Global Initiative For Chronic Obstructive Lung Disease Guidelines Research Articles

The need to change the method for defining mild airway obstruction

Dear colleagues, members of GOLD committee, This letter arises from discussions and correspondence between colleagues involved in respiratory research or the diagnosis and treatment of lung diseases, as well as from a review of the literature on chronic obstructive pulmonary disease (COPD). As discussed below, it is written in the hope that we can persuade members of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) committee to vote to change the method by which mild airway obstruction is defined by the GOLD guidelines. We very much welcome the continued efforts of the GOLD group to stimulate interest and awareness of the high prevalence of COPD, its morbidity, effects on quality of life and on mortality. There is no doubt that COPD is a major public health problem of which the public, health workers and health authorities were insufficiently aware. It is therefore an important achievement that the World Health Organization (WHO), the European Respiratory Society (ERS), the American Thoracic Society (ATS), the Asian Pacific Society of Respirology (APSR), the Asociacion Latinoamericana de Torax (ALAT), and the World Organization of Family Doctors (WONCA) and many distinguished individuals have joined forces to increase awareness about the burden of disease, by publishing reports and guidelines for diagnostic procedures and interventions which have been adopted by numerous international and national organisations. However, there is one area which has given rise to continuous published criticism: the criterion for confirming airway obstruction. It is well known that the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio declines with increasing age and height, even in healthy lifelong nonsmokers, in whom the lower limit of normal drops below a ratio of 0.7 from about 45 yrs of age [1–6]. It has been shown 4–27 that using the fixed ratio causes up …

Determinants of polypharmacy and compliance with GOLD guidelines in patients with chronic obstructive pulmonary disease

BackgroundPolypharmacy of respiratory medications is commonly observed in patients with chronic obstructive pulmonary disease (COPD). The aims of this study were to investigate determinants of polypharmacy and to study the consistency of actual respiratory drug use with current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in pulmonary rehabilitation candidates with COPD.MethodsData were extracted from the records of all patients with a diagnosis of COPD referred for pulmonary rehabilitation to CIRO+ between 2005 and 2009. Use of respiratory medications, self-reported COPD exacerbations, lung function, blood gases, exercise capacity, Medical Research Council (MRC) dyspnea grade, and St George’s Respiratory Questionnaire (SGRQ) were recorded as part of assessment of health status.ResultsIn total, 1859 COPD patients of mean age (± standard deviation) 64.3 ± 9.7 years and with a forced expiratory volume in one second (FEV1) of 44.7% ± 18.2% were included. On average, patients used 3.5 ± 1.5 respiratory medications; this number increased with increasing GOLD stage, MRC score, and SGRQ scores. FEV1 (% predicted), SGRQ, and number of recent exacerbations were independent determinants of polypharmacy. Use of long-acting bronchodilators and inhaled corticosteroids was substantial and comparable in all GOLD stages. Use of corticosteroids was not restricted to patients with frequent exacerbations.ConclusionPolypharmacy of respiratory medications is common in COPD patients with persistent symptoms. In addition to severity of disease, health status is an independent predictor of polypharmacy. Actual drug use in COPD patients referred for pulmonary rehabilitation is partially inconsistent with current GOLD guidelines.

Interpreting Lung Function Data Using 80% Predicted and Fixed Thresholds Misclassifies More Than 20% of Patients

Differences in COPD classification have been shown in population data sets when using fifth percentiles as the lower limit of normal (LLN) vs the current GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines of FEV(1)/FVC < 0.70 for detecting airway obstruction and an FEV(1) of 80% predicted for detecting and classifying the severity of COPD (GOLD/PP). Many lung function laboratories use 80% predicted to determine whether results are abnormal. Misclassification of the full range of lung diseases in large patient groups when using GOLD/PP criteria instead of the LLN has not been explored previously. We determined the discrepancy rates in pulmonary function test interpretation between the GOLD/PP and LLN methods on prebronchodilator lung function results from a large number of adult patients from the United Kingdom, New Zealand, and the United States. In 11,413 patients, the GOLD/PP method misclassified 24%. Ten percent of patients who had normal lung function were falsely classified with a disease category, and 7% of patients were falsely attributed with emphysema. The GOLD/PP method gave false-positive classifications for airflow obstruction and restrictive defects to significantly more men (P < .01) and older patients (P < .0001) and also missed airflow obstruction and restrictive defects in younger patients (P < .0001). Using lung function tests on their own with 80% predicted and fixed cut points to determine whether a test is abnormal could misdiagnose > 20% of patients referred for pulmonary function tests. The GOLD/PP method introduces clinically important biases in assessing disease status that could affect allocation to treatment groups. This misclassification is avoided by using the LLN based on the fifth-percentile values.

Bronchodilatory effects of NVA237, a once daily long-acting muscarinic antagonist, in COPD patients

NVA237 is a novel, once daily inhaled long-acting muscarinic antagonist administered via a dry powder inhaler. This study aimed to assess the 24-h bronchodilatory effect following 14 days of treatment with inhaled NVA237 in patients with mild, moderate or severe COPD. This was a randomized, double-blind, placebo-controlled, two-period, crossover, multicenter study. A total of 33 patients (≥ 40 years; smoking history of ≥ 10 pack-years) were randomized to receive NVA237 50 μg once daily followed by placebo or placebo followed by NVA237 50 μg for 14 days. Treatment periods were separated by a 7-14 day washout period. The primary variable was the mean forced expiratory volume in 1 s (FEV(1)) derived from the area under the curve (AUC) between 0 and 24 h post-dose on Day 14. The 24-h FEV(1) profiles showed a consistent bronchodilator effect for NVA237 versus placebo on Day 14. Least square (LS) mean difference in FEV(1) AUC(0-24 h) values between NVA237 and placebo was 163 mL (P < 0.001). There were significant increases in mean FEV(1) AUC(0-12 h) (LS mean difference 165 mL, P = 0.001) and FEV(1) AUC(12-24 h) (161 mL, P < 0.001) versus placebo. NVA237 significantly improved peak FEV(1) (by 208 mL, P < 0.001) and trough FEV(1) (by 154 mL, P = 0.003) versus placebo on Day 14. NVA237 was well tolerated; all adverse events were mild or moderate in intensity and not related to study drug. NVA237 50 μg once daily was well tolerated and showed significant and sustained 24-h bronchodilation in patients with COPD.

Recommandations et prise en charge de la BPCO en France : les recommandations sur la prise en charge de la BPCO ne sont pas suivies dans la vraie vie !

COPD management guidelines have been proposed to improve the major outcomes for COPD patients. In clinical practice, COPD treatment is only partially consistent with current guidelines and recommendations. Global initiative for chronic obstructive lung disease (GOLD) guidelines are based on a COPD severity scale and are subject to change as the evidence based evolves. The main purpose of our study was to access whether the treatments prescribed to patients with COPD were consistent with these guidelines. Treatments prescribed by French physicians to 542 patients with COPD in stable conditions were recorded according to the severity of obstruction, using GOLD classification. We compared our prescription data base with the GOLD guidelines. Forty percent of the initial physicians were chest specialists. 78.3 % men, (64.8+/-10.8years) and 25 % were still smokers at inclusion. We found an important discrepancy between recommended treatment and COPD severity. Bronchodilators were commonly prescribed, but 11 % in severe COPD (stages III and IV) did not receive them. Inhaled steroids (ICS) were used respectively in 55.2 %, 59.4 % of patients in stages I, II (FEV1>50 %) (for whom they are not recommended) and 77.4 and 85.3 % in stages III and IV. Only 30 % of patients used ICS+beta2 agonists in the same device. Influenza vaccination had been performed in only half of patients whatever the severity of COPD. Pulmonary rehabilitation had been used by 10 % of patients, (stage II: 6.4 %, stage III: 9.6 %, stage IV: 20.6 %). We confirmed that there are discrepancies between COPD guidelines and routine treatments. Some treatments such as ICS were overused in mild phenotypes, whereas in a high proportion of cases influenza immunisation and rehabilitation were omitted.

Health-related quality of life is associated with COPD severity: a comparison between the GOLD staging and the BODE index

Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease. Currently, severity Global initiative for chronic Obstructive Lung Disease (GOLD) criteria are used to diagnose the severity of COPD, but a new grading system, the body mass index, bronchial obstruction, dyspnea, exercise (BODE) index, was recently proposed to provide useful prognostic information. The objective of this study is to evaluate the association between health-related quality of life (HRQOL) and COPD severity assessed by two criteria: the GOLD classification and the BODE index. Sixty-four patients with COPD were examined with lung function tests and specific and generic HRQOL questionnaires (St. George's Respiratory Questionnaire [SGRQ], Nottingham Health Profile [NHP]). Participants were divided into four severity groups using the GOLD guidelines and the BODE index quartiles. The association between NHP and SGRQ subscales, and the BODE index was significant (P < 0.01). However, the GOLD classification shows a correlation only with SGRQ total score (P < 0.05) but not with NHP or SGRQ subscales. There was an association of the SGRQ total score between the severity groups of BODE (P = 0.0001), but there was no difference in the SGRQ total score between the severity groups of GOLD classification (P = 0.244). The present study suggests that COPD severity assessed by the BODE index can be more directly related with HRQOL.

Nebulized Respiratory Medications: Friend or Foe?

Older persons with chronic obstructive pulmonary disease (COPD) receive inhaled short-acting and long-acting beta-agonists, anticholinergic agents, and corticosteroids to optimize management of their respiratory condition. According to the most recently published COPD guidelines from Global Initiative for Chronic Obstructive Lung Disease (GOLD), the American College of Physicians (ACCP), and American Thoracic Society/European Respiratory Society, shortacting inhaled beta-agonists are recommended for acute symptom exacerbations, and longacting agents are recommended for maintenance. Table 1 depicts the stepwise approach to managing COPD according to the GOLD guidelines. Short-acting bronchodilators (e.g., albuterol by inhalation) are appropriate for all stages of COPD on an as-needed basis. In patients with moderate or more severe disease, longacting bronchodilators (e.g., long-acting inhaled beta-agonists, long-acting anticholinergic agents or combined anticholinergic/long-acting betaagonist products) are the recommended agents for maintenance in patients with persistent symptoms occurring multiple times weekly (Table 2). 3 Inhaled corticosteroids are a consideration when wheezing is present and when symptoms become severe. Beta-adrenergic agonists, anticholinergic agents, and corticosteroids can be delivered by metered dose inhaler (MDI), dry powder inhaler (DPI), or compressor nebulizer. Drug efficacy is a function of the amount of medication delivered to the airways, which can vary with inhalation technique, device, and drug potency. In older patients, coordination of the handheld inhalers, whether MDI or DPI, can be challenging. It has been reported that approximately 60% of older patients have adequate technique for delivery of medication from MDI, comparable to technique adequacy in younger patients.

Severity Staging of Chronic Obstructive Pulmonary Disease: Differences in Pre- and Post-Bronchodilator Spirometry

PurposeThe Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD) uses the post-bronchodilator spirometry for diagnosis and severity staging. We evaluated differences in the severity classification of COPD, based on pre- and post-bronchodilator spirometry.Materials and MethodsFrom 2000 to 2004, 207 COPD patients who underwent spirometry before and after inhalation of 400 µg of fenoterol were analyzed. A responder to the bronchodilator test (BDT) was defined by the American Thoracic Society (ATS) as an increase in forced expiratory volume in one second (FEV1) or forced vital capacity ≥ 12% and ≥ 200 mL, and by the European Respiratory Society (ERS) as an increase in FEV1 ≥ 10% of the predicted value. COPD severity was classified according to the 2008 GOLD guidelines.ResultsFor the entire study population, the FEV1 increased by 11.8 ± 12.5% of baseline after BDT and 41.1% and 27.1% of subjects were classified as responders using the ATS and ERS criteria, respectively. Based on pre-BDT spirometry, 55, 85, 58, and 9 patients were classified as Stage I-IV COPD, respectively. Sixty-seven (32.4%) patients changed severity staging after BDT, including 20.0%, 28.2%, 44.8%, and 66.7% of pre-BDT patients Stages I through IV, respectively. More ATS or ERS BDT-responders had a change in severity staging than non-responders (52.9% vs. 18.9% and 62.5% vs. 21.2%, both p < 0.001).ConclusionOur data suggest that the severity staging of COPD using pre-BDT spirometry might lead to significant differences as compared to staging, based on post-BDT spirometry, as recommended by the current GOLD guidelines.

EVALUATION OF CLINICAL APPLICATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE INDIAN GUIDELINES-2003 IN DIAGNOSING AND STAGING CHRONIC OBSTRUCTIVE PULMONARY DISEASE

PURPOSE: Global Initiative for Chronic Obstructive Lung disease (GOLD) guidelines are universally accepted management guidelines for Chronic Obstructive Pulmonary disease (COPD). “COPD Indian guidelines-2003” were formulated to manage the disease specifically in resource poor countries like India where spirometry is often not available. The study was conducted to evaluate the clinical application of these COPD guidelines in diagnosing and staging COPD by comparing them with GOLD guidelines.

Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction

Aim:The prevalence of airway obstruction varies widely with the definition used.Objectives:To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four...

A review of the GOLD guidelines for the diagnosis and treatment of patients with COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of death in the USA, and represents a major health, social and economic burden. COPD is underdiagnosed and often misdiagnosed, which likely contributes to the continuing increases in the prevalence, morbidity and mortality associated with this disease. This is unfortunate because whereas COPD cannot be cured, it can be treated effectively, particularly during the earlier stages of the disease. Evidence-based guidelines, developed to assist in the prevention, diagnosis and management of COPD, are available to healthcare professionals interested in learning more about COPD. These guidelines are updated and revised on a regular basis to reflect recent advances in our understanding of the pathophysiology of and treatments available for COPD. Nevertheless, primary-care physicians have reported a lack of awareness of the fundamental concepts underpinning the optimal treatment and management of COPD presented in the guidelines. Thus, the objective of this article is to summarise key physiologic, diagnostic and management concepts provided in the most recent update of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which were published in November 2006.

Survey of implementation of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in nine Asian countries

After the release of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in 2001 and update in 2003, its implementation in nine Asian countries was investigated. Questionnaire surveys involving thoraco‐pulmonary physicians or internists investigated the awareness and consensus of the GOLD guidelines including the care and management of chronic obstructive pulmonary disease (COPD) patients in Asian. Two surveys were conducted, in June 2002 and March 2004, through questionnaires by direct mail in Japan and face‐to‐face interviews in the other countries. Approximately 600 questionnaires were returned with approximately 84% awareness of the publication and its update and nearly 90% appreciated the globalization efforts. The survey revealed great variances concerning the definition of COPD, its diagnosis, and use of computed tomography. As for the implementation, the majority answered the use of the combined local and GOLD guidelines in five of nine countries surveyed, while the GOLD guidelines were implemented mainly in Korea, suggesting the influence in daily practice for care and management of COPD patients. Implication of rehabilitation in clinical practice has not been standardized despite high evidence of its advantages. Most respondents stated the necessity of developing a local or regional guideline for best practice. Our survey revealed: (i) awareness of the GOLD guidelines was high and well accepted; (ii) the possibility of developing a uniform or standard guideline in Asia is low due to local characteristics; (iii) modifications of the GOLD guidelines may be more practical; and (iv) that the multidisciplinary pulmonary rehabilitation program needs to be further activated in GOLD implementation for the Asia–Pacific region.

Spirometric Criteria for Airway Obstruction: Use Percentage of FEV1/FVC Ratio Below the Fifth Percentile, Not < 70%

Background:Current authoritative spirometry guidelines use conflicting percentage of FEV1/FVC ratios (FEV1/FVC%) to define airway obstruction. The American Thoracic Society/European Respiratory Society Task Force characterizes obstruction as a FEV1/FVC% below the statistically defined fifth percentile of normal. However, many recent publications continue to use the Global Initiative for Chronic Obstructive Lung Disease (GOLD) primary criterion that defines obstruction as a FEV1/FVC% < 70%. Data from the Third National Health and Nutrition Examination Survey (NHANES-III) should identify and quantify differences, help resolve this conflict, and reduce inappropriate medical and public health decisions resulting from misidentification.Methods:Using these two guidelines, individual values of FEV1/FVC% were compared by decades in 5,906 healthy never-smoking adults and 3,497 current-smokers of black (African American), Hispanic (Latin), or white ethnicities aged 20.0 to 79.9 years.Results:In the never-smoking population, the lower limits of normal used in other reference equations fit reasonably well the NHANES-III statistically defined fifth percentile guidelines. But nearly one half of young adults with FEV1/FVC% below the NHANES-III fifth percentile of normal were misidentified as normal because their FEV1/FVC% was > 70% (abnormals misidentified as normal). Approximately one fifth of older adults with observed FEV1/FVC% above the NHANES-III fifth percentile had FEV1/FVC% ratios < 70% (normals misidentified as abnormal).Conclusions:The GOLD guidelines misidentify nearly one half of abnormal younger adults as normal and misidentify approximately one fifth of normal older adults as abnormal.

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

OBJECTIVES To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression. Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines. Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies.

From Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines to Current Clinical Practice

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD). To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines. This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure 'variant prescription', i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis. At discharge, prescription of short-acting beta(2)-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-actingbeta(2)-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82). Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the 'variant prescriptions' seen at discharge from the acute care hospital.

Analysis of the current care model of the COPD patient: a health outcomes assessment and economic evaluation.

Because chronic obstructive pulmonary disease (COPD) is a common but serious illness affecting millions worldwide, we present an overview of the disease and discuss its underdiagnosis and treatment options. COPD, a disease encompassing emphysema and chronic bronchitis, is associated with cigarette smoking, chronic exposure to environmental pollutants, and, occasionally, genetic conditions. The disease is severely underdiagnosed and underrecognized. The economic costs of COPD, which accounted for about 14 million office visits and 3.5 million hospital days in 1993, are estimated at more than $7 billion, and another $8 billion worth of productivity was lost to morbidity and mortality in the same year.1 The death rate from COPD is rising, principally among women. Uniform diagnosis and treatment standards are now being realized. The American Thoracic Society and European Respiratory Society recommend treatment, based on worsening symptoms, with bronchodilators and, in more advanced cases, inhaled corticosteroids. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment algorithm also uses a step-care approach. The GOLD guidelines recommend a management program that prevents disease progression, relieves symptoms, improves exercise tolerance and health status, and prevents and treats complications and exacerbations, thereby reducing mortality. The GOLD guidelines recommend avoiding risk factors, using short- or long-acting bronchodilators, and adding rehabilitation and inhaled glucocorticoids. In severe cases, the GOLD guidelines recommend long-term oxygen administration and even surgery. Decisions in managing COPD require a consideration of multiple outcomes measures. Although spirometry remains the foundation for diagnosis and demonstration of efficacy, the patients and their families may be more concerned with symptoms, quality of life, and prevention of exacerbations. In patients with COPD, bronchodilators such as tiotropium produce significant improvements in all of these outcomes measures. COPD is a common disease that substantially affects patients, health care systems, and society. With increasing awareness of the disease, improved diagnostic guidelines, and newer cost-effective pharmacologic regimens, this chronic progressive disorder can be effectively recognized and treated, helping to improve patients. overall health and quality of life.

Contemporary issues in the care of patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is estimated to be responsible for 119,000 deaths in the year 2000 alone. Additionally, COPD places a tremendous burden on the health care system, with estimated annual costs of US 24 billion dollars in 2000, and it is generally expected that costs will continue to rise as more individuals are diagnosed. COPD was responsible for approximately 8 million physician outpatient visits, 1.5 million emergency department visits and 726,000 hospitalizations, also in the year 2000. The objective of this article is to review current, pertinent clinical issues in the management of patients with COPD, with estimates of their relative utility and efficacy. COPD is a disease characterized by airflow limitation that is not fully reversible. Patients with COPD may frequently experience symptoms of chronic cough with sputum production, dyspnea, and reduced exercise capacity. They may frequently experience exacerbations characterized by increased symptoms that often require medical intervention. The diagnosis of COPD is usually fairly straightforward and made in a cigarette smoker, with the aforementioned symptoms and airflow obstruction measured by spirometry. Spirometry should be performed in all patients in whom COPD is suspected, as it provides useful prognostic information and may be used to stage the disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has provided evidenced-based management guidelines for COPD. GOLD guidelines advocate staging COPD by spirometry and make specific treatment recommendations based on COPD stage. The most important risk factor for the development of COPD is cigarette smoking, and smoking cessation has been shown to reduce all-cause mortality and to alter the natural history of COPD. Smoking cessation strategies that employ both counseling and medications like buproprion and nicotine replacement are most effective, but relapse rates remain high. It has not been shown that medications like bronchodilators or inhaled steroids change the natural history of COPD, nor do they reduce mortality, but they can affect other important outcomes. Long-acting bronchodilators, including beta- 2-adrenergic agonists such as salmeterol and formoterol, and the anticholinergic agent tiotropium, improve lung function and exercise tolerance, reduce symptoms, and modestly reduce exacerbation rates. Long-acting bronchodilators are indicated for all COPD patients with chronic symptoms. Short-acting bronchodilators are indicated for rescue when acute symptoms occur. Inhaled corticosteroids minimally improve lung function, but, importantly, reduce exacerbation rates and are indicated in severe COPD or when exacerbations are frequent. Continuous oxygen therapy has been shown to reduce mortality when severe hypoxemia is present and can improve quality of life when moderate hypoxia is present. Finally, well-designed, multidisciplinary disease management programs and pulmonary rehabilitation can improve important disease outcomes in a cost-effective manner. COPD is a common, preventable disease that affects a significant number of people. It may be managed by utilizing various readily available medical therapies, as well as other nonpharmacologic interventions, such as pulmonary rehabilitation. Proper coordination of care is important in this disease, and efforts should be focused on improving quality of life and reduction of symptoms.

Underuse of spirometry by general practitioners for the diagnosis of COPD in Italy

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) underlines that spirometry is the gold standard as the most reproducible, standardised, and objective way of measuring airflow limitation in the diagnosis and assessment of Chronic Obstructive Pulmonary Disease (COPD). However, studies undertaken in different countries have suggested a widespread underuse of spirometry by general practitioners to establish the diagnosis of COPD. Precise estimates of the prevalence of physician-diagnosed COPD in Italy are not currently available. In collaboration with the Italian Academy of General practitioners (SIMG) we have investigated the degree of use of spirometry to establish the diagnosis of COPD in Italy. A standardised questionnaire has been self-administered to a sample of 2425 Italian general practitioners (representing 5% of all the Italian doctors involved in general practice). They have been chosen to cover each of the Italian counties. The prevalence of physician-diagnosed COPD was found to be approximately 4%. However, 30% of general practitioners do not use spirometry to establish the diagnosis of COPD. The main reasons given for the failure to use spirometry are (i) that spirometry is not necessary for the diagnosis of COPD or (ii) there are logistical limitations to the access of the patients to lung function laboratories. This data suggests that contrary to GOLD Guidelines, in Italy, as with other countries, spirometry is not always used in the diagnosis of COPD. There is a clear necessity for further education initiatives targeted to this group of physicians.

Oordeel en houding van de huisarts bij chronisch obstructieve longziekte (COPD)

Chronic obstructive pulmonary disease (COPD) carries a heavy burden for health care. The general practitioner is particularly well placed for an early diagnosis and treatment of this mainly smoking-related disorder. In order to assess their perception of COPD and the diagnostic and therapeutic means utilised, a written questionnaire containing open questions was addressed to a representative sample of 425 Belgian general practitioners. The results of this questionnaire reveal that, general practitioners usually recognise the importance of an early diagnosis of COPD and of smoking as its main risk factor. However, the diagnosis is mainly based on symptoms and clinical signs, but not so much on a systematic use of spirometry, even though the latter is usually recommended by national and international guidelines. As a result of his poor use of spirometry, the staging of the severity of COPD, on which a treatment should be based, is insufficiently known. The implementation of the GOLD (Global initiative for chronic Obstructive Lung Disease) guidelines, in particular the use of spirometry, and the correct positioning of the various treatment modalities, should enable general practitioners to fulfill their essential role in the fight against COPD.

Redefining treatment in COPD: new directions in bronchodilator therapy.

COPD is a growing international health concern and it is estimated that by the year 2020 it will rank fifth as a cause of disability worldwide. In response to this problem, the World Health Organization and the US National Institutes of Health convened a panel of experts to draft a consensus strategy to treat patients with COPD. Called the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, they are designed to define and stage the severity of COPD, make recommendations for treatment, and to expand global awareness of the disease. The GOLD guidelines describe a multimodality approach to provide optimal care for the COPD patient population. This includes respiratory and rehabilitative therapy, nutrition services, psychosocial counseling, and surgical care. Bronchodilators form the cornerstone of pharmacologic treatment for COPD. These medications can significantly lessen dyspnea, enhance quality of life, increase airflow, and improve exercise performance. While bronchodilators decrease airway resistance and lessen hyperinflation in patients with COPD, they have not been shown to influence the decline in FEV1 over time or improve survival in this patient population. Recently, long-acting beta2-adrenoceptor agonists (beta2-agonists) such as formoterol and salmeterol and anticholinergic medications including tiotropium bromide have been developed which may further improve symptom management in COPD patients. This article discusses bronchodilator pharmacologic therapy for patients with COPD focusing on beta2-agonists, anticholinergics, and methylxanthines in the light of the recent GOLD consensus statements.