0
Editorials |

A Unified Front Against COPDA Unified Front Against COPD: Clinical Practice Guidelines From the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society FREE TO VIEW

Nicola A. Hanania, MD, FCCP; Darcy D. Marciniuk, MD, FCCP; for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society
Author and Funding Information

From the Section of Pulmonary and Critical Care Medicine (Dr Hanania), Baylor College of Medicine; and Division of Respirology (Dr Marciniuk), Critical Care and Sleep Medicine, University of Saskatchewan.

Correspondence to: Darcy D. Marciniuk, MD, FCCP, Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, 5th Floor Ellis Hall, 103 Hospital Dr, Saskatoon, SK, S7N 0W8, Canada; e-mail: darcy.marciniuk@usask.ca


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Hanania and Marciniuk were coauthors on the guideline discussed, representing the American College of Chest Physicians. Dr Hanania has received research grant support (paid to his institution) from GlaxoSmithKline, Boehringer Ingelheim GmbH, Novartis, Pfizer Inc, and Sunovion Pharmaceuticals Inc. He has received honoraria for serving on the speaker’s bureau of GlaxoSmithKline, AstraZeneca, and Sunovion Pharmaceuticals Inc and for serving as a consultant or on an advisory board for GlaxoSmithKline, Novartis, Pfizer Inc, Boehringer Ingelheim GmbH, Pearl Therapeutics Inc, and Sunovion Pharmaceuticals Inc. Dr Marciniuk has received research funding (paid to his institution) from AstraZeneca, Boehringer Ingelheim GmbH, Canadian Agency for Drugs and Technology in Health, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Novartis, Nycomed, Pfizer Inc, Saskatchewan Health Research Foundation, Saskatchewan Ministry of Health, and Merck/Schering-Plough. He has participated on advisory boards, undertaken consulting, and provided continuing education for AstraZeneca, Boehringer Ingelheim GmbH, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer Inc, Public Health Agency of Canada, Saskatchewan Medical Association, and Saskatoon Health Region.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(3):565-566. doi:10.1378/chest.11-1152
Text Size: A A A
Published online

COPD is one of the world’s leading causes of morbidity and mortality. Currently the fifth leading cause of death worldwide, it is predicted that COPD will become the third leading cause of death by the year 2020.1-4 In fact, COPD already has surpassed cerebrovascular disease to become the third leading cause of death in the United States.5 In addition, COPD is now recognized as a life-limiting illness that imposes significant symptom burden on those with the disease. The varied and diverse pathology of COPD, which is caused by cigarette smoke exposure in the majority of patients, typically involves multiple components, including small airway inflammation and remodeling, mucociliary dysfunction, and lung architecture damage. These pathologic changes lead to airflow limitation, resulting in gas trapping and hyperinflation, with resultant disability and handicap.

The diagnosis of COPD is based fundamentally on spirometric measurement, which demonstrates airway obstruction that may be partially reversible. Because of the slow progression of the disease over years, symptoms early in the course are subtle and insidious, resulting in delay in seeking medical advice, early diagnosis, and appropriate management. In a recent study performed in primary-care practice, 20% of patients with risk factors for COPD met spirometry criteria for moderate, severe, or very severe COPD,5 which highlights the reality that underdiagnosis of COPD in primary care is widespread. The goals of COPD management aim to improve symptoms, lung function, and health status and to reduce exacerbations, disease progression, and mortality. To achieve these goals, several effective pharmacologic and nonpharmacologic interventions need to be implemented on the basis of disease severity and patient symptoms. Although such interventions have led to striking successes in patient-focused outcomes, there is much more that needs to be done to overcome the rising burden of this disease and to improve therapeutic outcomes.

Several guidelines for COPD have been published to date.7-9 Although these guidelines aim to optimize the diagnosis and management of COPD, many issues exist that affect their practical implementation.10 One important issue is that each guideline addresses a different audience and targets different geographic locales. To unify and improve our approach to this disease, the American College of Physicians (ACP), American College of Chest Physicians, American Thoracic Society, and European Respiratory Society recently released an updated clinical practice guideline for COPD.11 This guideline tackles several important issues and updates a previous ACP document published in 2007.12 Although the guideline highlights that history and physical examination in isolation are not sensitive for use in the diagnosis of COPD, clinicians should be aware that many patients may deny symptoms because they have already restricted their activities to those that would not cause symptoms. Patients with very low daily levels of activity indeed may be symptomatic if they were to engage in activities normal for persons their age. Therefore, it is imperative to actively question patients about their daily activities and not to restrict questions to symptoms alone.

There continues to be a strong recommendation to use spirometry for the early diagnosis of COPD in patients with respiratory symptoms, but evidence does not support the use of “screening spirometry” in those without respiratory symptoms. The new guideline now suggests that inhaled bronchodilators may be used effectively in patients with COPD with respiratory symptoms and an FEV1 between 60% and 80% predicted. In patients with more progressed disease (FEV1<60% predicted) in whom combination therapy may be considered, this recommendation is even stronger. However, clinical gaps in knowledge regarding pharmacologic therapy in patients with mild or asymptomatic COPD are still present. Although there is a paucity of reported research examining therapies in this population to support any recommendations at this point, one must keep in mind that lack of evidence does not necessarily equate to lack of benefit.

The guideline emphasizes the importance of pulmonary rehabilitation, which should be considered in symptomatic patients with an FEV1< 50% predicted. Pulmonary rehabilitation also may be considered in symptomatic or exercise-limited patients with an FEV1>50%, as endorsed elsewhere.13 The guideline continues to recommend supplemental oxygen therapy for patients with severe resting hypoxemia (Pao2≤55 mm Hg or arterial oxygen saturation of ≤88%).

COPD has become a global medical urgency. Our awareness, attitudes, and acceptance of the burden and consequences of COPD for patients, families, physicians, and health-care systems have to knowingly change. COPD has an important negative impact on patient health, and the meaningful patient-centered benefits of optimizing pharmacologic and nonpharmacologic therapies can no longer be ignored or minimized. The new clinical practice guideline on COPD from the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society takes an important step forward by highlighting an evidence-based and unifying approach to the diagnosis and management of COPD. It is now time for the rest of us to roll up our sleeves and put these guidelines to work for the millions of patients with COPD who will benefit from their implementation.

References

Urbano FL, Pascual RM. Contemporary issues in the care of patients with chronic obstructive pulmonary disease. J Manag Care Pharm. 2005;115 suppl A:S2-S13 [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Deaths from chronic obstructive pulmonary disease—United States, 2000-2005. MMWR Morb Mortal Wkly Rep. 2008;5745:1229-1232 [PubMed]
 
Mannino DM. Epidemiology and global impact of chronic obstructive pulmonary disease. Semin Respir Crit Care Med. 2005;262:204-210 [CrossRef] [PubMed]
 
Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. Respir Care. 2002;4710:1184-1199 [PubMed]
 
Miniño AM, Xu J, Kochanek KD. Deaths: Preliminary Data for 2008. National Vital Statistics Reports. 2010; Hyattsville, MD National Center for Health Statistics
 
Hill K, Goldstein RS, Guyatt GH, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. CMAJ. 2010;1827:673-678 [CrossRef] [PubMed]
 
Rabe KF, Hurd S, Anzueto A, et al; Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555 [CrossRef] [PubMed]
 
National Clinical Guideline CentreNational Clinical Guideline Centre Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. 2010; London, England National Clinical Guideline Center http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed May 5, 2011.
 
O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease-2007 update. Can Respir J. 2007;14suppl B:5B-32B [PubMed]
 
Rabe KF. Guidelines for chronic obstructive pulmonary disease treatment and issues of implementation. Proc Am Thorac Soc. 2006;37:641-644 [CrossRef] [PubMed]
 
Qaseem A, Wilt TJ, Weinberger  SE, Hanania NA, Criner G, van der Molen T, et al; for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society 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. Ann Intern Med. 2011;1553:179-191 [PubMed]
 
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians Clinical Efficacy Assessment Subcommittee of the American College of Physicians Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;1479:633-638 [PubMed]
 
Marciniuk DD, Brooks D, Butcher S, et al. Optimizing pulmonary rehabilitation in COPD—practical issues: a Canadian Thoracic Society clinical practice guideline. Can Respir J. 2010;174:159-168 [PubMed]
 

Figures

Tables

References

Urbano FL, Pascual RM. Contemporary issues in the care of patients with chronic obstructive pulmonary disease. J Manag Care Pharm. 2005;115 suppl A:S2-S13 [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Deaths from chronic obstructive pulmonary disease—United States, 2000-2005. MMWR Morb Mortal Wkly Rep. 2008;5745:1229-1232 [PubMed]
 
Mannino DM. Epidemiology and global impact of chronic obstructive pulmonary disease. Semin Respir Crit Care Med. 2005;262:204-210 [CrossRef] [PubMed]
 
Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. Respir Care. 2002;4710:1184-1199 [PubMed]
 
Miniño AM, Xu J, Kochanek KD. Deaths: Preliminary Data for 2008. National Vital Statistics Reports. 2010; Hyattsville, MD National Center for Health Statistics
 
Hill K, Goldstein RS, Guyatt GH, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. CMAJ. 2010;1827:673-678 [CrossRef] [PubMed]
 
Rabe KF, Hurd S, Anzueto A, et al; Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555 [CrossRef] [PubMed]
 
National Clinical Guideline CentreNational Clinical Guideline Centre Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. 2010; London, England National Clinical Guideline Center http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed May 5, 2011.
 
O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease-2007 update. Can Respir J. 2007;14suppl B:5B-32B [PubMed]
 
Rabe KF. Guidelines for chronic obstructive pulmonary disease treatment and issues of implementation. Proc Am Thorac Soc. 2006;37:641-644 [CrossRef] [PubMed]
 
Qaseem A, Wilt TJ, Weinberger  SE, Hanania NA, Criner G, van der Molen T, et al; for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society 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. Ann Intern Med. 2011;1553:179-191 [PubMed]
 
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians Clinical Efficacy Assessment Subcommittee of the American College of Physicians Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;1479:633-638 [PubMed]
 
Marciniuk DD, Brooks D, Butcher S, et al. Optimizing pulmonary rehabilitation in COPD—practical issues: a Canadian Thoracic Society clinical practice guideline. Can Respir J. 2010;174:159-168 [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543