- The Global Initiative for Chronic Obstructive Lung Disease 2019 report defines chronic obstructive pulmonary disease (COPD) as a “common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.”
- Pharmacologic treatment for COPD aims to improve quality of life (QOL) and control symptoms while reducing the frequency of exacerbations.
Table 1. Implications of Strong and Conditional Recommendations
(“The ATS recommends...”)
(“The ATS suggests...”)
|Patients||The overwhelming majority of individuals in this situation would want the recommended course of action, and only a small minority would not. (It is the right course of action for >95% of patients.)||Most individuals in this situation would want the suggested course of action, but many would not. (It is the right course of action for >50% of patients.)|
|Clinicians||The overwhelming majority of individuals should receive the recommended course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. (It is reasonable to recommend it strongly to patients and caregivers.)||Different choices will be appropriate for different patients, and the clinician must help each patient arrive at a management decision consistent with her or his values and preferences. Decision aids may be useful to help individuals make decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working toward a decision. (Slow down, think about it, discuss it with the patient.)|
|Policy makers||The recommendation can be adopted as policy in most situations, including for use as a performance indicator. (The recommended course of action may be an appropriate performance measure.)||Policy making will require substantial debates and involvement of many stakeholders. Policies are also more likely to vary between regions. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place. (The recommended course of action is not appropriate for a performance measure.)|
- In patients with COPD who complain of dyspnea or exercise intolerance, the ATS recommends long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy (strong recommendation, moderate certainty evidence).
- In patients with COPD who complain of dyspnea or exercise intolerance despite dual therapy with LABA/LAMA, the ATS suggests the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization (conditional recommendation, moderate certainty evidence).
- In patients with COPD who are receiving triple therapy (ICS/LABA/LAMA), the ATS suggests that the ICS can be withdrawn if the patient has had no exacerbations in the past year (conditional recommendation, moderate certainty evidence).
- The ATS does not make a recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom we suggest ICS as an additive therapy (conditional recommendation, moderate certainty evidence).
- In patients with COPD and a history of severe and frequent exacerbations despite otherwise optimal therapy, the ATS advises against the use of maintenance oral corticosteroid therapy (conditional recommendation, low certainty evidence).
- In individuals with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy, the ATS suggests that opioid-based therapy be considered for dyspnea management, within a personalized shared decision-making approach (conditional recommendation, very low certainty evidence).