Laurie Barclay, MD
August 1, 2011 — The American College of Physicians (ACP), American College of Chest Physicians, American Thoracic Society (ATS), and European Respiratory Society have issued a joint clinical practice guideline on diagnosis and management of stable chronic obstructive pulmonary disease (COPD).
The new recommendations, which update the 2007 ACP clinical practice guideline, are published in the August 2 issue of the Annals of Internal Medicine. They are intended to help clinicians diagnose and manage stable COPD, prevent and treat COPD exacerbations, reduce COPD-related hospitalizations and mortality rates, and improve the quality of life of patients with COPD.
COPD is a slowly progressive disease characterized by airflow obstruction resulting from involvement of the airways and/or pulmonary parenchyma. Symptoms and complications may include shortness of breath, poor exercise tolerance, chronic productive or nonproductive cough, wheezing, respiratory failure, and cor pulmonale. In the United States, COPD is the third leading cause of death, and worldwide, it is the fourth leading cause. It occurs predominantly in cigarette smokers.
"It is important for patients with COPD to stop smoking and for physicians to help their patients to quit smoking," said lead author Amir Qaseem, MD, FACP, PhD, MHA, who is ACP director of clinical policy, in a news release.
To update the 2007 ACP clinical practice guideline on diagnosis and management of stable COPD based on recent evidence, the study authors performed a targeted literature search from March 2007 to December 2009.
Specific topics covered in the updated guidelines include the importance of history and physical examination to predict airflow obstruction and the role of spirometry in screening for or diagnosing COPD. Although history and physical examination alone are poor predictors of airway obstruction and its severity, the presence of greater than a 55 pack-year history of smoking, wheezing on auscultation, and patient self-reported wheezing predict airflow obstruction, defined as a postbronchodilator ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70.
Treatment options discussed in the new recommendations include inhaled therapies (anticholinergic agents, long-acting beta-agonists, and corticosteroids), pulmonary rehabilitation programs, and use of supplemental oxygen. Most trials comparing the efficacy of various inhaled monotherapies did not show any differences among these medications, but monotherapy with a long-acting inhaled agent (long-acting anticholinergic, long-acting beta-agonist, or corticosteroid) was superior to placebo or short-acting anticholinergic therapy in reducing exacerbations. It remains unclear when combination therapy is preferred to monotherapy.
Specific recommendations in the guidelines include the following:
Recommendation 1: Patients with respiratory tract symptoms such as chronic cough, wheezing, shortness of breath, or significant activity limitation should undergo spirometry to diagnose airflow obstruction (grade: strong recommendation, moderate-quality evidence).
"While targeted use of spirometry for diagnosis of airflow obstruction is beneficial for patients with respiratory tract symptoms, particularly dyspnea, it does not appear to have an independent influence on the likelihood of quitting smoking or maintaining abstinence," said Nicola A. Hanania, MD, MS, FCCP, chair of the ACP Airways Disorders Network.
Individuals without respiratory tract symptoms should not be screened for airflow obstruction by spirometry (grade: strong recommendation, moderate-quality evidence).
"The routine use of spirometry for patients without respiratory symptoms could lead to unnecessary testing, increased costs, unnecessary disease labeling, and the harms of long-term treatment with no known preventive effect on avoiding future symptoms," said Gerard Criner, MD, professor of medicine at Temple University, and past chair of the ATS Assembly on Clinical Problems.
Recommendation 2: Treatment with inhaled bronchodilators may be given to patients with stable COPD, respiratory tract symptoms, and an FEV1 between 60% and 80% predicted (grade: weak recommendation, low-quality evidence).
Recommendation 3: Treatment with inhaled bronchodilators is recommended for patients with stable COPD, respiratory tract symptoms, and an FEV1 less than 60% predicted (grade: strong recommendation, moderate-quality evidence).
Recommendation 4: Symptomatic patients with COPD and an FEV1 less than 60% predicted should receive monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled beta-agonists, based on patient preference, cost, and adverse effect profile (grade: strong recommendation, moderate-quality evidence).
Recommendation 5: Symptomatic patients with stable COPD and an FEV1 less than 60% predicted may receive combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled beta-agonists, or inhaled corticosteroids; grade: weak recommendation, moderate-quality evidence).
Recommendation 6: Symptomatic patients with an FEV1 less than 50% predicted should receive pulmonary rehabilitation (grade: strong recommendation, moderate-quality evidence). For symptomatic or exercise-limited patients with an FEV1 greater than 50% predicted, pulmonary rehabilitation may be considered (grade: weak recommendation, moderate-quality evidence).
Recommendation 7: Patients with COPD and severe resting hypoxemia (PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%) should receive continuous oxygen therapy (grade: strong recommendation, moderate-quality evidence).
Financial support for the development of this guideline came exclusively from the ACP operating budget. Some of the study authors have disclosed various financial relationships with such entities as Novartis, Boehringer-Ingelheim, Merck, AstraZeneca, GlaxoSmithKline, and Pfizer. A complete description of disclosures is available in the original article.
Ann Intern Med. 2011;155:179-191.
اللَّهُمَّ نَجِّ الْمُسْتَضْعَفِينَ مِنَ الْمُؤْمِنِينَ اللَّهُمَّ اشْدُدْ وَطْأَتَكَ عَلَى مُضَرَ اللَّهُمَّ اجْعَلْهَا عَلَيْهِمْ سِنِينَ كَسِنِي يُوسُفَ