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COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update

Ian A Yang, Juliet L Brown, Johnson George, Sue Jenkins, Christine F McDonald, Vanessa M McDonald, Kirsten Phillips, Brian J Smith, Nicholas A Zwar and Eli Dabscheck
Med J Aust 2017; 207 (10): 436-442. || doi: 10.5694/mja17.00686

Abstract

Introduction: Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities. Advances in the management of COPD are updated quarterly in the national COPD guidelines, the COPD-X plan, published by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand and available at http://copdx.org.au.

Main recommendations:

  • Spirometry detects persistent airflow limitation (post-bronchodilator FEV1/FVC < 0.7) and must be used to confirm the diagnosis.
  • Non-pharmacological and pharmacological therapies should be considered as they optimise function (ie, improve symptoms and quality of life) and prevent deterioration (ie, prevent exacerbations and reduce decline).
  • Pulmonary rehabilitation and regular exercise are highly beneficial and should be provided to all symptomatic COPD patients.
  • Short- and long-acting inhaled bronchodilators and, in more severe disease, anti-inflammatory agents (inhaled corticosteroids) should be considered in a stepwise approach.
  • Given the wide range of inhaler devices available, inhaler technique and adherence should be checked regularly.
  • Smoking cessation is essential, and influenza and pneumococcal vaccinations reduce the risk of exacerbations.
  • A plan of care should be developed with the multidisciplinary team. COPD action plans reduce hospitalisations and are recommended as part of COPD self-management.
  • Exacerbations should be managed promptly with bronchodilators, corticosteroids and antibiotics as appropriate to prevent hospital admission and delay COPD progression.
  • Comorbidities of COPD require identification and appropriate management.
  • Supportive, palliative and end-of-life care are beneficial for patients with advanced disease.
  • Education of patients, carers and clinicians, and a strong partnership between primary and tertiary care, facilitate evidence-based management of COPD.

 

Changes in management as result of the guideline: Spirometry remains the gold standard for diagnosing airflow obstruction and COPD. Non-pharmacological and pharmacological treatment should be used in a stepwise fashion to control symptoms and reduce exacerbation risk.

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  • Ian A Yang1,2
  • Juliet L Brown3
  • Johnson George4
  • Sue Jenkins5,6
  • Christine F McDonald7,8
  • Vanessa M McDonald9,10
  • Kirsten Phillips3
  • Brian J Smith11
  • Nicholas A Zwar12
  • Eli Dabscheck13

  • 1 University of Queensland, Brisbane, QLD
  • 2 Prince Charles Hospital, Brisbane, QLD
  • 3 COPD National Program, Lung Foundation Australia, Brisbane, QLD
  • 4 Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
  • 5 Curtin University, Perth, WA
  • 6 Sir Charles Gairdner Hospital, Perth, WA
  • 7 Austin Hospital, Melbourne, VIC
  • 8 University of Melbourne, Melbourne, VIC
  • 9 Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW
  • 10 John Hunter Hospital, Newcastle, NSW
  • 11 Queen Elizabeth Hospital, Adelaide, SA
  • 12 University of New South Wales, Sydney, NSW
  • 13 Alfred Health, Melbourne, VIC


Acknowledgements: 

We thank Lung Foundation Australia and the Thoracic Society of Australia and New Zealand for their support in the preparation of these guidelines.

Competing interests:

The conflict of interest declarations for Ian Yang, Johnson George, Sue Jenkins, Christine McDonald, Vanessa McDonald, Brian Smith, Nick Zwar and Eli Dabscheck are listed on the Lung Foundation Australia website ().

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access_time 11:30, 11 December 2017
David C Currow, Magnus Ekström, Miriam J Johnson

The authors of COPD-X Australian New Zealand Guidelines for the diagnosis and management of chronic obstructive pulmonary disease (COPD) (1) are to be congratulated for a timely update as evidence evolves.

A notable omission is that, in the real world, the majority of people with COPD progress to a point where the disease modifying treatments have been exhausted leaving people with worsening chronic breathlessness that brings disability to their daily lives. (2)

The Guidelines refer to a conceptual framework for thinking about palliative care but do not look at the evidence for managing people’s chronic breathlessness or their lived experience of compromised activities of daily living, often for years. (1)

People with modified Medical Research Council (mMRC) breathlessness scores of 3 or 4 despite optimal disease-modifying treatment have chronic breathlessness that affects their physical and mental quality of life. (3)

The Canadian Thoracic Society has a 3 step ‘ladder’ for managing chronic breathlessness (4):
- optimising underlying modifiable factors;
- introducing evidence-based, non-pharmacological symptomatic therapies; and, in selected patients with continuing symptoms
- pharmacological treatment.

In people with COPD, a meta-analysis of randomised trials that reach steady state (5) showed clinically significant symptomatic benefit that is safe and sustained. (6)

In the real world, many people with COPD progress to a point where close attention to optimising symptom control is the most important clinical response. Evidence-based treatments enable clinicians to reduce symptom intensity in the face of continuing physical decline, with benefits to patients and their caregivers.


1. Yang IA, Brown JL, George J, et al. COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update. Med J Aust 2017; 207 (10): 436-442
2. Johnson MJ, Yorke J, Hansen-Flaschen J, et al. An international Delphi process to delineate the clinical syndrome of chronic breathlessness. Eur Resp J 2017;49(5): DOI: 10.1183/13993003.02277-2016.
3. Currow DC, Dal Grande E, Ferreira D, et al. Chronic breathlessness associated with poorer physical and mental health-related quality of life (SF-12) across all adult age groups. Thorax 2017;72(12):1151-1153. doi: 10.1136/thoraxjnl-2016-209908.
4. Marciniuk DD, Goodridge D, Hernandez P, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011 Mar-Apr;18(2):69-78.
5. Ekstrom M, Nilsson F, Abernethy AP, Currow DC. Effects of opioids on breathlessness and exercise capacity in chronic obstructive pulmonary disease. A systematic review. Ann Am Thoracic Soc 2015;12(7):1079-1092.
6. Verberkt CA, van den Beuken-van Everdingen M, Schols J, et al. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50(5).

Competing Interests: No relevant disclosures.

Dr David C Currow
Flinders University

Dr Magnus Ekström
Lund University

Dr Miriam J Johnson
Hull York Medical School, University of Hull

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