COPD-Guidelines-2

According to ACP/ACCP/ATS/ERS, when to use combination therapy instead of monotherapy has not been clearly established. The evidence is insufficient to support a strong recommendation for the broad use of combination therapy, and clinicians should weigh its potential benefits and harms on a case-by-case basis. Taking this into consideration, the guideline suggests that clinicians may administer combination inhaled therapies (LAAC, LABA, or ICS) for symptomatic patients with stable COPD and FEV₁ < 60% predicted.

GOLD recommends against regular use of antitussives, immunoregulators, mucolytic agents, antioxidant agents, AAT augmentation therapy (for COPD that is unrelated to AAT deficiency), and vasodilators. GOLD is the only guideline developer to address phosphodiesterase-4 inhibitors, specifically roflumilast. According to GOLD, roflumilast can reduce exacerbations treated with oral or systemic glucocorticosteroids, and these effects are seen when it is added to long-acting bronchodilators. Note that ACP/ACCP/ATS/ERS provided no guidance in this area.

Other points made in recommendations:

GOLD also says that treatment for very severe COPD can be administered in 3 ways: long-term continuous therapy, during exercise, and to relieve acute dyspnea. 

UMHS points out that in patients with very severe COPD, long-term oxygen therapy has been shown to improve the following outcomes:

• Mortality
• Quality of life
• Cardiovascular morbidity (ie, pulmonary hypertension)
• Depression
• Cognitive function
• Exercise capacity
• Frequency of hospitalization

Virtually no adverse effects occur with long-term oxygen therapy.

Appropriate patient education topics cited by GOLD and UMHS include: information about the nature of COPD, including pathophysiology, triggers, and risk factors; smoking cessation; advance directives and end-of-life decisions; exacerbation recognition and self-management; strategies to help minimize dyspnea; and appropriate usage of inhalers, oxygen, and medications.

GOLD describes bullectomy as an older surgical procedure for bullous emphysema. Removal of a large bulla that does not contribute to gas exchange decompresses the adjacent lung parenchyma. Bullectomy can be performed thoracoscopically. In carefully selected patients, this procedure is effective in reducing dyspnea and improving lung function. Note: ACP/ACCP/ATS/ERS did not provide guidelines for surgery.

GOLD notes that in appropriately selected patients with very advanced COPD, transplantation has been shown to improve quality of life and functional capacity. UMHS adds that consideration of transplantation potential requires comanagement with a pulmonary specialist for detailed assessment of baseline pulmonary physiology and potential contraindications.

ACP/ACCP/ATS/ERS did not provide guidelines for surgery.