American College of Physicians Issues Guidelines for COPD

November 6, 2007 — The American College of Physicians (ACP) has issued clinical recommendations for chronic obstructive pulmonary disease (COPD), including use of spirometry, treatment, rehabilitation, and management. The guidelines are published in the November 6 issue of the Annals of Internal Medicine.
"Chronic obstructive pulmonary disease (COPD) is a slowly progressive lung disease involving the airways and/or pulmonary parenchyma, resulting in a gradual loss of lung function," write Amir Qaseem, MD, PhD, MHA, from the ACP in Philadelphia, Pennsylvania, and colleagues from the ACP Clinical Efficacy Assessment Subcommittee. "The symptoms of COPD range from chronic cough, sputum production, and wheezing to more severe symptoms, such as dyspnea, poor exercise tolerance, and signs of symptoms of right-sided heart failure. In the United States, COPD affects more than 5% of the adult population and is the 4th leading cause of death and the 12th leading cause of morbidity."
The guidelines authors searched the literature, including studies from MEDLINE and the Cochrane database from 1966 to May 2005. They also updated searches for oxygen, inhaled therapies, and disease management through March 2007. Children and individuals with asthma, restrictive lung disease, or alpha-1 antitrypsin deficiency were excluded from the search.
The guidelines authors aimed to evaluate the relevant evidence base regarding the following questions:
How helpful is clinical examination in predicting airflow obstruction (AO)?
What is the incremental value of spirometry for case finding and diagnosing adults who are candidates for COPD treatment?
What management strategies are effective to treat COPD, such as inhaled therapies, pulmonary rehabilitation programs, and supplemental long-term oxygen therapy?
In response to these questions, the available evidence from the literature suggests that history and clinical examination are poor predictors of AO and its severity.
Although evidence does not support the use of spirometry as a screening strategy for individuals without respiratory symptoms, adding spirometry to clinical examination has been shown to be helpful for individuals with respiratory symptoms, especially for those with dyspnea.
The benefits of treating COPD mainly include decreased exacerbations in patients who are more likely to have exacerbations, dyspnea that limits activity, or severe to very severe AO.
Compared with short-acting inhalers, inhaled corticosteroids and long-acting bronchodilators are more effective in reducing exacerbations. For patients with very severe AO and resting hypoxemia, the use of long-term supplemental oxygen therapy is associated with decreased mortality.
Specific recommendations issued in these guidelines are as follows:
In patients with respiratory symptoms, particularly dyspnea, spirometry should be used to diagnose AO. However, it should not be performed to screen for AO in asymptomatic individuals. (Grade: strong recommendation, moderate-quality evidence.)
In patients with stable COPD, treatment should be reserved for patients who have respiratory symptoms and forced expiratory volume at 1 second (FEV1) of less than 60% predicted, as measured by spirometry. (Grade: strong recommendation, moderate-quality evidence.)
Symptomatic patients with COPD and FEV1 less than 60% predicted should be treated with one of the following maintenance monotherapies: long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. (Grade: strong recommendation, high-quality evidence.)
For symptomatic patients with COPD and FEV1 of less than 60% predicted, clinicians may consider using combination inhaled therapies. (Grade: weak recommendation, moderate-quality evidence.)
Patients with COPD and resting hypoxemia (PaO2 ≤ 55 mm Hg) should be treated with oxygen therapy. (Grade: strong recommendation, moderate-quality evidence.)
For symptomatic individuals with COPD who have an FEV1 of less than 50% predicted, clinicians should consider prescribing pulmonary rehabilitation (Grade: weak recommendation, moderate-quality evidence.)
"Studies of combination therapies do not consistently demonstrate benefits of combination therapy over monotherapy," the guidelines authors conclude. "Use of supplemental oxygen for 15 or more hours daily can help improve survival in patients with severe AO (FEV1 < 30% predicted) and resting hypoxemia.... Evidence supports the use of pulmonary rehabilitation programs for patients with severe AO, because they reduce hospitalizations and improve health status and exercise capacity."
Some of the guidelines authors have disclosed various financial relationships with GlaxoSmithKline, the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Novo Nordisk, Pfizer Inc., Merck & Co. Inc., Bristol-Myers Squibb, Atlantic Philanthropies, and Sanofi Pasteur.
Ann Intern Med. 2007;147:633-638, 639-653.