Key Point:

The new ATS/ERS recommendations for the diagnosis and management of COPD are based on the GOLD guidelines but provide considerably more clinical details.

ORLANDO, FLA—About 150,000 Americans die of COPD annually, making it the fourth leading cause of death in the United States. And that number keeps rising: The latest projections suggest that by 2020 COPD will be the third leading cause of death. The number of deaths attributable to COPD is increasing in most other countries as well.

Nevertheless, COPD has largely been neglected by health care systems everywhere. “There is not, I think, a single place in the world that [makes COPD] a priority,” said William MacNee, MD, at the annual meeting of the American Thoracic Society (ATS).

During that meeting, Dr. MacNee, from the University of Edinburgh, and colleagues from the ATS and the European Respiratory Society (ERS) unveiled new COPD guidelines that have been jointly developed by the two organizations. These guidelines can be accessed (in a fully searchable format) at www.thoracic.org/COPD/default .asp; a summary has been published in the European Respiratory Journal.¹

The ATS/ERS recommendations are similar to the guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), but they provide considerably more clinical detail. In addition, the new recommendations emphasize the systemic features of COPD, not just its pulmonary consequences. They also put greater focus on the prevention and treatment of COPD, and they contain much more information for COPD patients than the GOLD guidelines do.

Among the features in the new recommendations are expanded sections on oxygen therapy, pulmonary rehabilitation, surgical options, and end-of-life care. For example, the new recommendations stipulate that the goal of long-term oxygen therapy is to maintain an arterial oxygen saturation above 90% during rest, sleep, and exertion.

Pulmonary rehabilitation should be considered for COPD patients who have any of the following: dyspnea, other respiratory symptoms, reduced exercise tolerance, impaired health status, or activity restriction. Although rehabilitation appears to have only a minimal effect on pulmonary function measurements, it has been shown to alleviate respiratory symptoms, increase exercise tolerance and health status, and help patients better perform activities of daily living.

Some COPD patients may also derive benefit from bullectomy, lung-volume reduction surgery, or lung transplantation; in highly selected candidates, these procedures may reduce dyspnea and improve spirometric results, exercise capacity, lung volumes, health-related quality of life, and (possibly) survival. However, surgical candidates must be warned to stop smoking at least four to eight weeks preoperatively to decrease the risk of postoperative complications.

Mechanical ventilation should be considered when COPD patients continue to have acidosis, hypercapnia, and tachypnea (respiratory frequency above 24 breaths per minute) despite optimal medical therapy and oxygen administration. Noninvasive positive-pressure ventilation with a nasal or face mask is preferable to invasive ventilation with an endotracheal tube.

In patients with end-stage COPD, the need for permanent ventilatory support—or the acceptance of death—may eventually become apparent. Patient autonomy and respect for each person’s wishes should be the main concerns at this time.

—Timothy Begany

Reference
1. Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.

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