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      A Simplified Algorithm for the Diagnosis, Treatment, and Management of COPD in Routine Primary Care Practice

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          Abstract

          Background

          Diagnostic and treatment strategies for chronic obstructive pulmonary disease (COPD) vary greatly. Despite international efforts to standardize the management of COPD, two-thirds of primary care patients are not diagnosed, treated, or managed according to current evidence-based guidelines, probably because of the difficulty of applying these in routine practice. The aim of this study was to develop a simplified algorithm for diagnosing, treating, and managing COPD in primary care whose consistency, scientific relevance, and applicability to routine clinical practice met approval bct 3y family doctors (FDs) and pulmonologists.

          Methods

          The algorithm was developed in a series of sequential phases, consisting of a preliminary meeting among group coordinators to design the initial structure, an input meeting with FDs and pulmonologists to refine and validate the proposal, an algorithm design stage, and a Delphi survey in which FDs and pulmonologists evaluated and approved the final version. A target of 75% or more was established for each of the 20 items in the Delphi survey in the FDs group as well as the pulmonologists group. It was estimated that at least two Delphi rounds would be needed to reach consensus.

          Results

          In total, 118 physicians (75 FDs and 43 pulmonologists) participated in the Delphi process. Fourteen of the 20 items (70%) were approved in the first round. In the second round (in which 74 FDs and 42 pulmonologists participated), the remaining six items, which had been reformulated based on feedback from the first round, were approved, together with an additional question on the face validity of the algorithm as a whole. Dyspnea was positioned as the main determinant of treatment decisions in the new algorithm.

          Conclusion

          According to the experts consulted, this new simplified algorithm for the diagnosis, treatment, and management of COPD in primary care is a clear, functional, and useful tool for routine practice and meets the requirements for the correct management of this condition.

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          Most cited references 23

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          Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.

          This guideline is an official statement of the American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory Society (ERS). It represents an update of the 2007 ACP clinical practice guideline on diagnosis and management of stable chronic obstructive pulmonary disease (COPD) and is intended for clinicians who manage patients with COPD. This guideline addresses the value of history and physical examination for predicting airflow obstruction; the value of spirometry for screening or diagnosis of COPD; and COPD management strategies, specifically evaluation of various inhaled therapies (anticholinergics, long-acting β-agonists, and corticosteroids), pulmonary rehabilitation programs, and supplemental oxygen therapy. This guideline is based on a targeted literature update from March 2007 to December 2009 to evaluate the evidence and update the 2007 ACP clinical practice guideline on diagnosis and management of stable COPD. RECOMMENDATION 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 2: For stable COPD patients with respiratory symptoms and FEV(1) between 60% and 80% predicted, ACP, ACCP, ATS, and ERS suggest that treatment with inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence). RECOMMENDATION 3: For stable COPD patients with respiratory symptoms and FEV(1) 50% predicted. (Grade: weak recommendation, moderate-quality evidence). RECOMMENDATION 7: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao(2) ≤55 mm Hg or Spo(2) ≤88%) (Grade: strong recommendation, moderate-quality evidence).
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            Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary.

            This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (2) for each of the groups A to D, escalation strategies for pharmacologic treatments are proposed; (3) the concept of deescalation of therapy is introduced in the treatment assessment scheme; (4) nonpharmacologic therapies are comprehensively presented; and (5) the importance of comorbid conditions in managing chronic obstructive pulmonary disease is reviewed.
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              Frequency of Exacerbations in COPD: An Analysis of the SPIROMICS Cohort

              Background Current treatment strategies to stratify exacerbation risk rely on history of ≥2 events in the previous year. To understand year-to-year variability and factors associated with consistent exacerbations over time, we present a prospective analysis of the SPIROMICS cohort. Methods We analyzed SPIROMICS participants with COPD and three years of prospective data (n=1,105). We classified participants according to yearly exacerbation frequency. Stepwise logistic regression compared factors associated with individuals experiencing ≥1 AECOPD in every year for three years versus none. Results During three years follow-up, 48·7% of participants experienced at least one AECOPD, while the majority (51·3%) experienced none. Only 2·1% had ≥2 AECOPD in each year. An inconsistent pattern (both years with and years without AECOPD) was common (41·3% of the group), particularly among GOLD stages 3 and 4 subjects (56·1%). In logistic regression, consistent AECOPD (≥1 event per year for three years) as compared to no AECOPD were associated with higher baseline symptom burden assessed with the COPD Assessment Test, previous exacerbations, greater evidence of small airway abnormality by computed tomography, lower Interleukin-15 (IL-15) and elevated Interleukin-8 (IL-8). Conclusions Although AECOPD are common, the exacerbation status of most individuals varies markedly from year to year. Among participants who experienced any AECOPD over three years, very few repeatedly experienced ≥2 events/year. In addition to symptoms and history of exacerbations in the prior year, we identified several novel biomarkers associated with consistent exacerbations, including CT-defined small airway abnormality, IL-15 and IL-8.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                copd
                copd
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove
                1176-9106
                1178-2005
                16 December 2020
                2020
                : 15
                : 3347-3355
                Affiliations
                [1 ]Hospital Universitario de Gran Canaria Dr. Negrín , Las Palmas de Gran Canaria, Spain
                [2 ]Consultorio Auxiliar Arquitecto Tolsá , Valencia, Spain
                [3 ]Esteve Pharmaceuticals , SA, Barcelona, Spain
                [4 ]Health Outcomes Research Department, Advanced Outcomes Research , SL. Barcelona, Spain
                Author notes
                Correspondence: Carlos Cabrera López Email ccablopn@gmail.com
                Article
                281422
                10.2147/COPD.S281422
                7751579
                © 2020 Cabrera López et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 3, Tables: 2, References: 29, Pages: 9
                Categories
                Original Research

                Respiratory medicine

                consensus, primary care, management, treatment, delphi technique, copd

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