COPD: Guideline-1

What they say about spirometry:
ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms. Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms.

GOLD: For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation. The presence of a postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity < 0.70 confirms the presence of airflow limitation that is not fully reversible.

UMHS: Spirometry is the diagnostic "gold standard" because it is the most reproducible, standardized, and objective way of measuring airflow limitation. Spirometry should be ordered with bronchodilator and the postbronchodilator values used to assess both the presence of airflow obstruction and severity.

Areas of Difference in Clinical Presentation and Spirometry

What they say about spirometry to screen for airflow obstruction in asymptomatic patients, including those with current or past exposure to risk factors for COPD:

GOLD: A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.

UMHS: Consider COPD in any patient with dyspnea, chronic cough or sputum production, and/or a history of inhalational exposures known to be risk factors.

ACP/ACCP/ATS/ERS: Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms. There is no difference in the annual rate of FEV₁decline or prevention of symptoms in these individuals with treatment. No evidence from randomized controlled trials supports treating asymptomatic individuals, with or without risk factors for airflow obstruction, who do not have spirometric evidence of airflow obstruction. In addition, evidence does not show any independent benefit of obtaining and providing spirometry results on success rates in smoking cessation.

What GOLD and UMHS said about imaging use for COPD (Note: ACP/ACCP/ATS/ERS did not provide recommendations):

GOLD: An abnormal chest x-ray is seldom diagnostic in COPD unless obvious bullous disease is present, but it is valuable in excluding alternative diagnoses and establishing the presence of significant comorbidities such as cardiac failure. CT of the chest is not routinely recommended. However, when there is doubt about the diagnosis of COPD, high-resolution CT scanning might help in the differential diagnosis. In addition, if a surgical procedure such as LVRS is contemplated, a chest CT scan is necessary.

UMHS: Routine chest x-ray may suggest a diagnosis of COPD, particularly if it demonstrates hyperinflation. However, a chest x-ray should not be considered diagnostic of the disease. Current evidence is not sufficient to recommend routine chest CT in early or moderate COPD. In patients with severe disease, high-resolution CT is required to evaluate the appropriateness of therapies such as LVRS or transplant.

What GOLD and UMHS said about AAT deficiency screening (Note: ACP/ACCP/ATS/ERS did not provide recommendations):

GOLD: In white patients who develop COPD at a young age (< 45 years) or who have a strong family history of the disease, it may be valuable to identify coexisting AAT deficiency. This could lead to family screening or appropriate counseling. A serum concentration of AAT below 15%-20% of the normal value is highly suggestive of homozygous AAT deficiency.

UMHS: Assess for deficiency in settings of clinical suspicion: age < 45 years, absence of other risk factors or severity of disease out of proportion to risk factors, prominent basilar lucency, family history, or bronchiectasis

What GOLD and UMHS said about other investigations (Note: ACP/ACCP/ATS/ERS did not provide recommendations):

GOLD: In advanced COPD, measurement of arterial blood gases while the patient is breathing air is important. The inspired oxygen concentration ... should be noted, a particularly important point if patient is using an O₂-driven nebulizer... [Twenty] to 30 minutes should pass before rechecking the gas tensions when the FiO₂ has been changed ... Adequate pressure must be applied at the arterial puncture site for at least 1 minute, as failure to do so can lead to painful bruising.

UMHS: In patients with a room air resting oxygen saturation between 89% and 93%, a 6-minute walk test with oxygen saturation should be considered to rule out ambulatory desaturation (see indications for supplemental oxygen therapy in the original guideline document).

GOLD and UMHS agree that pharmacologic therapy should proceed in a stepwise progression based on disease severity, recommending a short-acting beta agonist when needed for all stages of COPD, long-term treatment with a long-acting beta agonist (LABA) for patients with FEV₁ 50%-79% predicted, and addition of an ICS for patients with frequent exacerbations and FEV₁ < 50% predicted. The groups further agree that inhaled bronchodilators are preferred to theophylline, and maintenance treatment with oral corticosteroids is not recommended in COPD.

What else they said:
For patients with FEV1 between 60% and 80% predicted, ACP/ACCP/ATS/ERS suggest that treatment with inhaled bronchodilators may be used, noting that there is limited and conflicting evidence of health benefits resulting from initiation of inhaled bronchodilators (anticholinergics or LABA) in this patient population.

With regard to selection of an inhaled bronchodilator (LABA or long-acting anticholinergic [LAAC]), ACP/ACCP/ATS/ERS and GOLD recommend the choice be made on the basis of availability, patient preference, cost, and adverse effects. UMHS differs from the other 2 groups in that it recommends a LAAC (specifically tiotropium) be considered the first-line agent for baseline bronchodilator control.