This is the current release of the guideline.

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).

* Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup.

None provided

The type of supporting evidence is specifically stated for each recommendation.

Not applicable: The guideline was not adapted from another source.

2007 Nov

American College of Physicians - Medical Specialty Society

Clinical practice guidelines are guides only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

American College of Physicians

Clinical Efficacy Assessment Subcommittee of the American College of Physicians

Authors: Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD; Katherine Sherif, MD; Timothy J. Wilt, MD, MPH; Steven Weinberger, MD; and Douglas K. Owens, MD, MS

Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD

Stock ownership or options (other than mutual funds): S. Weinberger (GlaxoSmithKline).

Grants received: V. Snow (Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Novo Nordisk, Pfizer Inc., Merck & Co. Inc., Bristol-Myers Squibb, Atlantic Philanthropies, Sanofi Pasteur).

This is the current release of the guideline.

This NGC summary was completed by ECRI Institute on February 12, 2008. The information was verified by the guideline developer on February 29, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.