Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update

Abstract

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.

Figures

Figure 1)

Number of chronic obstructive pulmonary disease (COPD) deaths (A) and hospitalizations (B), actual and projected, in Canada. International Classification of Diseases, 10th Edition (ICD10) codes: J40–J44. Note that the coding schemes for this condition changed in 1968, 1978 and 2000 and this may influence trends. Standardized rate uses 1991 Canadian population. Prior to 1993, includes only the 10 Canadian provinces. Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006, using Statistics Canada, Vital Statistics Data

Figure 2)

Prevalence of physician-diagnosed chronic obstructive pulmonary disease in Canadian adults 35 years of age and over, by sex, in 2000/01, 2002, 2003 and 2005. Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, using data from Canadian Community Health Survey (share file), Statistics Canada, 2006

Figure 3)

Resting maximal flow-volume loops (spirometry) (A) and lung volumes (B) in a typical patient with chronic obstructive pulmonary disease (COPD). EELV End-expiratory lung volume; EILV End-inspiratory lung volume; IC Inspiratory capacity; IRV Inspiratory reserve volume; RV Residual volume; TLC Total lung capacity; VT Tidal volume

Figure 4)

A comprehensive approach to the management of chronic obstructive pulmonary disease (COPD). AECOPD Acute exacerbation of COPD; MRC Medical Research Council; PRN As needed; Rx Treatment

Figure 5)

Percentage of current smokers aged 12 years or older in Canada 2000/2001 to 2005

Figure 6)

Recommendations for optimal pharmacotherapy in chronic obstructive pulmonary disease (COPD). *The inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower ICS dose should be used for patients with infrequent acute exacerbations of COPD (AECOPD). LAAC Long-acting anticholinergic; prn As needed; SABA Short-acting beta2-agonist; SABD Short-acting bronchodilator

Figure 7)

The effect of exercise training on 6 minute walk distance in chronic obstructive pulmonary disease (n=669) as summarized in the meta-analysis of Lacasse et al (263)