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Standards for the Diagnosis and Treatment of Patients with COPD

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Standards for the Diagnosis and Treatment of Patients with COPD Copyright #ERSJournals Ltd 2004 EurRespir J 2004;23: 932– 946 EuropeanRespiratory Journal DOI: 10.1183/09031936.04.00014304 ISSN0903-1936 Printedin UK –allrights reserved ATS/ ERSTASK FORCE Standardsfor the diagnosisand treatment of patientswith COPD: asummaryof the ATS/ERSposition paper B.R. Celli*, W. MacNee*,andcommittee members Committeemembers: A Agusti, A Anzueto, B Berg, A S Buist, P M A Calverley, N Chavannes, T Dillard, B Fahy, A Fein, J Heffner, S Lareau, P Meek, F Martinez, W McNicholas, J Muris, E Austegard, R Pauwels, S Rennard, A Rossi, N Siafakas, B Tiep, J Vestbo, E Wouters, R ZuWallack *P ulmonaryand Critical C are D ivision, St Elizabeth s’ Medical Center, Tufts U niversity School of Medicine, Boston, Massachusetts, USA # Respiratory Medicine ELE GI, Colt R esearch Lab Wilkie Building, CONTEMedical Schoo l, T eviot Place, Edinburgh, UK CONTENTSNTS Background. ............................ 932 Managementof stab eCOPD:surgery in and for Goals and objectives 933 COPD.. ............................... 938 Participants 933 Surgery in COPD 938 Evidence, methodology and validation 933 Surgery for COPD 938 Concept of a "live",modular document 933 Managementof stab e COPD: s eep. ........... 938 Organisation of the document 933 Managementof stab eCOPD:air-trave . 939 De® nitionof COPD. ...................... 933 Exacerbationof COPD: de® nition, eva uation and Diagnosisof COPD. ...................... 933 treatment ............................... 939 Epidemio ogy,risk factors andnatura history De® nition 939 ofCOPD ............................... 934 Assessment 940 Patho ogyand pathophysio ogyin COPD . ....... 934 Indication for hospitalisation 940 C inica assessment, testingand differentia diagnosisof Indications for admission to specialised or intensive COPD.. ............................... 934 care unit 940 Medicalhistory 935 Treatment of exacerbations 940 Physicalsigns 935 Exacerbationof COPD: inpatient oxygen therapy. 940 Smokingcessation ......................... 935 Setting and adjusting oxygen¯ ow 941 Brief intervention 935 Monitoring following hospital discharge 941 Managementof stab eCOPD:pharmaco ogica therapy 936 Exacerbationof COPD: assisted venti ation. ...... 942 Bronchodilators 936 Indications for mechanicalventilation 942 Glucocorticoids 936 Modes of mechanicalventilation 942 Outcomes of frequently used drugs 936 Criteria for hospital discharge 942 Combination therapy 937 Follow-up evaluation 943 Managementof stab e COPD: ong-termoxygen Ethica and pa iativecare issues inCOPD . ...... 943 therapy. ............................... 937 Integrateddisease management for primarycare in Managementof stab e COPD: pu monary COPD.. ............................... 943 rehabi itation. ........................... 937 Referral indications 943 Managementof stab eCOPD:nutrition . ........ 938 Conc usions. ............................ 944 Background been enough advances inthe ®eld to require an update, especially adapted to the particular needs of the ATS/ERS The Standards for the Diagnosis and Treatment of Patients constituency 3) Itallowsfor the creation of a "live" modular with COPD document 2004 updates the position papers on document based on the web;it should provide healthcare chronic obstructive pulmonarydisease ( COPD)published by professionals and patients witha user friendly and reliable the American Thoracic Society (ATS) and the European authoritative source of information 4) The care of COPD Respiratory Society (ERS)in1995 [1,2] Both societies felt should be comprehensive, is often multidisciplinaryand the need to update the previous documents due to the rapidlychanging 5) Both the ATS and the ERS acknowledge following 1) The prevalence and overall importance of the recent dissemination of the Global Initiative of Obstruc- COPD as ahealth problem is increasing 2) There have tive Lung Disease (GOLD)[3]as amajorworldwide *Pulmonaryand Critical Care Division, St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA #Respiratory Medicine ELEGI, Colt Research Lab Wilkie Building, Medical School, Teviot Place, Edinburgh, UK Correspondence: B R Celli, St Elizabeth’s Medical Center, 736 Cambridge St, Boston MA 02135, USA Fax:1 6175627756 E-mail: bcelli@cchcs org ATS/ERSCOPD STANDARDS 933 contribution to the battle against COPD However, some Concept of a "live",modulardocument speci® crequirements ofthe members of both societies require adaptation ofthe broad GOLD initiative Those requirements Understanding that medicine and,in particular, the area of include speci® crecommendations on oxygen therapy, pulmo- COPD is constantly undergoing changes, the ATS and the nary rehabilitation, noninvasive ventilation,surgery inand ERS considered that it was time to develop new instruments for COPD,sleep, air travel, and end-of-life In addition, capable of adjusting to the changes Assuch, this is the ®rst special emphasis has been placed on issues related to the habit statement conceived to be primarilybased on the web and of smokingand its control capable of being changed asneeded Toachieve this goal,the organisations have developed a COPD task force composed ofthree members from each society whose of® ce willlast for 3 yrs The maintask of the members is to constantly review Goalsand objectives advances inthe ®eld of COPD and to propose changes to the modules of the document Asiscustomary inboth organisa- The maingoals of the updated document are to improve tions, the need to do so mayarise from the membership the qualityof care provided to patients with COPD and to through the current existing mechanisms One of the members develop the project using adisease-oriented approach To of the task force from each society willrepresent the society achieve these goals,both organisations have developed a on the executive GOLD committee The overall goalis to modularelectronic web-based document withtwo compo- attempt to maintaina synchronous ¯owwith the wider objec- nents 1) A component for health professionals that intends tives of GOLD to: raise awareness of COPD;inform on the latest advances in the overall pathogenesis, diagnosis,monitoring and manage- ment of COPD;and promote the concept that COPD is a Organisationof the document treatable disease 2) A component for the patient that intends to: provide practical information on allaspects of COPD; and The document has two distinct components The ® rst, promote ahealthy lifestyle to allpatients af¯icted withthe directed at patients and their needs, whichcan be accessed disease from the ATS/ERS website (www copd-ats-ers org) and from the website of each society (www ersnet org and www thoracic org), is not the subject of this summary The second is directed at healthcare practitioners and allthose interested in Participants the professional issues related to COPD This summary highlightsthe contents of the document for health practi- The committee members whowere involvedin the produc- tioners, but the readers are encouraged to access the tion of this document are clinicians,nurses, respiratory thera- document via the website, where an easy navigationaltool pists and educators interested inthe ®eld of COPD The current willallow you to explore its contents The reader is also Standards for the Diagnosis and Treatment of Patients with encouraged to access the patient document inorder to COPD document is unique inthat it also had input from familiarise themselves withits content Itwas designed for patients suffering from COPD Thecommittee members were and withpatients so as to serve as areliable resource for proposed and approved bythe ATS and ERS The members everyone were selected because of their expertise and willingnessto participate inthe generation of the document A unique feature of this project was the development of apatient De® nitionof COPD document that could serve as aformal source of information for the patients, thereby makingthem partners inthe effort to Chronic obstructive pulmonarydisease ( COPD) is a decrease the burden of the disease preventable and treatable disease state characterised by air¯ow limitation that is not fullyreversible The air¯ ow limitationis usuallyprogressive and is associated withan abnormalin¯ ammatory response of the lungs to noxious Evidence,methodology and validation particles or gases, primarilycaused by cigarette smoking Although COPD affects the lungs,it also produces signi®cant Several well-accepted guidelines served as the blueprint for systemic consequences the document Namely, the ATS and the ERS standards of 1995 [1,2] and the GOLD initiativepublished in2001 [3] At the initialmeeting, each member of the committee was Diagnosisof COPD assigned aspeci® csection of the document and was asked to select asubcommittee to gather literature and review the The diagnosis of COPD should be considered inany existing evidence The document was discussed infour group patient whohas the following:symptoms of cough; sputum meetings, and the content and validityof each section was production; or dyspnoea; or history of exposure to risk fac- thoroughly reviewed The ®nalstatement is the product of tors for the disease those discussions and has been approved by allthe members The diagnosis requires spirometry; apost-bronchodilator of the committee Several of the basic source documents forced expiratory volumein one second ( FEV1)/forced vital reviewed have used an evidence-based approach, and the capacity (FVC) 40 7con® rms the presence of air¯ow committee utilised those references as asource of evidence limitationthat
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