COPD Guidelines: An Update

Nicholas Gross, MD, PhD

Authors and Disclosures

Posted: 09/29/2011

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update From the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society

Qaseem A, Wilt TJ, Weinberger SE, et al
Ann Intern Med. 2011;155:179-191

Study Summary

The updated chronic obstructive pulmonary disease (COPD) guidelines are official recommendations from authoritative bodies in the United States and Europe. They make 7 consensus recommendations and assign a grade to the evidence in favor of each recommendation on the basis of published research. The updated recommendations are:

1. Spirometry should be used to diagnose and determine the severity of airflow obstruction, but only in patients with respiratory symptoms (evidence grade: strong).
2. For patients whose COPD is stable and whose forced expiratory volume in 1 second of expiration (FEV₁) is between 60% and 80% of predicted, treatment with inhaled bronchodilators may be used (grade: weak).
3. For patients whose COPD is stable but whose FEV₁ is less than 60% of predicted, inhaled bronchodilators should be used (grade: strong).
4. For patients whose FEV₁ is less than 60% of predicted, the recommendation is to prescribe long-acting monotherapy with either an inhaled anticholinergic agent or a beta-agonist, the choice being based on patient preference, cost, and adverse-effect profile (grade: strong).
5. For patients whose FEV₁ is less than 60% of predicted, an inhaled combination of 2 long-acting therapies including an anticholinergic agent, a beta-agonist, and/or an inhaled corticosteroid may be administered (grade: weak).
6. For patients whose FEV₁ is less than 50% of predicted and who are symptomatic, clinicians should prescribe pulmonary rehabilitation (grade: strong). They may consider pulmonary rehabilitation for symptomatic patients whose FEV₁ is greater than 50% of predicted if the patient also has limitation of exercise capacity (grade: weak).
7. Clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia, including a partial pressure of oxygen in arterial blood (PaO₂) of ≤ 55 mm Hg or an arterial saturation of ≤ 88% on room air (grade: strong).

Viewpoint

These recommendations, which are updated from time to time, are the official recommendations of 4 major specialty organizations: the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society. They are based on articles from MEDLINE that were published between March 2007 and December 2009. As such, the recommendations are very simple to follow and the evidence grade, which is based on the balance between benefit and risk for each modality, is useful. The full publication presents the reasoning behind each recommendation.

These guidelines are not to be regarded as directives. The recommendations, which are based on lung function, relate to the study population included in the relevant trials and are more or less arbitrary. A flexible approach that is based on clinical considerations is still appropriate. Also, FEV₁ is not a very good measure of disease severity in COPD. It is used because it is objective, quick, and easy to measure and can be reproduced. However, clinical outcomes such as quality of life, disease progression, and mortality of patients with COPD are related to many factors, of which FEV₁ is important but accounts for only a limited portion.^[1] Again, measurement of lung function is strongly recommended in patients with respiratory symptoms but should only guide, not rule one's clinical decision-making.

What has been omitted? The purpose of this publication, as stated in the introduction, is to update the 2007 guidelines, so some additional management issues are not mentioned but are nevertheless important. The most important of these is smoking cessation and the various modalities now available to help people with COPD quit smoking. A second recommendation, not included in the updated guidance, would be vaccination against pneumococcal pneumonia. The current recommendation is 1 dose; a second dose can be given under some circumstances.^[2] The annual influenza vaccination is also important for patients with COPD. I would also recommend a blood test screening for alpha-1 antitrypsin deficiency. The condition still tends to be overlooked, and fewer than 10% of Americans with this devastating but treatable form of COPD have been diagnosed, according to the Alpha-1 Association.^[3]

The updated guidelines are highly recommended for all healthcare providers given the large number of COPD sufferers, the impact of the condition on their lives, and the cost of the disease to society. However, even strict compliance with these guidelines will not, so far as present evidence shows, alter the progression of the disease or reduce its mortality. For that, we await the discovery of a disease-modifying treatment for this condition, the third greatest cause of mortality in the United States and the incidence of which is still increasing worldwide.