Canadian Thoracic Society COPD Guidelines : Summary of highlights for family doctors

Denis E ODonnell MD*,, Paul Hernandez MD,, Shawn Aaron MD, Jean Bourbeau MD, Darcy Marciniuk MD, Rick Hodder MD, Meyer Balter MD, Gordon Ford MD, Andre Gervais MD, Roger Goldstein MD, Francois Maltais MD, Jeremy Road MD, Valoree McKay§, Jennifer Schenkel§ *Chair, CTS COPD Guideline Development Committee; Chair, CTS Implementation/Dissemination Committee; Editorial Committee; §Canadian Lung Association Administrative Staff


Assessing Disability in COPD
a combination of a long-acting anticholinergic and an LABA is recommended in addition to an as-needed short-acting beta 2 -agonist for immediate symptom relief.• In patients with severe symptoms despite the use of both a long-acting anticholinergic and an LABA, a long-acting oral theophylline may be tried.Monitoring of theophylline blood levels for adverse effects and for drug interactions is necessary.• Long term maintenance treatment with oral corticosteroids has no proven benefit in COPD and is associated with a high risk of serious adverse effects.• Unlike asthma, inhaled corticosteroids (ICSs) should not be used as a first-line medication in COPD.However, ICSs should be considered in patients with moderate to severe COPD who experience three or more acute exacerbations per year, especially if these exacerbations require treatment with oral steroids.• Patients who remain breathless despite optimal bronchodilator therapy may benefit from the addition of a combination of ICS/LABA, but this should be considered on an individual basis.

Key Message #13:
All COPD patients should be encouraged to maintain an active lifestyle.COPD patients with activity-related shortness of breath tend to reduce activity levels to avoid precipitating respiratory discomfort.Deconditioning due to inactivity contributes to generalized skeletal muscle dysfunction so that even minor activity provokes limb fatigue.Clinically stable COPD patients who remain breathless and limited in their activity despite optimal bronchodilators should be referred to an exercise training program.Formal pulmonary rehabilitation programs that include supervised exercise training and patient education have been shown to consistently improve breathlessness, exercise endurance and quality of life, and may reduce emergency visits and hospitalizations in patients with COPD.

Key Message #14: Acute exacerbations of COPD (AECOPD) are the most frequent cause of medical visits, hospitalizations and death among COPD patients. AECOPD is defined as a sustained worsen-ing of dyspnea, cough or sputum production leading to an increase in the use of maintenance medications and/or supplementation with additional medications. AECOPD is further classified as either purulent or nonpurulent. Antibiotics should only be considered in patients with purulent AECOPD.
History, physical examination and chest x-rays are recommended for patients with AECOPD.Sputum Gram stain and culture should be considered for patients with very poor lung function, those with frequent exacerbations or those who have been on antibiotics in the previous three months.Spirometry should be completed in patients suspected of having COPD only after recovery and when they are stable.
• Combination therapy with short-acting beta 2 -agonists and anticholinergic bronchodilators should be used to treat dyspnea in AECOPD.Patients already on an oral methylxanthine may continue this therapy during AECOPD, but there is no role for the new initiation of therapy.• Oral or intravenous steroids should be administered for 14 days in most moderate to severe COPD patients with AECOPD; however, shorter treatment periods of between seven and 14 days may also be effective.Doses equivalent to 25 to 50 mg of prednisone per day are recommended.

TABLE 1 Canadian Thoracic Society chronic obstructive pulmonary disease (COPD) classification by symptoms/disability* COPD stage Symptoms
*Postbronchodilator forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) less than 0.7 and FEV 1 less than 80% predicted are both required for the diagnosis of COPD to be established; † In the presence of non-COPD conditions that may cause shortness of breath (eg, cardiac dysfunction, anemia, muscle weakness, metabolic disorders), symptoms may not appropriately reflect COPD disease severity.Classification of COPD severity should be undertaken with care in patients with comorbid diseases or other possible contributors to shortness of breath.MRC Medical Research Council Figure 1) Medical Research Council dyspnea scale.COPD Chronic obstructive pulmonary disease.Data from reference 1

Early Diagnosis (spirometry) + prevention End of Life Care Rx AECOPD Follow-up Education / Self-management Short-acting bronchodilators Long-acting bronchodilators Rehabilitation Inh. steroids O 2 Sx Dyspnea FEV 1 B. Management of COPD (Current) Rx AECOPD Follow-up Education / Self-management O 2 Sx Dyspnea FEV 1 Short-acting bronchodilators Long-acting bronchodilators Inh. steroids Rehabilitation End of Life Care Early Diagnosis (spirometry) + prevention Figure 2) A Escalating
For patients with activity-related breathlessness and minimal disability, initial treatment should be with a short-acting beta 2agonist as needed (or a regular anticholinergic or combination anticholinergic/beta 2 -agonist).The choice of first-line therapy is based on clinical response and tolerance of adverse effects.•If symptoms persist despite this, add a long-acting bronchodilator such as an anticholinergic (tiotropium 18 µg qd) or a long-acting beta 2 -agonist (LABA) (formoterol 12 µg bid or salmeterol 50 µg bid) should be added.Continue a short-acting bronchodilator as needed for immediate symptom relief.• For patients with moderate to severe persistent symptoms, management paradigm for chronic obstructive pulmonary disease (COPD) based on increasing symptoms and disability.B Current management deficiencies include lack of screening spirometry, education and rehabilitation, overuse of inhaled corticosteroids (Inh.steroids) in early disease and lack of structured end-of-life care.FEV 1 Forced expiratory volume in 1 s; O 2 Oxygen therapy; Rx AECOPD Treatment of acute exacerbations of COPD; Sx Lung volume reduction surgery or lung transplantation Pharmacotherapy in COPD •

15: COPD is a progressive, disabling condition that ultimately ends in respiratory failure and death. Physicians have a responsibility to provide support to COPD patients and their care- givers at the end of life.
• Antibiotics are beneficial in severe AECOPD, which are episodes associated with increased dyspnea and increased sputum purulence or volume.Patients with simple AECOPD (Table2) have no risk factors for treatment failure; relatively inexpensive antibiotics can target likely pathogens.Patients with complicated AECOPD have risk factors for treatment failure and/or infection with more virulent or resistant organisms.If a patient requires repeated antibiotic therapy within three months, a different class of antibiotics should be used to minimize the risk of resistance.•In severe AECOPD complicated by acute respiratory failure not responsive to initial bronchodilator therapy, ventilatory support may be indicated and beneficial.Consultation with a COPD specialist is recommended in this setting.
Please refer to the Canadian Respiratory Journal, Volume 10, Supplement A, for the complete document of CTS COPD Guidelines.CTS COPD GuidelinesCan Respir J Vol 10 No 4 May/June 2003 185

TABLE 2 Antibiotic treatment recommendations for purulent acute exacerbations of chronic obstructive pulmonary disease (COPD)
REFERENCE1.Fletcher CM, Elmes PC, Wood CH.The significance of respiratory symptoms and diagnosis of chronic bronchitis in a working population.Br Med J 1959;1:257-66.