreme obesity

•Suspected COVID-19 infec on

12
 • We recommend that invasive mechanical ventilation be given for the following patients:2, 46-47
o Cardio-respiratory arrest
o Non-invasive mechanical ventilation failure
o Massive aspiration
o Inability of patient to remove respiratory secretions
o Hemodynamic instability unresponsive to initial treatment
o Severe ventricular arrhythmias

• We suggest that all patients requiring mechanical ventilator or non-invasive ventilation use be managed in an
ICU setting, when available.

• We recommend the following discharge criteria when assessing readiness for discharge in ECOPD patients:2

o Inhaled SABA is required no more frequently than every 4 hours

o Patient is able to walk across room (if previously ambulatory)
o Patient is able eat and able to sleep without frequent awakening due to dyspnea
o The patient has been stable for 24 hours
o Patient is able to correctly take his/her medications
o Patient, family and physician are confident that the patient can be managed successfully at home and
equipment are ready
o Follow-up and home care arrangements have been completed

13
ALGORITHM 6. MANAGEMENT OF ECOPD IN LEVEL 2 OR LEVEL 3 HEALTH FACILITIES
Any COPD pa ent with any of the following symptoms:
a. Increase in the volume of sputum
b. Change in sputum character or purulence
c. Increase in dyspnea
Are any of the following present?
a.Any systemic signs such as: fever, malaise, headache,
nasal conges on, weakness, or myalgia
b.History of exposure to a contact with a probable infec ous diseases
(COVID, tuberculosis, pneumonia)
NO
Does the pa ent have the following signs of
severe ECOPD?
a. Use of accessory muscles
b. Paradoxical chest wall movement
c. Worsening or new onset cyanosis
d. New peripheral edema
e. Hemodynamically unstable
f. Mental status changes
NO
Does the pa ent have increased
sputum purulence as a symptom? YES
NO
Administer inhaled SABA+SAMA
Did the symptoms improve a�er
administra on of inhaled SABA+SAMA?
YES
MILD ECOPD
Con nue and reassess maintenance
COPD medica ons
Inves gate for COVID-19 and for other
infec ous disease as per local guidelines
YES
and concomitantly manage COPD
exacerba on as outlined below
SEVERE ECOPD.
• Admit to hospital
• Give oxygen if peripheral satura ons <88%
• Give inhaled SABA + SAMA via metered-dose
inhaler (preferably with spacer) or
nebuliza on (nebuliza on avoided if
YES with COVID-19 illness)
• Give systemic cor costeroids (IV or oral)
• Consider NIV in selected pa ents
• Consider intuba on and mechanical
ven la on if pa ent fulfills criteria
• Give an -pseudomonal an bio cs
• Give an bio cs
• Administer inhala onal
MILD ECOPD
SABA + SAMA as needed
• Consider con nuing outpa ent
YES an bio cs
Did the symptoms improve
• Con nue and reassess
a�er administra on of
maintenance COPD medica ons
inhaled SABA+SAMA?
NO
MODERATE ECOPD
• Start systemic cor costeroids (Prednisolone
NO 40mg OD or equivalent)
• Consider con nuing an bio cs
• Consider hospital admission for persistent
or worsening symptoms
14
PART IV. MONITORING AND NON-PHARMACOLOGIC MANAGEMENT OF STABLE COPD

General Key points:

• Regular follow-up of COPD patients is essential. Lung function may worsen over time, even with the best available
care. Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine
when to modify management and to identify any complications and/or comorbidities that may develop.
• Monitoring disease progression and development of complications and/or comorbidities:

A. Measurements:

1. Lung function testing (using Peak flow meter for Level 1 and spirometry for Level II and III) is recommended
at baseline and annually to monitor disease progression.
2. Functional capacity (using the 6 minute walk test or 6 MWT) at baseline and at least every 3 months, if
possible.
B. Symptoms of cough and sputum production, breathlessness, fatigue, activity limitation and sleep
disturbances are important to note. COPD Assessment Test (CAT) and Dyspnea MMRC questionnaires are
validated tools to assess this.
C. Exacerbations especially the frequency, severity and type should be monitored.
D. Chest x-ray examinations are recommended to be used in patients with worsening symptoms or repeated
exacerbations to detect other illnesses.
E. Smoking Status should be assessed at every visit and proper advice should be given.

• Self-management interventions motivate, engage and coach the patients to positively adapt their health
behavior(s) and develop skills to better manage their disease on a day-to-day basis and to prevent complications
of exacerbations and hospital admissions.
- Physical activity is a strong predictor of mortality and we recommend that all patients be encouraged to
increase the level of physical activity.
- The following vaccinations are recommended: COVID-19 vaccine according to local guidelines, influenza
vaccine annually and pneumococcal vaccination, both PCV 13 and PPSV 23 for all patients > 65 years and
younger but with co-morbidities.
- Nutritional assessment and advice should be done in all COPD patients.
- In patients with severe resting hypoxemia, long-term oxygen therapy should be recommended.

The individual patient’s evaluation and risk assessment with respect to exacerbations, patient’s needs, preferences,
and personal goals should inform the personalized design of the self-management education plan.

We recommend a personalized design that would include the following:

■ Groups A, B, C & D – addressing behavioral risk factors, including smoking cessation, maintaining or increasing
physical activity, and ensuring adequate sleep and a healthy diet as well as flu and pneumococcal vaccination.

■ Groups B & D – learning to self-manage breathlessness, energy conservation techniques, and stress management
strategies.

■ Groups C & D–avoiding aggravating factors, monitoring and managing worsening symptoms, having a written
action plan and maintaining regular contact/communication with a healthcare professional.

■ Group D – discussing with their healthcare providers palliative strategies and advance care directives.

15
SECTION A. MONITORING AND NON-PHARMACOLOGIC MANAGEMENT OF STABLE COPD
IN LEVEL 1 FACILITIES
(Table 1)

Services Health Personnel Equipment Supplies / Forms

Non-Pharmacologic Barangay Health Clinic (space for Non-Pharmacologic

Pa ent educa on Workers consulta on) Educa onal leaflet on smoking,
Smoking cessa onVaccina on Nurse Pulse oximetry COPD and vaccines
(COVID-19, flu and pneumonia) Physician Video on proper inhaler Video on proper inhaler technique
Physical ac vity technique
Peakflow meter Monitoring
Monitoring CAT ques onnaires, MMRC
Compliance of medica on and Oxygena on
right inhaler technique Peakflow monitoring

Refer to Level II or III if:

- Uncontrolled symptoms
- if frequent exacerba on
(> 2 /yr) to specialist
- If oxygena on status or
SaO2 < 90%
- If decreasing trend in peakflow

Treat concomitant co-morbidi es

SECTION B. MONITORING AND NON-PHARMACOLOGIC MANAGEMENT OF STABLE COPD IN LEVEL II

AND III FACILITIES
(Table 2)

Services Health Personnel Equipment Supplies

Non-Pharmacologic Nurse Clinic (space for Non-Pharmacologic

Patient education
Smoking cessation
Vaccination
(COVID-19, flu and pneumonia)
Physical activity
Nutritional
Pulmonary Rehabilitation
Monitoring
Compliance of medication and
right inhaler technique
Frequency of exacerbations and
symptom control
Treat concomitant co-morbidities
Exercise capacity using the
6MWT
Refer
- if frequent exacerbation (> 2 /yr)
to specialist
- If oxygenation status < 90%
- If decreasing trend in peakflow
consulta on) Educa onal leaflet on smoking
Respiratory Spirometry and COPD and vaccines
Facility for pulmonary
therapists
rehabilita on Monitoring
CAT ques onnaires, MMRC
Physician Arterial blood gas analysis
sub-specialists (ABG) Lung func on
Exercise capacity using the
Video or computer for 6 MWT – cones and floor s ckers
instruc on and educa on Acid base and oxygena on status
Chest radiograph, if with
Pulse oximeter worsening symptoms
Referral to smoking cessa on
Space to conduct 6 MWT clinic
Refer to nutri onist
Refer to other sub-specialist
Refer to pulmonary rehabilita on
programs if available

16
APPENDICES:

Appendix 1: The British Medical Research Council dyspnea scale and its Tagalog version.

MODIFIED MRC DYSPNEA SCALEa

PLEASE TICK IN THE BOX THAT APPLIES TO YOU | ONE BOX ONLY | Grades 0-4

mMRC Grade 0. I only get breathless with strenuous exercise.

mMRC Grade 1. I get short of breath when hurrying on the level or walking up a slight hill.

mMRC Grade 2. I walk slower than people of the same age on the level because of
breathlessness, or I have to stop for breath when walking on my
own pace on the level.

mMRC Grade 3. I stop for breath after walking about 100 meters or after a few
minutes on the level.

mMRC Grade 4. I am too breathless to leave the house or I am breathless when

dressing or undressing.

Fletcher CM. BMJ 1960; 2: 1662.

a

TABLE 2.5

https://mrc.ukri.org/research/facilities-and-resources-for-researchers/mrc-scales/mrc-dyspnoea-scale-mrc-
breathlessness-scale/

Modified Medical Research Council Questionnaire (Tagalog)

Pakilagyan ng bilog ang numero na naglalarawan ng iyong kahirapan sa paghinga o hapo.

0 Walang problema sa paghingal maliban sa masigasig na ehersisyo

1 May problema sa pangangapos ng hininga kapag nagmamadali sa patag o

naglalakas sa bahagyang pataas na lugar

2 Naglalakad nang mas mabagal sa patag kaysa sa mga taong kasing-edad dahil sa pangangapos ng hininga
o kailangang huminto para sa paghinga kapag naglalakad sa sariling bilis sa patag

3 Humihinto para sa paghinga pagkatapos maglakad nang humigit-kumulang 100 yarda o pagkatapos ng ilang
minuto sa patag

4 Masyadong humihingal upang umalis ng bahay o humihingal kapag nagbibihis o naghuhubad

17
Appendix 2. How to determine the Peak expiratory flow rate using a mini-Wrights peak flow
meter:

Step 1: Before each use, make sure the sliding marker or arrow on the Peak Flow Meter is at the bottom of the
numbered scale (zero or the lowest number on the scale).

Step 2: Stand up straight. Remove gum or any food from your mouth. Take a deep breath (as deep as you can).
Put the mouthpiece of the peak flow meter into your mouth. Close your lips tightly around the mouthpiece.
Be sure to keep your tongue away from the mouthpiece. In one breath, blow out as hard and as quickly as
possible. Instead of slowly blowing, blow a fast, hard blast until you have emptied out nearly all of the air
from your lungs.

Step 3: The force of the air coming out of your lungs causes the marker to move along the numbered scale. Note
the number on a piece of paper.

Step 4: Repeat the entire routine three times. (You know you have done the routine correctly when the numbers
from all three tries are very close together.)

Step 5: Record the highest of the three ratings. Do not calculate an average. This is very important. You can’t
breathe out too much when using your peak flow meter but you can breathe out too little.

https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/
measuring-your-peak-flow-rate

18
Appendix 3. The COPD Assessment Test (CAT), English and Filipino versions.

COPD Assessment Test (CAT) ®

CAT ASSESSMENT
TM

For each item below, place a mark (x) in the box that best describes you currently.
Be sure to only select one response for each ques on.

EXAMPLE: I am very happy 0 x

1 2 3 4 5 I am very sad SCORE

I never cough 0 1 2 3 4 5 I cough all the me

I have no phlegm (mucus) My chest is completely full

0 1 2 3 4 5
in my chest at all of phlegm (mucus)

My chest does not feel ght at all 0 1 2 3 4 5 My chest feels very ght

When I walk up a hill or one flight When I walk up a hill or one flight
0 1 2 3 4 5 of stairs I am very breathless
of stairs I am not breathless

I am not limited doing any I am very limited doing

0 1 2 3 4 5
ac vi es at home ac vi es at home

I am confident leaving my home I am not at all confident leaving my

0 1 2 3 4 5 home because of my lung condi on
despite my lung condi on

I don’t sleep soundly because

I sleep soundly 0 1 2 3 4 5
of my lung condi on

I have lots of energy 0 1 2 3 4 5 I have no energy at all

Reference� �ones et al. ER� 200�� 34 (3)� �4��54.�

FIGURE 2.3
SCORE

19
COPD Assessment Test (CAT), Filipino version ®

Halimbawa: Napakasaya ko 0 x
1 2 3 4 5 Napakalungkot ko
SCORE

Hinding-hindi ako inuubo 0 1 2 3 4 5 Lagi akong inuubo

Walang-wala akong plema Punong-puno ng plema (uhog)

(uhog) sa aking dibdib 0 1 2 3 4 5
ang dibdib ko

Hinding-hindi naninikip ang Masyadong naninikip ang

dibdib ko 0 1 2 3 4 5
dibdib ko

Kapag umaakyat ako sa burol o

Kapag umaakyat ako sa burol o
isang palapag ng hagdanan,
isang palapag ng hagdanan, 0 1 2 3 4 5
masyado akong kinakapos ng
hindi ako kinakapos ng hininga
hininga

Hindi ako nalilimitahan sa Masyado akong nalilimitahan sa

paggawa ng anumang mga 0 1 2 3 4 5 paggawa ng mga ak bidad sa
ak bidad sa bahay bahay

Walang-wala akong
Kumpiyensa akong lumabas ng
kumpiyensang lumabas ng
bahay sa kabila ng kalagayan ng 0 1 2 3 4 5
bahay dahil sa kalagayan ng
baga ko
baga ko

Hindi ako mahimbing matulog

Mahimbing akong matulog 0 1 2 3 4 5 dahil sa kalagayan ng baga ko

Napakasigla ko 0 1 2 3 4 5 Walang-wala akong sigla

KABUUANG ISKOR

20
Appendix 4: Computing for the Blood Eosinophil Count

Computed Blood eosinophil count (eosinophil/uL) = % eosinophils in the differential count x white blood cell count in
venous blood containing EDTA or Wright-stained blood smears in which 200 leukocytes are examined.

Appendix 5. The Six-minute walk test (6MWT)

1. “Warm up” should not be performed

2. Have patient sit in chair for at least 10 minutes before test
3. Have patient stand and rate baseline dyspnea and overall fatigue using Borg Scale
4. Set lap counter to zero and timer to 6 minutes
5. Give patient instructions
6. Position patient at starting line. As soon as patient starts to walk, start timer. Do not walk with patient.
7. Use standard phrases of encouragement. Use even tone of voice. Do not talk to anyone during walk.
8. Click lap counter each time patient completes a lap.
9. If patient needs to rest, instruct them to lean against wall but to continue walking whenever able.
Do not stop timer.
10. If patient stops before 6 minutes are up, have patient sit on chair. Note distance walked, time stopped,
reason for stopping pre-maturely.
11. Ask patient to stop when time is up. Mark spot where they stopped.
12. Record post-walk Borg dyspnea and fatigue level and ask, “what if anything, kept you from walking farther”.
13. Measure post-test pulse rate and O2sat
14. Calculate total distance walked and record on worksheet
15. Congratulate patient on good effort and offer a drink of water

■ Absolute contra-indications: unstable angina or myocardial infarction during previous month

■ Relative contra-indications: resting HR > 120, SBP > 180 mm Hg, DBP > 100 mm Hg
■ Stable exertional angina not absolute contra-indication (should perform test with anti-angina
medications)

Reasons for stopping 6MWT:

1. Chest pains
2. Intolerable dyspnea
3. Leg cramps
4. Staggering
5. Diaphoresis
6. Pale or ashen appearance

Location:
■ Should be performed indoors
■ Long, flat, straight, enclosed corridor with hard surface
■ 30 m length (100 feet) marked every 3 meters
■ Starting line marked with brightly colored tape
■ Turn-around points marked with cone (orange traffic cone)

Required equipment:
1. Countdown timer (or stopwatch)
2. Mechanical lap counter
3. Cones to mark turn-around points
4. Chair
5. Worksheets

Patient preparation:
1. Wear comfortable clothing
2. Use proper walking shoes
3. Use usual walking aids
4. Continue usual medical regimen
5. Light meal acceptable before early AM or PM tests
6. No vigorous exercise 2 hours before test

21
Appendix 6. Some Pharmacologic medications available in the Philippines for COPD

Drug Prepara on RemarksBeta2 Agonist

Beta2 Agonist
Short Ac ng (SABA) Use with cau on in pa ents with
• Procaterol MDI, Pill • Hyperthyroidism
• Salbutamol MDI, DPI, Neb solu on, Pill, Syrup • DM
• Terbutaline DPI, Pill, Syrup, IV prepara on • Myocardial infarc on or
Long-Ac ng (LABA) Dysrhythmias
• Bambuterol Pill • Hypokalemia
• Formoterol DPI
• Indacaterol DPI
• Tulubuterol Patch
An cholinergics
Short-Ac ng (SAMA) Use with cau on in pa ents with
• Ipratropium-bromide Neb solu on • Prosta c Hyperplasia
Long-Ac ng (LABA) • Narrow angle glaucoma
• Tiotropium DPI, SMI • Bladder neck obstruc on
Combina on short-ac ng beta2-agonist plus an cholinergic in one inhaler (SABA/SAMA)
• Salbutamol/Ipratropium Use cau on in pa ents with same
condi ons listed for SABA & SAMA
Inhaled Cor costeroids (ICS)
• Beclomethasone MDI May increase risk for
• Budesonide DPI, Neb solu on • Pneumonia
• Flu casone MDI, DPI, Neb solu on • Fracture
Combina on long-ac ng beta2-agonist plus cor costeroids in one inhaler (LABA/ICS)
• Formoterol/ Budesonide DPI Same remarks listed for its
• Salmeterol/ Flu casone MDI, DPI components (LABA & ICS)
• Formoterol/Flu casone MDI
• Formoterol/Beclomethasone MDI, DPI
• Vilanterol/Flu casone DPI
Combina on long-ac ng beta2-agonist plus long-ac ng muscarinic antagonist (LABA/LAMA)
• Indacaterol/Glycopyrronium DPI
• Olodaterol/Tiotropium SMI
• Vilanterol/Umeclidinium DPI
Combina on long-ac ng beta2-agonist plus long-ac ng muscarinic antagonist plus cor costeroid (LABA/LAMA/ICS)
• Vilanterol/Umeclidinium/Flu casone DPI
Systemic Cor costeroids
• Prednisone Pill Long-term administra on may cause
• Methyl-Prednisolone Pill, Intravenous solu on • Adrenal insufficiency
• Dexamethasone • Osteoporosis
• Increased suscep bility to infec on
Phosphodiesterase-4 inhibitors (PDE4)
• Roflumilast Use with cau on for pa ents with
Pill • Moderate to severe liver impairment
• Psychiatric condi ons
Methylxanthines
• Aminophylline Intravenous solu on Use with cau on in pa ents with
• Doxofylline Pill, Syrup • Pep c ulcer disease
• Theophylline (SR) Pill • Hyperthyroidism
• Hypertension
• Dysrhythmias
• Epilepsy
• Hepa c Dysfunc on
• Advanced age
• Drugs that may interact
with theophylline
Cysteine Deriva ve Mucoly c
• Carbocysteine Pill Primarily used for its possible
• N-acetyl cysteine Pill, Suspension an -proper es
• Erdosteine Pill, Suspension

Abbreviations used
• MDI: Metered Dose Inhaler
• SMI: Endosteine

22
Appendix 7. Patient education booklets

1. Patient Education Booklet on COPD, 2020

(In 4 languages: English, Tagalog, Visayan, Hiligaynon)

http://philchest.org/xp/copd-and-pulmonary-rehabilitation/

2. Patient Education Booklet on COPD, Tagalog version 2010

23
 3. Sample Patient exercise diary & action plan

Comprehensive Ambulatory Respiratory Rehabilitation Program (CARE) Diary

Pangalan: ___________________________________

Ang mga gamot ko ay:

GAMOT DOSE

Ang exercise na gagawin sa bahay ay:

Paano sasagutin ang diary?

EXERCISE - Maglagay ng tsek (√ ) kung ginawa ng exercises at ( X ) kung hindi ginawa ang exercise.
HINGAL - Ilagay ang katumbas na numero na magsasabi ng gaano katindi ang hingal na naramdaman sa araw na iyon:
1 – Matinding-matindi ang hingal
2 – Matindi ang hingal
3 – Medyo matindi ang hingal
4 – Bahagyang hingal
5 – May konting hingal
6 – Konting-konting hingal
7 – Walang hingal
PETSA Ginawa ang Ininom o Ginamit Gaano ka ndi Mayroong PETSA Ginawa ang Ininom o Ginamit Gaano ka ndi Mayroong
Exercise? ang mga gamot? ang hingal? atake ng Exercise? ang mga gamot? ang hingal? atake ng
(✓) (X) (✓) (X) (1 – 7) COPD*? (✓) (X) (✓) (X) (1 – 7) COPD*?
(✓) (X) (✓) (X)

May ATAK NG COPD kapag mayroon ng isa sa mga ito: May ATAK NG COPD kapag mayroon ng isa sa mga ito:
• lumalang hingal • lagnat • lumalang hingal • lagnat
• lumalang ubo • nanghihina/matamlay • lumalang ubo • nanghihina/matamlay
• dumaming plema • manas sa paa • dumaming plema • manas sa paa
• umiiba ang kulay ng plema • umiiba ang kulay ng plema

24
Appendix 8. Pulmonary Rehabilitation Programs in the Philippines.

List of available pulmonary rehabilitation programs in the Philippines:

Chong Hua Hospital, Cebu City

255-8000 loc 76240; 09154913407
Dr. Katrina J. Villegas/ Ms. Saskia K. Lasa

Lung Center of the Philippines

8924-6101 loc 3011 – 3012
Dr. Glynna O. Cabrera/ Ms. Myra Torres

Perpetual Help Medical Center, Las Pinas

874-8515 loc 484 or 416
Dr. Jose Edzel V. Tamayo/ Ms. Marife Bombase

Philippine General Hospital

8554-8400 loc 3157
Dr. Lenora C. Fernandez/ Mrs. Leyden Sempio

Philippine Heart Center

8925-2401 loc 3805
Dr. Abner T. Koh/ Ms. Maria Gemma Betos/ Ms. Jacqueline T. Torres

St. Luke’s Medical Center, Quezon City

8723-0301 loc 4189
Dr. Tim S. Trinidad/ Mr. Bong Mostacho

St. Luke’s Medical Center, Global City

8789-7700 loc 2029 and 2034
Dr. Celeste Mae L. Campomanes/ Ms. Cyril Tan

The Medical City, Pasig

8635-67899 loc 6238
Dr. May Agno/ Ms. Jahziel Fernandez

The Medical City, Iloilo

(033) 500-1000 loc 50004
Dr. Rhea Ann C. Celis/ Mr. Mark Carreon

University of Santo Tomas Hospital

8731-3001 loc 2561
Dr. Tim S. Trinidad/ Ms. Maricel Nicomienda

Veterans Memorial Medical Center

8927-6426 local 1501
Dr. Chona A. De Vera/ Ms. Abby Carpio

25
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