Posted: 09/29/2011
Qaseem A, Wilt TJ, Weinberger SE, et al
Ann Intern Med. 2011;155:179-191
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:
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.
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