Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines (2018)

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

Reviewed and summarized by Medscape editors

October 30, 2018

The clinical practice guidelines on chronic obstructive pulmonary disease (COPD) were released in October 2018 by the Global Initiative for Chronic Obstructive Lung Disease.[1,2]

Diagnosis and Initial Assessment

COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors.

Spirometry is required to make the diagnosis; a postbronchodilator FEV1/FVC ratio of less than 0.70 confirms the presence of persistent airflow limitation.

COPD assessment goals are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (eg, exacerbations, hospital admissions, death) to guide therapy.

Concomitant chronic diseases occur frequently in COPD patients and should be treated because they can independently affect mortality and hospitalizations.

Prevention and Maintenance Therapy

Smoking cessation is key. Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates, as do legislative bans on smoking. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain.

Pharmacologic therapy can reduce the symptoms of COPD, can reduce the severity and frequency of exacerbations, and can improve exercise tolerance and health status.

Pharmacologic treatment regimens should be individualized. They should be guided by symptom severity; exacerbation risk; adverse effects; comorbidities; drug availability and cost; and patient response, preference, and ability to utilize the various drug delivery devices.

Inhaler technique should be assessed regularly.

Pneumococcal and influenza vaccinations decrease the incidence of lower respiratory tract infections.

Pulmonary rehabilitation improves symptoms, physical and emotional participation in everyday activities, and quality of life.

Patients with severe resting chronic hypoxemia have improved survival with long-term oxygen therapy.

In patients with stable COPD and resting or exercise-induced moderate desaturation, routine long-term oxygen treatment is not recommended; however, consider individual patient factors regarding the need for supplemental oxygen.

With severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term noninvasive ventilation may prevent rehospitalization and decrease mortality.

Select patients with advanced emphysema refractory to optimized medical care may benefit from surgical or bronchoscopic interventional treatments.

In advanced COPD, palliative approaches are effective in controlling symptoms.

Stable COPD

In stable COPD, base the management strategy on an individualized assessment of the symptoms and risk of exacerbations.

Strongly urge smoking cessation in patients who smoke.

Treatment goals are symptom reduction and reduction in future exacerbations. Pharmacologic treatments should be complemented by nonpharmacologic interventions.

Exacerbations

A COPD exacerbation is defined as acute respiratory symptom worsening with the need for additional therapy. Several factors can lead to an exacerbation, the most common being respiratory tract infections.

The recommended initial bronchodilators to treat an exacerbation are short-acting beta2-agonists, with or without short-acting anticholinergics.

As soon as possible before hospital discharge, initiate maintenance therapy with a long-acting bronchodilator.

Systemic corticosteroids can improve lung function and oxygenation. They also shorten recovery time and hospital duration. The duration of systemic corticosteroid therapy should not exceed 5-7 days.

If indicated, antibiotic therapy can shorten recovery time, reduce the risk of early relapse and treatment failure, and reduce hospitalization duration. The duration of antibiotic therapy should not exceed 5-7 days.

Owing to increased adverse effect profiles, methylxanthines are not recommended.

The first mode of ventilation used in COPD with acute respiratory failure and without contraindications is noninvasive mechanical ventilation. It improves gas exchange, reduces the work of breathing, decreases the need for intubation, decreases hospitalization duration, and improves survival.

COPD and Comorbidities

Treat COPD comorbidities with the usual standard of care, regardless of the presence of COPD. COPD treatment should not be altered by the presence of comorbidities.

Lung cancer is a common comorbidity with COPD and is a main cause of mortality.

Cardiovascular disease is an important frequent COPD comorbidity, as are osteoporosis and anxiety/depression. The latter two are underdiagnosed and associated with poor health status and prognosis.

Gastroesophageal reflux disease can increase the risk of exacerbations and poor health status.

Simplicity of treatment and minimization of polypharmacy are emphasized in a multimorbidity and COPD treatment plan.

For more information, please go to Chronic Obstructive Pulmonary Disease (COPD) and Chronic Obstructive Pulmonary Disease (COPD) and Emphysema in Emergency Medicine.

For more Clinical Practice Guidelines, please go to Guidelines.

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