the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has just come out with new guidelines (to see document summary, go to http://www.guideline.gov/content.aspx?id=43794. The AHRQ (agency for healthcare research and quality) just promoted the new guidelines and provided a brief synthesis of the document. will also add the useful out-patient management reference (see http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf). in brief:
–COPD, a common and preventable/treatable disease, which is progressive and assoc with significant personal as well as social/economic consequences
–should be considered in anyone with dyspnea, chronic cough or sputum production and history of exposure to risk factors (cigarette smoke or other noxious particles such as smoke from biomass fuels — occup and environmental exposure)
–spirometry required to make dx, with post-bronchodilator FEV1.0/FVC <0.70, which is similar to recommendations by ACP/ACCP/ATS/ERS (am college physicians, am college of chest physicians, am thoracic society and european resp society)
–important to assess severity of disease including functional effects on patient (impact on health status, activities, etc), social supports, and risk of future events (exacerbations, admissions, death); also need to assess common comorbidities (cardiovasc, skeletal muscle dysfunction, metabolic synd, osteoporosis, depression, lung cancer) in overall assessment of specific patient. important to know particulars of patient’s dz (timing/precipitants of exacerbations). and, ability to reduce exposures (smoking, environ/occup exposures). one validated tool to assess symptoms is the Modified British Medical Research Council (mMRC) questionnaire (see http://copd.about.com/od/copdbasics/a/MMRCdyspneascale.htm). GOLD also reinforces some older studies (there was one in the annals of internal medicine around 20 years ago) which find (not surprisingly) that, controlling for pack-yrs of cigarettes, people with COPD have higher risk of lung cancer (3-times higher in the annals study). unlike the ACP/ACCP/ATS/ER recommendations, GOLD does suggest that the following studies “be considered”: CXR, CT, diffusing capacity, a-1 antitrypsin, exercise testing — not so much to diagnose COPD but may be important in overall assessment of patient/significant comorbidities/treatment
–treatment: meds do not alter long-term decline of lung function (though: smoking cessation and removal of noxious exposures does help!!), but are important to decrease symptoms/reduce exacerbations. flu/pneumococcal vaccines important . meds: inhaled bronchodilators prn, they do note that “choice of b-agonists, anticholinergics, theophylline or combo therapy depends on individual patient’s response”. they comment on potential cardiac events with anticholinergics, but suggest that further studies are needed. inhaled steroids help (though no comment that the actual studies are really all over the map here: some with good response to steroids, some with none. i personally do try steroids early on in therapy, but stop them if no clinical benefit, since data do not suggest that steroids actually alter the natural history of COPD). moderate-to-severe COPD (FEV1.0<80% of predicted) may respond better to combo long-acting b-agonist (LABA) plus steroid, vs individual component. recent meta-anal showed decreased mortality with combo. some increased risk of pneumonia, though. some (meager) data that triple combo (LABA/steroid/tiotropium) is better (and i have many patients on this combo with apparent clinical improvement over double therapy). some likely further improvement with 15-20% dec in severe exacerbations in pts with poorly controlled chronic bronchitis by adding roflumilast to steroids, though i’m not aware of any data on the incremental effect of adding roflumilast to full triple therapy as above.they do not suggest routinely using antibiotics (eg azithro), mucolytics, antitussives (though i do occasionally use codeine-containing antitussive in patients who are unable to sleep because of cough), vasodilators.
–the GOLD management reference (see above)divides patients into 4 categories (analogous to asthma guidelines), with proposed treaments:
— A= low risk less symptoms (<2 exacerb/yr, low mMRC of <2) — short acting b-agonist or anticholingeric — mMRC of 1 is “I only get breathless with strenuous exercise”.
— B= low risk more symptoms (<2 exacerb/yr, but mMRC>=2) — LABA or LA anticholinergic — mMRC of 2 is “On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace”
— C= high risk less sx (>=2 exacerb/yr with mMRC<2 — inhaled steroid plus LABA or LA anticholinergic
— D= high risk more sx (>=2 exacerb/yr with mMRC>=2) — inhaled steroid plus LABA and/or LA anticholinergic
GOLD more assertive in using combo therapies than previous guidelines
–pulm rehab (which we undoubtedly underuse in primary care). consider pulm rehab in anyone “who gets short of breath when walking on their own pace on level ground”. improves exercise capacity, dec pt perception of breathlessness, improves health-related QoL, dec hospitalizations,dec anxiety/depression assoc with COPD, improves survival and recovery after hospitalization, improves response to LABAs. benefits extend beyond the immediate period of rehab. Note that this is a much more inclusive guideline than ACP/ACCP/ATS/ERS, which really pushes pulm rehab for symptomatic patients with FEV1.0<50%
–oxygen therapy (>15 hrs/d) in pts with severe resting hypoxemia (PaO2 <55mmHg or SaO2 <=88% with or without hypercapnea and confirmed twice over a 3 week period. unlike ACP/ACCP/ATS/ER, GOLD suggests oxygen therapy if PaO2=55-60 or SaO2 of 88% with evidence of pulmonary htn, periph edem or hct>55%
–recommendations for surgery (lung volume reduction, bullectomy, transplant) in selected patients (see paper for details)
–palliative care, end-of-life-care, hospice — should be discussed with patients given predicted pulmonary decline (again, undoubtedly not done enough by us guys)
–for acute exacerbations, antibiotics if evidence of: increased sputum purulence, increased sputum volume and increased dyspnea, esp in moderately to severely ill pts; or if 2 of these symptoms with one being increased sputum purulence, or anyone on mechanical ventillation. for 5-10 days.
the biggest difference (to me) with previous guidelines is attention paid to patient-centered care — ie, we should not be treating FEV1.0’s (esp since they do not correlate so well with clinical disease), but look at the individual’s symptoms, and risk of exacerbations.
i would add: i think it is really useful to know the specific clinical course of the individual patient, what their precipitants are to exacerbations, how bad are the exacerbations and historically what works for them. early treatment is effective in preventing admissions/intubations. so, i have some patients with COPD who get more aggressive baseline treatment during the winter, if URIs are their usual precipitant. some patients with very severe COPD/many hospital admissions even get prednisone at home to take when they are beginning to get an exacerbation (i go through the indications for starting prednisone in detail with them) — and this has undoubtedly decreased admissions/intubations for some of them.
geoff