Definitions for the strength of evidence (high, moderate low, insufficient evidence to determine benefits or risks) and strength of recommendations (strong, weak, I recommendation) are repeated at the end of the "Major Recommendations."
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 (AO) in asymptomatic individuals. (Grade: strong recommendation, moderate-quality evidence.)
Targeted use of spirometry for diagnosis of AO is beneficial for individuals with respiratory symptoms, particularly dyspnea. Evidence does not support the use of spirometry to screen for AO in asymptomatic individuals, including those who have risk factors for chronic obstructive pulmonary disease (COPD). No high quality evidence supports obtaining and providing spirometry results to improve smoking cessation, or to identify and treat asymptomatic individuals to prevent future respiratory symptoms or reduce spirometric decline in lung function.
Recommendation 2: Treatment for stable COPD should be reserved for patients who have respiratory symptoms and forced expiratory volume in 1 second (FEV1) less than 60% predicted as documented by spirometry. (Grade: strong recommendation, moderate-quality evidence.)
Evidence shows that individuals who will benefit the most from therapy are those who have respiratory symptoms and clinically significant AO (FEV1 <60% predicted). No evidence supports treating asymptomatic patients, because treatment does not improve outcomes. The evidence does not support periodic spirometry after initiation of therapy to monitor ongoing disease status or to modify therapy. This recommendation does not address the occasional use of bronchodilators for acute symptomatic relief.
Recommendation 3: Clinicians should prescribe 1 of the following maintenance monotherapies for symptomatic patients with COPD and FEV1 less than 60% predicted: long acting inhaled beta-agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. (Grade: strong recommendation, high-quality evidence.)
Monotherapy with a long-acting inhaled beta-agonist, a long-acting inhaled anticholinergic, or an inhaled corticosteroid is beneficial in reducing exacerbations. Inhaled corticosteroids and long-acting inhaled bronchodilators have similar effectiveness but differ in adverse effects, reductions in deaths, and hospitalizations. The review did not systematically evaluate all other outcomes. Evidence is insufficient to recommend 1 monotherapy over another.
Recommendation 4: Clinicians may consider combination inhaled therapies for symptomatic patients with COPD and FEV1 less than 60% predicted. (Grade: weak recommendation, moderate-quality evidence.)
When to use combination therapy instead of monotherapy has not been clearly established. In one trial, combination therapy with long-acting beta-agonists and corticosteroids reduced exacerbations more than did monotherapy. Although deaths with combination therapy decreased in the trial compared with monotherapy, the reduction did not reach the predetermined level of statistical significance. In a recent randomized trial, addition of salmeterol–fluticasone to tiotropium therapy did not statistically influence rates of COPD exacerbation but did improve lung function, quality of life, and hospitalization rates in patients with moderate to severe COPD. However, studies of combination therapies do not consistently demonstrate benefits of combination therapy over monotherapy.
Recommendation 5: Clinicians should prescribe oxygen therapy in patients with COPD and resting hypoxemia (PaO2 <55 mm Hg). (Grade: strong recommendation, moderate quality evidence.)
Use of supplemental oxygen for 15 or more hours daily can help improve survival in patients with severe AO (FEV1 <30% predicted) and resting hypoxemia.
Recommendation 6: Clinicians should consider prescribing pulmonary rehabilitation in symptomatic individuals with COPD who have an FEV1 less than 50% predicted. (Grade: weak recommendation, moderate-quality evidence.)
Evidence supports the use of pulmonary rehabilitation programs for patients with severe AO, because they reduce hospitalizations and improve health status and exercise capacity. However, the evidence is not clear for individuals with FEV1 greater than 50% predicted.
Definitions:
This guideline grades the evidence and recommendations by using the American College of Physicians' clinical practice guidelines grading system adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup (see Table below).
American College of Physicians' Clinical Practice Guidelines Grading System* |
Quality of Evidence |
Strength of Recommendation |
|
Benefits Do or Do Not Clearly Outweigh Risks |
Benefits, Risks, and Burdens Are Finely Balanced |
High |
Strong |
Weak |
Moderate |
Strong |
Weak |
Low |
Strong |
Weak |
Insufficient evidence to determine net benefits or harms |
I recommendation |
* Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup.