Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Steven E. Weinberger, MD; Nicola A. Hanania, MD, MS; Gerard Criner, MD; Thys van der Molen, PhD; Darcy D. Marciniuk, MD; Tom Denberg, MD, PhD; Holger Schünemann, MD, PhD, MSc; Wisia Wedzicha, PhD; Roderick MacDonald, MS; Paul Shekelle, MD, PhD; for the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society
This guideline is an official statement of the American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory Society (ERS). It represents an update of the 2007 ACP clinical practice guideline on diagnosis and management of stable chronic obstructive pulmonary disease (COPD) and is intended for clinicians who manage patients with COPD. This guideline addresses the value of history and physical examination for predicting airflow obstruction; the value of spirometry for screening or diagnosis of COPD; and COPD management strategies, specifically evaluation of various inhaled therapies (anticholinergics, long-acting β-agonists, and corticosteroids), pulmonary rehabilitation programs, and supplemental oxygen therapy.
This guideline is based on a targeted literature update from March 2007 to December 2009 to evaluate the evidence and update the 2007 ACP clinical practice guideline on diagnosis and management of stable COPD.
ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence).
For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, ACP, ACCP, ATS, and ERS suggest that treatment with inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence).
For stable COPD patients with respiratory symptoms and FEV1 <60% predicted, ACP, ACCP, ATS, and ERS recommend treatment with inhaled bronchodilators (Grade: strong recommendation, moderate-quality evidence).
ACP, ACCP, ATS, and ERS recommend that clinicians prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV1 <60% predicted. (Grade: strong recommendation, moderate-quality evidence). Clinicians should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile.
ACP, ACCP, ATS, and ERS suggest that clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV1<60% predicted (Grade: weak recommendation, moderate-quality evidence).
ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV1 <50% predicted (Grade: strong recommendation, moderate-quality evidence). Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV1 >50% predicted. (Grade: weak recommendation, moderate-quality evidence).
ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao2 ≤55 mm Hg or Spo2 ≤88%) (Grade: strong recommendation, moderate-quality evidence).
ACP = American College of Physicians; ACCP = American College of Chest Physicians; ATS = American Thoracic Society; COPD = chronic obstructive pulmonary disease; ERS = European Respiratory Society.
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ACP collaborated with three other physician organizations to develop a clinical practice guideline on chronic obstructive pulmonary disease (COPD).
Norman H. Edelman
Stony Brook University School of medicine, Stony Brook, New York, 11794-8036
August 3, 2011
Characterizing COPD Solely on Basis of Single Spirometric Measurement?
The authors of the new revision of the COPD clinical guidelines should be congratulated for the integrity of their efforts. Although each of the sponsoring institutions receives substantial support from the pharmaceutical industry the recommendations are notably parsimonious concerning the use of highly promoted medications, especially combination inhalers. On the other hand they may have been a bit too reductionist in choosing to characterize COPD solely on the basis of a single spirometric measurement. It has long been clear that COPD is a spectrum of entities with diverse phenotypes. A recent study shows, for example, that frequent exacerbations may exist as a separate phenotype over a wide range of severity by spirometric criteria . Might not this, by itself, be an indication for prescribing treatment shown to reduce exacerbations? Definitive evidence for this approach may not have been present in the literature reviewed but surely the possibility should be recognized in guiding physicians.
Norman H Edelman MD Stony Brook University School of medicine Stony Brook, New York, 11794-8036
1] Hurst, JR et. al. Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease. New England Journal of Medicine 2011; 363: 1128-1138
manchester medical society
August 7, 2011
defining airflow obstruction using FEV1/FVC ratio below the 5th percentile
Given the fact that FEV1/FVC ratio decreases naturally with age( as a result of the fact that age-related decline is greater for FEV1 than for FVC)(1), it has been proposed that an FEV1/FVC ratio which falls below the 5th percentile(ie below lower limit of normal) should be the preferred parameter for defining airflow obstruction so as to mitigate the risk of overdiagnosis of airflow obstruction(including chronic obstructive airways disease)(2) inherent in the use of the fixed 0.7 ratio advocated by the Global Initiative for Chronic Obstructive Lung Disease(3). In a population -based sample of 3,802 subjects aged 40-80 subjects were classified according to both criteria, namely, FEV1/FVC < 5th percentile(so-called < LLN), vs FEV1/FVC < 0.70 after bronchodilator challenge. Subjects were allocated to the "ratio-only" group if their FEV1/FVC was < 0.70 but > LLN(175 subjects), and into mild,and moderate to severe COPD(chronic obstructive pulmonary disease)groups if they had FEV1/FVC < 0.70 as well as <LLN(211 subjects). The rest(3,416 subjects) were classified an non-COPD. In the "ratio-only" subgroup the proportion of never-smokers was 27.1% as opposed to 19.4%, and 12.6%, respectively, in patients with mild COPD and moderate to severe COPD, respectively. Ratio- only subjects comprised 4.6% of the study population of 3,802 subjects(2). If one accepts the proposition that, some, if not all of the patients in that subgroup had age-related decline in lung function as opposed to COPD, then, at the very least, the proportion of never-smokers in the ratio-only category might have been completely misclassified as having COPD. Accordingly, guidelines such as the ones recently published in the Annals(4) ought to acknowledge the existence of an alternative classification of COPD, and the potential for misclassification, especially of never-smokers, with sole reliance on the "ratio-only" parameter.
(1)Garcia-Rio F., Pino JM., Dorgham A., Alonso A., Villamor J Spirometric reference equations for caucasian european women and men aged 65-86 years Eur Respir J 2004;24:397-405
(2)Garcia-Ro F., Soriano JB., Miravitlles M et al Overdiagnosing subjects with COPD using the 0.7 fixed ratio: Correlation with a poor health-related quality of life CHEST 2011;139:1072-1080
(3) Rabe KF., Hurd S., Anzueto A et al Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: Gols executive summary Am J Respir Crit Care Med 2007;176:532-555
(4)Qaseem A., Wilt TJ., Weinberg SE et al Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the Americam Cpllege of Physicians, American College of Chest Physicians, American Thoracic Society, and European respiratory Society Ann Intern Med 2011;155:179-191
Robert P. Young
Schools of Biological Science and Health Sciences, University of Auckland, New Zealand
August 8, 2011
Clinical Practice Guidelines on the diagnosis and management of COPD.
We read with disappointment the first recommendation of these recently published guidelines which state "Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms" (1). In our opinion, this would be like recommending fasting blood sugar not be measured in obese patients until angina develops. Even if performing spirometry does not in itself modify the underlying risk (smoking cessation) or warrant immediate treatment (use of bronchodilators), airflow limitation is a marker of premature death from all causes, in particular heart attack and lung cancer (2,3).
We believe this recommendation reflects an unduly nihilistic attitude to the wider use of spirometry, primarily due to its poor implementation to date rather than poor clinical utility. By not screening high risk individuals, such as chronic asymptomatic smokers, we are loosing the opportunity for a teachable moment, which demonstrates to smokers their inherent susceptibility and irreversible "end-organ damage". That smokers do not quit smoking in greater numbers in response to poor spirometry is possibly because we do not sufficiently emphasise the substantial increased risk of heart attack and lung cancer conferred by reduced FEV1 (2,3). Moreover, if we wait for symptoms before spirometry is offered, many smokers will have irreversibly lost as much as 50% of their lung function (2). Evidence shows the greatest potential to optimize lung health (preservation of lung function and reduced lung cancer risk) comes from quitting smoking before significant airflow limitation is established. Another lost opportunity would be in identifying smokers most at risk of lung cancer (3) at a time when CT-based screening for lung cancer appears to show a significant survival benefit (4). For lung cancer screening to be widely and cost-effectively adopted, it will be necessary to identify current and former smokers at greatest risk, over and above that conferred by age and smoking exposure (3). If we abandon spirometric screening of asymptomatic smokers we will lose this opportunity, as we and others have shown reduced FEV1 confers a 6 fold greater risk of lung cancer compared to smokers with normal lung function (5). We believe the use of spirometry as a diagnostic test is far outweighed by it's utility in establishing end organ lung damage, increased all-cause mortality and targeted risk mitigating interventions. In our view, to abandon the use of spirometry in asymptomatic smokers will certainly promote (if not worsen) the continued under-diagnosis (and under resourcing) of COPD.
1. Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen M, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Int Med 2011; 155: 179-91.
2. Young RP, Hopkins R, Eaton TE. FEV1: not just a lung function test but a marker of premature death from all causes. Eur Respir J 2007; 30: 616-622. 3. Young RP, Hopkins R. Lung function predicts lung cancer. Eur Respir J 2010; 35: 1421-22.
4. The National Lung Screening Trial Research Team. Reduced lung cancer mortality with low-dose computed tomographic screening. N Eng J Med 2011; 365: 395-409.
5. Young RP, Hopkins RJ, Christmas T, Black PN, Metcalf P, Gamble GD. COPD prevalence is increased in lung cancer independent of age, gender and smoking history. Eur Respir J 2009; 34: 380-386.
RPY, and the funding of his research, has been supported by grants from the University of Auckland, Health Research Council of New Zealand and Synergenz BioSciences Ltd.
American College of Physicians
October 5, 2011
Author's Response Re: Utility of Spirometry for Screening Asymptomatic Patients
We thank Dr. Young and Ms Hopkins for their comments regarding the American College of Physicians' recent clinical guideline on the diagnosis and management of stable COPD (1). However, we respectfully disagree with their argument that the ACP recommendation against using spirometry for screening asymptomatic patients is nihilistic. There is an agreed upon criteria that defines when to consider screening (2). It includes: 1) there should be an accepted treatment available and 2) if treatment is started at an early stage, it will be beneficial and change clinical outcomes compared to waiting until patients develop disease signs or symptoms. The current evidence indicates that identification and treatment of individuals with asymptomatic airflow obstruction does not improve clinical outcomes and that spirometry acts does not act as a motivator to help patients stop smoking (1,3,4,5). In addition, we found no evidence to support the use of routine periodic spirometry after initiation of therapy in order to monitor disease status or guide therapy modification. On the contrary, spirometry in asymptomatic patients may be associated with harms such as "labeling", follow-up visits, repeated office spirometry, full pulmonary function tests with bronchodilator testing, lung imaging and use of unnecessary and ineffective treatments (6). With this evidence in mind, the there is no net benefit to obtaining spirometry in asymptomatic individuals.
Current Addresses of Authors: Amir Qaseem, MD, PhD, MHA American College of Physicians 190 N. Independence Mall West, Philadelphia, PA 19106
Timothy Wilt, MD, MPH Minneapolis VA Center for Chronic Disease Outcomes Research 1 Veterans Drive (111-0), Minneapolis, MN 55417
Paul Shekelle, MD, PhD Greater Los Angeles VA Health Center/RAND 1776 Main Street, Santa Monica, CA 90401
1. Qaseem, A, Wilt, TJ, Weinberger, SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011. 155: 179-91.
2. Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Chronicle 1968;22(11):473.
3. Qaseem, A, Snow, V, Shekelle, P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007. 147: 633-638.
4. Wilt, TJ, Niewoehner, D, MacDonald, R, Kane, RL. Management of stable chronic obstructive pulmonary disease: A systematic review for a clinical practice guideline. Ann Intern Med. 2007. 147: 639-53.
5. Screening for Chronic Obstructive Pulmonary Disease Using Spirometry, Topic Page. March 2008. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscopd.htm
6. Krahn, M and Chapman, KR. Economic issues in the use of spirometry for lung health assessment. Can Respir J. 2003.10(6):320-6.
Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179–191. doi: 10.7326/0003-4819-155-3-201108020-00008
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Published: Ann Intern Med. 2011;155(3):179-191.
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