In the latest practice guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the primary-care practitioner (PCP) occupies a prominent role: In fact, the document includes an added section on “Translating Guideline Recommendations to the Context of (Primary) Care.”
“PCPs are pivotal,” says Antonio Anzueto, MD, professor of medicine in the division of pulmonary critical care at The University of Texas Health Sciences Center at San Antonio and a member of the committee that wrote the guidelines. “Not only do they treat patients early in the course of the disease, PCPs also are the ones to identify and diagnose it.” Greater emphasis on the systemic consequences of chronic obstructive pulmonary disease (COPD) and the importance of comorbidity also underline the centrality of primary care, he states.
The revised Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease reflects both the findings of recent clinical studies and an understanding of the disease process that has evolved since the original document was published in 2001. The result is a more strongly optimistic tone, notes Dr. Anzueto. “The big news is that current medications can not only treat the precipitating condition but prevent exacerbations and improve quality of life.”
The section on pathology, pathogenesis, and pathophysiology has been “considerably updated and revised,” according to the guidelines’ authors, and the discussion of prevention and management of exacerbations has been expanded. “This section had been small and underplayed in earlier guidelines,” notes Dr. Anzueto.
Diagnosis and assessment
Identifying individuals in the early stages of COPD continues to be problematic, Dr. Anzueto observes. Recent figures cited by the guidelines say that 15%-25% of adults aged 40 or older might be classified with mild or more serious disease, and some data suggest that >80% of them have not been diagnosed or treated.
While clinical signs and symptoms may be suggestive, the diagnosis can be confirmed only with spirometry (as before, a ratio of forced expiratory volume in one second-to-forced vital capacity [FEV1/FVC] <0.70 is the threshold), and the guidelines strongly advocate that high-quality spirometry be accessible to PCPs.
Spirometry is also the basis for classifying COPD into four stages (mild, moderate, severe, and very severe), but what had earlier been classified as “stage 0”—chronic symptoms like cough and sputum production but normal spirometry—has been eliminated in the latest guidelines. While such individuals may be “at risk” of COPD, the authors point out, there is insufficient evidence that they will necessarily progress to actual disease.
A motif of the new guidelines is the need to “individualize” the management of stable COPD to ameliorate symptoms and improve each patient’s quality of life.
Education: Patient education is important in reducing the risk factors that can exacerbate established disease. Smoking cessation is paramount, but patients should also be counseled to reduce exposure to air pollution by avoiding vigorous outdoor exercise when levels are high; those with advanced disease might do well to stay indoors at such times.
Strategies on coping with and minimizing dyspnea as well as deciding when to seek help are also recommended as part of education programs.
Pharmacotherapy: Bronchodilators are “central to the symptomatic management of COPD,” and good evidence shows that long-acting agents are more effective than short-acting ones, as well as being more convenient. The regular use of long-acting bronchodilators improves health status, reduces exacerbations, and makes pulmonary rehabilitation more effective. Short-acting agents might best be reserved for use as rescue medication.
The guidelines describe inhaled glucocorticosteroids as “appropriate” for regular use by patients in stages III and IV who have repeated exacerbations. Long-term oral steroids are not recommended, nor are prophylactic antibiotics, mucolytic agents, or antitussives (Figure 1).
As before, the guidelines recommend influenza vaccine for all patients and pneumococcal polysaccharide vaccine for those 65 and older. The guidelines add that vaccination may reduce community-acquired pneumonia in younger patients with advanced COPD (FEV1 <40% predicted).
Exercise: An exercise training program appears beneficial for patients at all stages of COPD; a recent study noted that such interventions may bring about symptomatic improvements (particularly in dyspnea and fatigue) as well as increased exercise tolerance.
“In preparing the guidelines, we wanted to emphasize that exacerbations are the major driver of morbidity and mortality behind COPD,” Dr. Anzueto says.
Increased dyspnea heralds an exacerbation; wheezing, increased cough or sputum, and fever are common as well. These symptoms, along with physical examination findings, arterial blood gas measurements as well as other laboratory tests, and the patient’s medical history and comorbidities should be considered in assessing the severity of the episode. But spirometry is inaccurate and difficult to perform in this situation, and it is not recommended. A change in mental status indicates severe exacerbation in a stage IV patient and suggests the need for prompt hospital evaluation.
Even in end-stage disease, some exacerbations can be managed at home, the authors say, although hospital evaluation and possible admission are indicated for older patients or when underlying COPD is severe. Significant comorbidities, a sudden and marked increase in symptoms, new physical signs (such as cyanosis), or a failure to respond to initial management also suggest the need for hospital care.
Increasing the dose or frequency of inhaled short-acting bronchodilators (and adding an anticholinergic if the patient is not already taking one) is the foundation of home management. A limited course (7-10 days) of systemic glucocorticosteroids may shorten recovery time, improve lung function, and reduce the risk of early relapse. Such a course should be considered if baseline FEV1 is <50% predicted.
Antibiotics are indicated when the exacerbation is accompanied by signs of infection: increased sputum purulence with increased sputum volume and/or dyspnea.
It may take weeks for function to return to normal—a situation in which patience and clinical restraint become paramount, Dr. Anzueto says. “We often get frustrated and start very aggressive treatment, but giving more medication can make things worse. The patient may need multiple courses of antibiotics—but not of systemic corticosteroids.”
Management of an exacerbation, whether in the hospital or at home, should include discussion of strategies to prevent future episodes, such as smoking cessation, vaccination, and review of inhaler technique.
The executive summary of the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease appeared in American Journal of Respiratory and Critical Care Medicine (2007;176:532-555).