Guideline source: American College of Physicians
Literature search described? Yes
Evidence rating system used? Yes
Published source: Annals of Internal Medicine, November 6, 2007
Available at: http://annals.org/cgi/content/full/147/9/633
The American College of Physicians (ACP) released a guideline providing recommendations on the diagnosis and treatment of chronic obstructive pulmonary disease (COPD). The evidence and recommendations in this guideline were graded with the ACP's clinical practice guidelines grading system and were based on a systematic evidence review published in Annals of Internal Medicine and on a Minnesota Evidence-based Practice Center evidence report sponsored by the Agency for Healthcare Research and Quality. According to the ACP, the objective of the guideline was to analyze the evidence for the following questions: What is the value of clinical examination for prediction of airflow obstruction? What is the incremental value of spirometry for case finding and diagnosis of adults who are candidates for COPD treatment? What management strategies are effective for COPD treatment?
Symptoms of COPD include chronic cough, sputum production, wheezing, dyspnea, poor exercise tolerance, and signs and symptoms of right-sided heart failure. Cigarette smoking is the most common cause of COPD. A patient with any combination of two findings (i.e., at least a 70-pack-year history of smoking, a history of COPD, or decreased breath sounds) is considered likely to have airflow obstruction. The ACP defined airflow obstruction as a forced expiratory volume in one second (FEV1) of less than 60 percent predicted or FEV1–forced vital capacity ratio of less than 0.60. The ACP found that the combination of factors that best excluded COPD were having never smoked, no reported wheezing, and no wheezing on examination.
Recommendation 1: In patients with respiratory symptoms (particularly dyspnea), spirometry should be performed to diagnose airflow obstruction. Spirometry should not be used to screen for airflow obstruction in asymptomatic persons. (Strong recommendation, moderate-quality evidence). Spirometry may help identify patients who might benefit from initiating therapy (Table 1). However, no high-quality evidence has shown that obtaining and providing spirometry results will help improve smoking cessation rates.
Recommendation 2: Treatment for stable COPD should be reserved for patients who have respiratory symptoms and FEV1of less than 60 percent predicted, as documented by spirometry. (Strong recommendation, moderate-quality evidence). Most likely to benefit from therapy are patients with respiratory symptoms and clinically significant airflow obstruction. Evidence does not support treating asymptomatic patients, nor does it support periodic spirometry for monitoring disease status or modifying treatment after therapy is initiated. This recommendation does not address the occasional use of bronchodilators for acute symptomatic relief.
Recommendation 3: Physicians should prescribe one of the following maintenance mono-therapies for symptomatic patients with COPD and FEV1of less than 60 percent predicted: long-acting inhaled beta agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. (Strong recommendation, high-quality evidence). Although there is similar effectiveness with inhaled corticosteroids and long-acting inhaled bronchodilators, these therapies differ in their adverse effects, reductions in deaths, and hospitalizations. There is not enough evidence to recommend one monotherapy over another.
Recommendation 4: Physicians may consider combination inhaled therapies for symptomatic patients with COPD and FEV1of less than 60 percent predicted. (Weak recommendation, moderate-quality evidence). It has not been clearly established when it is better to use combination therapy over monotherapy, and studies have not consistently shown that combination therapy is better.
Recommendation 5: Physicians should prescribe oxygen therapy in patients with COPD and resting hypoxemia (arterial partial pressure of oxygen [PaO2]of 55 mm Hg or less). (Strong recommendation, moderate-quality evidence). For patients with resting hypoxemia and severe airflow obstruction (i.e., FEV1 of less than 30 percent predicted), use of supplemental oxygen for 15 hours or longer per day can help improve survival.
Recommendation 6: Physicians should consider prescribing pulmonary rehabilitation in symptomatic patients with COPD who have FEV1of less than 50 percent predicted. (Weak recommendation, moderate-quality evidence). Evidence shows that pulmonary rehabilitation programs reduce hospitalization rates and improve health status and exercise capacity in patients with severe airflow obstruction; however, the evidence is not clear concerning the benefits for patients with FEV1 of greater than 50 percent predicted.