(Chest. 2000;117:23S-28S.)
© 2000
American College of Chest Physicians
Recommendations for the Management of COPD*
Gary T. Ferguson, MD, FCCP
*
From the Botsford Pulmonary Associates, Farmington Hills, and Wayne State University, Detroit, MI.
Correspondence to: Gary T. Ferguson, MD, FCCP, Botsford Pulmonary Associates, 28080 Grand River Ave, Suite 306N, Farmington Hills, MI 48336
 |
Abstract
|
|---|
Three sets of guidelines for the management of COPD that are widely
recognized (from the European Respiratory Society [ERS], American
Thoracic Society [ATS], and British Thoracic Society [BTS]) are
reviewed and compared. None of the documents uses classic
evidence-based documentation, and, in many instances, the
recommendations are empiric because of a lack of scientific evidence.
Overall, there is strong agreement between the documents. All three
guidelines recommend inhaled bronchodilators as first-line therapy.
Anticholinergics are noted to be well tolerated, although potential
problems with ß2-agonists are mentioned. The ERS and BTS
suggest that inhaled corticosteroids may be of value in patients
documented to be steroid responders, whereas the ATS does not recommend
their use at all. All three guidelines support the use of oxygen and
pulmonary rehabilitation. There are varying levels of disagreement
between the guidelines related to the role of spirometry,
stratification of disease severity, and the use of theophylline and
systemic corticosteroids. Other differences include the role for
nebulizers and metered-dose inhalers, secretion clearance
methodologies, and the treatment of acute COPD exacerbations and acute
respiratory failure. All three guidelines agree that more research is
needed to improve our understanding and management of
COPD.
Key Words: COPD • evidence-based medicine • management guidelines
|
Introduction
|
|---|
Over
the last several years various national and regional professional
organizations have published guidelines for the management of COPD. As
might be expected, the documents vary in length, detail, and
referencing. Of the various guidelines, three reach a large audience
and are commonly quoted. These include the consensus statement of the
European Respiratory Society (ERS) published in August
1995,1
the American Thoracic Society (ATS) standards
statement published in November 1995,2
and the guidelines
of the British Thoracic Society (BTS) published in December
1997.3
The purpose of this article is to review, compare,
and contrast the various aspects of these documents.
Development of the three guidelines (ERS, ATS, and BTS) has been
discussed in the previous papers. Although recommendations are based on
scientific information as much as possible, none of the documents
provides classic evidence-based documentation, and, in many instances,
the recommendations are empiric because of a lack of scientific
information. Overall, there is strong agreement between the three sets
of guidelines with many common themes and recommendations, even in the
face of inadequate scientific evidence. Such agreement provides a
convincing foundation for the care of COPD patients based on sound
clinical judgment while awaiting more scientific evidence. All of the
guidelines acknowledge and agree on the importance of COPD, the disease
burden of COPD on patients and health-care resources, the progressive
nature of COPD, and the importance and need for guidelines. In
addition, they all provide consistent information on COPD pathology,
pathophysiology, definitions, epidemiology, risk factors, and
differential diagnosis. Importantly, all of the guidelines highlight
areas requiring further investigation and encourage research in these
areas.
Guideline goals are most clearly defined in the BTS statement with an
intent for early and accurate diagnosis, best control of symptoms,
prevention of deterioration, prevention of complications, and improved
quality of life. By comparison, the ERS goals are to inform health
professionals, reverse a widespread nihilistic approach to management
of COPD patients, and improve their quality and length of life. No
goals are specifically stated for the ATS document, although goals
within the rehabilitation section suggest they are to lessen airflow
limitation, prevent and treat secondary medical complications, decrease
respiratory symptoms, and improve quality of life. The audiences toward
which the guidelines are directed are also somewhat different, with the
ERS guidelines more focused on respiratory specialists, whereas the ATS
and BTS documents address a broader audience ranging from general
practitioners to intensivists. The ATS document is the most
comprehensive, with extensive discussion and detail, whereas
information in the ERS and BTS documents is presented as more of an
overview.
|
Diagnosis
|
|---|
All three documents attest to the importance of cigarette smoking
and its history in the diagnosis of COPD. The ATS document also
suggests information on past episodes of acute chest illnesses is
important, whereas the BTS document suggests a history of childhood
respiratory illnesses is important. All of the documents emphasize the
importance of symptoms, especially dyspnea, cough, and spu- tum,
in the diagnosis of COPD. Wheezing is also noted in all three documents
with an emphasis that wheezing does not equal asthma. There is also
agreement related to physical examination in the diagnosis of COPD with
an emphasis on prolonged exhalation, hyperinflation, decreased breath
sounds, wheezing, and abnormalities associated with more severe
disease. Importantly, only the BTS document highlights the poor
sensitivity of the physical examination in the diagnosis of COPD.
There is some disagreement between the recommendations for diagnostic
testing (Table 1)
.
All three documents emphasize the need for spirometry with pre- and
postbronchodilator testing, yet do not define how information from the
bronchodilator response is to be used and indicate that bronchodilator
treatment should be independent of the bronchodilator response.
Multiple other pulmonary function tests have varying recommendations
(Table 1)
. Arterial blood gases and chest radiographs are generally
recommended, and all three guidelines do not recommend routine sputum
evaluation. Evaluation for 
1-antiprotease
deficiency is not recommended by the BTS, but is recommended for
patients with early, severe disease by the ERS and ATS, with the ATS
document highlighting the importance of early diagnosis and need for
therapy.
|
Disease Staging, Monitoring, and Screening
|
|---|
In all three guidelines, disease severity is staged on the basis
of spirometry measurements, using the FEV1. In
each case, patients are categorized as mild, moderate, or severe (Table 2)
.
However, there are marked differences with poor overlap and
comingling between the different disease stages, resulting in agreement
only at the extremes of mild and severe disease.
There are also differences in recommendations for frequency of
monitoring of spirometry (Table 3)
.
The ERS recommends spirometry on a yearly basis in patients with mild
disease and every 6 months in patients with moderate to severe disease.
The ATS suggests "periodic" assessment, and the BTS suggests
evaluation "at intervals." A recommendation for assessing rate of
decline in FEV1 is also provided by the ERS and
BTS, with both cautioning that 4 to 5 years of monitoring is required
to define the rate of decline in FEV1 for an
individual. The ATS does not discuss rate of decline in
FEV1.
All three guidelines discuss problems with delayed recognition of COPD
and the importance of screening patients for risk factors, especially
cigarette smoking and occupational exposures, with a need for
intervention to decrease the risk for disease. Only the BTS advocates
the routine use of spirometry to screen for patients with COPD,
especially in smokers and those with occupational risk (Table 3)
. No
statement for or against spirometry screening is provided in the ERS or
ATS documents.
|
Management of Stable COPD
|
|---|
There is good agreement between the guidelines on the medical
management of stable COPD, with all documents providing general
management algorithms. Cigarettes and smoking cessation are emphasized
by all three guidelines, with the ATS guidelines providing a
smoking-cessation protocol plus more practical information. Influenza
immunization is recommended by all, but only the ATS recommends
pneumococcal vaccination.
There are some differences in the recommendations for pharmacologic
management between the three guidelines. All recommend inhaled
bronchodilators as first-line therapy, with the ERS and BTS offering no
preference between anticholinergic agents or
ß2-agonists for initial therapy. The ATS
suggests initial therapy with an anticholinergic drug if regular
therapy is needed and initial therapy with a
ß2-agonist if therapy as needed is all that is
required. All discuss the value of combination therapy with a
ß2-agonist and anticholinergic agents, with the
simplicity associated with having both agents in a single metered-dose
inhaler (MDI) mentioned by the ATS and BTS. The ERS and ATS suggest a
possible role for long-acting agents in patients with nighttime or
early morning symptoms, whereas the BTS recommends limited use of
long-acting agents until more information is available. The ERS and ATS
note the positive safety profile of anticholinergic drugs, even at high
doses, and all three documents note potential problems with using
ß2-agonists. The ATS places more value on the
use of theophylline when inhaled bronchodilators are not adequate, with
much less support for this by the ERS and BTS.
All three guidelines emphasize the need to document corticosteroid
responsiveness before long-term use, do not recommend corticosteroids
for patients who are not steroid responders, and encourage use of the
lowest dose possible in patients who are steroid responders and need
corticosteroids. The ERS and BTS recommend the use of inhaled
corticosteroids to replace or reduce oral corticosteroids in patients
who are steroid responders and require long-term corticosteroids. The
ERS also suggests a role for inhaled corticosteroids in patients with
mild disease who are "fast decliners" in
FEV1. The ATS does not recommend the use of
inhaled corticosteroids until more information is available.
MDIs are recommended over nebulizers by all three guidelines.
Mucokinetic agents are generally not recommended, although the ERS is
somewhat noncommittal. Routine antibiotics and respiratory stimulants
are not recommended in any of the documents. Appropriate psychoactive
drugs are suggested by all, as is the judicious treatment of cor
pulmonale. 1-Antiprotease replacement therapy
is recommended for appropriate candidates by the ATS, but not
recommended by the ERS or BTS.
|
Oxygen and Pulmonary Rehabilitation
|
|---|
The importance of oxygen therapy in selected patients and the
various oxygen systems and delivery methods are discussed in all three
guidelines. Differences in assessment of oxygenation are noted, with
the ATS and BTS recommending oximetry at rest and with activity,
whereas the ERS only suggests resting oximetry in patients with
moderate to severe disease. Nocturnal oximetry is recommended only with
evidence of polycythemia and cor pulmonale by the ERS and ATS and not
at all by the BTS. Formal nocturnal sleep studies are not recommended
unless sleep apnea is suspected.
An overview of pulmonary rehabilitation is provided by all three
guidelines with varying indications for rehabilitation ranging from
patients with muscle weakness (ERS) to increased health-care
utilization, symptoms, and reduced function on optimal medical
management (ATS) to moderate to severe disease (BTS). Education,
psychosocial support, nutritional assessment, and lower extremity
exercise are recommended and inspiratory muscle training is not
recommended by all three guidelines. Upper extremity training and
breathing retraining are supported by the ATS. Home mechanical
ventilation on an elective and nonelective basis are discussed by the
ERS and ATS, with modest support for both by the ERS, but with positive
support for nonelective and negative support for elective noninvasive
ventilation by the ATS. No recommendations are provided by the
BTS.
|
Indications for Specialist Referral
|
|---|
Only the BTS provides recommendations for referral of a COPD
patient for specialist care. BTS indications include suspected severe
COPD, cor pulmonale, oxygen therapy, nebulizer therapy, assessment of
corticosteroids, bullous disease, disease with < 10 pack-years, rapid
decline in FEV1, disease with age < 40 years,
uncertain diagnosis, symptoms disproportionate to
FEV1, and frequent infections. The ATS suggests
that COPD patients with stage II and III disease
(FEV1 < 50% predicted) be seen by a
specialist, and the ERS does not make any recommendations.
|
Acute/Emergency Evaluation
|
|---|
As with initial diagnosis, recommendations by the three guidelines
for the symptomatic and physical examination evaluation of the COPD
patient in acute distress are very similar. Unlike the ERS and BTS, the
ATS document does not mention vital signs as part of the evaluation. On
the other hand, the ATS emphasizes a need for evaluation of comorbid
conditions, which is not mentioned by the ERS or BTS. All three
documents recommend the measurement of arterial blood gases, a chest
radiograph, and ECG. A WBC count, serum biochemistries, peak flow, and
spirometry are recommended by the ERS and BTS, but not the ATS.
Theophylline concentration is highlighted by the ATS, but not mentioned
by the ERS and BTS. Sputum Gram’s stain is recommended by the ERS,
with sputum culture recommended in all three guidelines.
|
Hospitalization, ICU, and Discharge Criteria
|
|---|
All three documents provide recommendations for hospitalization,
with the ATS and BTS criteria listed in a table and the ERS
recommendations easily identified in their acute management algorithm.
The specific recommendations are quite different. ERS criteria are
based on objective criteria related to vital signs and laboratory and
spirometry values, whereas ATS criteria are based on clinical end
points. BTS criteria for hospitalization tend to be a combination of
objective and clinical end points.
As with hospitalization criteria, ATS criteria for ICU admission are
based on clinical outcomes, but with specific guidelines related to
hypoxemia, respiratory acidosis, work of breathing, and need for
ventilatory support. Neither the ERS nor BTS provide specific criteria
for ICU admission. However, the ERS lists life-threatening criteria
based on arterial blood gases and the presence of confusion, coma, or
cardiac or respiratory arrest, whereas the BTS discusses respiratory
failure, the need for mechanical ventilation and criteria for
mechanical ventilation based on hypoxemia and respiratory acidosis.
Overall, much more information is provided by the ATS as compared with
the ERS and BTS related to ICU issues.
Only the ATS provides criteria for discharge from the hospital. The BTS
does describe desirable clinical outcomes during management of COPD
that can be construed as discharge criteria. No mention of discharge
criteria is provided by the ERS.
|
Acute Hospital Management
|
|---|
As with chronic management of COPD, there is significant agreement
on the management of acute exacerbations of COPD. However, there are
more areas of disagreement (Table 4)
.
All three guidelines highlight the need to look for exacerbations,
with the ERS listing frequent causes of acute exacerbations. There is
again a reticence about the use of theophylline by the ERS and BTS. The
ERS emphasizes the use of IV corticosteroids, with lesser degrees of
support on the part of the ATS and BTS. Both the ERS and BTS support
the use of nebulizers, whereas MDIs with spacers are advocated by the
ATS. Chest physiotherapy is not supported by the ATS and BTS, whereas
alternative secretion clearance methods are raised by the ATS. ATS and
ERS recommendations on oxygen titration focus on prevention of the
deleterious effects of hypoxemia, with alternative ventilatory support
advocated in patients who develop hypercapnia. The BTS provides much
stricter controls on oxygen supplementation, advocating the use of
Venturi masks for more precise control of inspired oxygen concentration
(FIO2) and limitation of
FIO2 to 28% until arterial blood
gases can be drawn, and suggesting more cautious adjustments in
FIO2 to minimize the development of
acute respiratory acidosis. The BTS suggests a role for respiratory
stimulants in the treatment of reversible causes of respiratory
acidosis, which is not recommended by the
ERS and ATS (Table 4)
. All guidelines support the appropriate use of
noninvasive and invasive mechanical ventilation.
In the hospital, monitoring of oxygen saturation is suggested by all
three guidelines. The ERS and ATS also advocate monitoring of arterial
blood gases. Monitoring of airflow limitation using peak flows and
spirometry is strongly encouraged by the BTS, and peak flow monitoring
is suggested by the ERS (Table 3)
. The ATS does not recommend
in-hospital monitoring of airflow.
|
Other Areas
|
|---|
All three guidelines discuss surgery in COPD. Only the ATS
provides information on preoperative evaluation of COPD patients. The
ATS also provides more detailed information on various surgical
interventions for COPD. Information about air travel, advance
directives, and living wills is provided in all three documents.
|
Conclusion
|
|---|
Consensus on the diagnosis and management of COPD has been
reached, with solid guidelines provided by the ERS, ATS,
and BTS. Although there are individual differences, strong agreement
between the guidelines supports their value. Specific recommendations
that have the greatest divergence include testing during the initial
diagnostic evaluation, criteria for severity of disease, spirometry
screening, and monitoring of patients, criteria for referral to
specialists, and acute management of COPD related to the use of
nebulizers, oxygen titration, and the treatment of acute respiratory
acidosis. Additional effort should now be invested to build consensus
between the various professional organizations. In addition, more
scientific information on COPD management is needed, and ongoing
research into these areas should be actively encouraged.
|
Footnotes
|
|---|
Abbreviations:
ATS = American Thoracic Society; BTS = British Thoracic
Society; ERS = European Respiratory Society;
FIO2 = inspired oxygen concentration;
MDI = pressurized metered-dose inhaler
|
References
|
|---|
-
Siafakas, NM, Vermeire, P, Price, NB, et al (1995) Optimal assessment and management of chronic obstructive pulmonary disease (COPD): The European Respiratory Society Task Force. Eur Respir J 8,1398-1420[CrossRef][ISI][Medline]
-
Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease: American Thoracic Society. Am J Respir Crit Care Med 1995; 152(suppl):S77–S121
-
BTS guidelines for the management of chronic obstructive pulmonary disease: The COPD Guideline Group of the Standards of Care Committee of the BTS. Thorax 1997; 52(suppl 5):S1–S28
This article has been cited by other articles:
|
|
|
|
 
B J Smith, K Dalziel, H J McElroy, R E Ruffin, P A Frith, K A McCaul, and F Cheok
Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease
Chronic Respiratory Disease,
July 1, 2005;
2(3):
121 - 131.
[Abstract]
[PDF]
|
|
|
|
|
|
|
B J Smith, F Cheok, A R Heard, A J Esterman, A M Southcott, R Antic, P A Frith, K Hender, and R E Ruffin
Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline
Chronic Respiratory Disease,
January 1, 2004;
1(1):
17 - 28.
[Abstract]
[PDF]
|
|
|
|
|
|
|
J. A Dougherty, B. L Didur, and L. S Aboussouan
Long-Acting Inhaled {beta}2-Agonists for Stable COPD
Ann. Pharmacother.,
September 1, 2003;
37(9):
1247 - 1255.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Rupp, H. Kothe, A. Mueller, M. Maass, and K. Dalhoff
Imbalanced secretion of IL-1{beta} and IL-1RA in Chlamydia pneumoniae-infected mononuclear cells from COPD patients
Eur. Respir. J.,
August 1, 2003;
22(2):
274 - 279.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. K. Stoller
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
N. Engl. J. Med.,
March 28, 2002;
346(13):
988 - 994.
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
