SUMMARY OF RECOMMENDATIONS FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

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1 SUMMARY OF RECOMMENDATIONS FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Diagnosis and diagnostic tools Recommendation 1 Diagnosis of COPD (IV) It is recommended that spirometry should be performed in any patient over the age of 35 who has risk factors (smoking) and who presents with one or more of the following symptoms: exertional breathlessness, chronic cough, sputum production, frequent bronchitis and wheezing. Recommendation 2 Diagnostic tools for COPD (IV) It is recommended to perform post bronchodilator spirometry, with a value of FEV1/FVC<0.70 confirming the diagnosis of COPD. Recommendation 3 COPD staging (IV) Staging of COPD should be made according to the FEV1/FVC ratio, the frequency of the exacerbations, the dyspnea assessment with the MRC dyspnea scale, and/or the health status assessment with the CAT or the CCQ and/or the multicomponent indexes as BODE, BODEx, DOSE. (*Abbreviations: FEV1;forced expiratory volume in 1 second. FVC;forced vital capacity. MRC; Medical Research Council. CAT; COPD Assessment Test. CCQ;Clinical COPD Questionnaire. BODE;BMI,Obstruction,Dyspnea,Exercise capacity. BODEx;BMI,Obstruction,Dyspnea, Exacerbations. DOSE;Dyspnea, Obstruction, Smoking, Exacerbation) Recommendation 4 Follow-up of COPD (IV) Patients with COPD should be reviewed at least once per year, or more frequently according to the disease severity. Interventions (pharmaceutical and non-pharmaceutical) Recommendation 5 Smoking cessation intervention (II) Smoking cessation is the key intervention for all COPD patients who continue to smoke. Recommendation 6 Inhaled beta2-agonists, anticholinergics (I,II) It is recommended that inhaled beta2-agonists and anticholinergics should be the basic pharmacotherapy for COPD (I), with a preference in long acting bronchodilators (II). Recommendation 7 Theophylline (I,IV) Theophylline is less effective than inhaled bronchodilators (I) and shouldn t be considered as a first choice treatment for COPD (IV). Recommendation 8 Monotherapy with inhaled corticosteroids (II)

2 Long-term monotherapy with inhaled corticosteroids is not recommended in patients with COPD as it is less effective than the combination of inhaled corticosteroids with long- acting beta2- agonists. Recommendation 9 Treatment with inhaled corticosteroids (II) It is recommended that inhaled corticosteroids should be considered in COPD patients with FEV1 < 60% predicted. Recommendation 10 Long-term therapy with inhaled corticosteroids (II) Long-term treatment with inhaled corticosteroids is recommended for patients with severe COPD (FEV1 <30% predicted) or very severe COPD (FEV1 <30% predicted) and frequent exacerbations that are not adequately controlled by long-acting bronchodilators. Recommendation 11 Combinations: inhaled corticosteroids and long acting beta2-agonists or anticholinergics (II) In patients with many symptoms and a high risk for exacerbation, therapy with inhaled corticosteroid plus long-acting beta2-agonist or long-acting anticholinergic should be considered, with evidence for triple therapy when symptoms or exacerbations insist. Recommendation 12 Inhaled corticosteroids - precautions (I) It is recommended patients to be informed that treatment with inhaled corticosteroids increases the risk of pneumonia. Recommendation 13 Phosphodiesterase 4 inhibitors (II) The phosphodiesterase-4 inhibitor, roflumilast, could be used to reduce exacerbations in patients with chronic bronchitis*, severe and very severe COPD, and frequent exacerbations that are not adequately controlled by long- acting bronchodilators.* A subcategory of chronic obstructive pulmonary disease. The disease is characterized by hypersecretion of mucus accompanied by a chronic (more than 3 months in 2 consecutive years) productive cough. Infectious agents are a major cause of chronic bronchitis. Recommendation 14 Roflumilast and long-acting bronchodilators (II) The beneficial effect of roflumilast in lung function also remains when it is added to long-acting bronchodilators. Recommendation 15 Factors that contribute in the treatment scheme selection (IV) Treatment selection should be made by taking in consideration the response in symptoms, patient's preferences, drugs ability to reduce exacerbations, possible side effects and cost. Recommendation 16 Treatment scheme selection in COPD patients with asthma as comorbidity (IV) It is recommended for COPD patients with asthma to receive inhaled corticosteroid treatment earlier, regardless of exacerbations.

3 Recommendation 17 Antibiotics (III-1) The use of antibiotics is not recommended for COPD patients without exacerbations. Recommendation 18 - Oral corticosteroids (IV) The use of oral corticosteroids is not recommended for COPD patients without exacerbations. Recommendation 19 - Mucolytics and antitussives (ΙV) Oral mucolytics and antitussives are not recommended for the COPD treatment. Recommendation 20 COPD exacerbations and oral corticosteroids (II,IV) Oral corticosteroid therapy is recommended for the treatment of COPD exacerbations (II): mg prednisolone per day for days (IV). Recommendation 21 COPD exacerbations and bronchodilators/anticholinergics (IV) Short-acting beta2-agonists with/or without short-acting anticholinergics are recommended for the COPD exacerbations treatment. Recommendation 22 COPD exacerbations and antibiotics (ΙV) It is recommended that the choice of antibiotics use in COPD patients with exacerbations should be based in criteria like increased dyspnea, increased sputum production and sputum purulence. Recommendation 23 COPD exacerbations and intravenous methylxanthines (II) In COPD exacerbations intravenous methylxanthines (theophylline or aminophylline) should be considered as a second-line therapy, only to be used in selected cases of patients with exacerbations when there is insufficient response to short-acting bronchodilators. Recommendation 24 COPD exacerbations and noninvasive mechanical ventilation (IV) Non-invasive mechanical ventilation should be considered as a treatment choice in patients with exacerbations and persistent hypercapnic ventilatory failure when they are not responding to the optimum medical therapy. Recommendation 25 Factors that contribute in the decision of home based care for COPD exacerbations (ΙV) In patients with COPD exacerbations the choice for home based care should be based on a number of factors including the clinical signs and symptoms, the comorbidities, the presence of adeguate home support and the SaO2 estimation. Recommendation 26 Comorbidities and COPD treatment (ΙV) Comorbidities are common in COPD (cardiovascular diseases, metabolic syndrome, anxiety and depression, osteoporosis, lung cancer) nevertheless there is no evidence that COPD patients with comorbidities should be treated differently.

4 Recommendation 27 COPD and ischemic heart disease or heart failure (I) The use of selective beta1-blockers is recommended for the treatment of ischemic heart disease or heart failure in patients with COPD. Recommendation 28 COPD and osteoporosis (IV) It is recommended that COPD patients should be screened for osteoporosis, especially when they have frequent exacerbations and receive often treatment with oral corticosteroids. Recommendation 29 COPD and depression or anxiety (IV) It is recommended that health professionals evaluate patients with COPD for depression or anxiety when they present hypoxia, severe dyspnea, or had been diagnosed and admitted to hospital due to exacerbations. Recommendation 30 - Assessment of patients for long-term oxygen therapy (IV) Long term oxygen therapy is recommended in patients with severe COPD, cyanosis, polyerythremia, peripheral oedema, SatO2<92%, high jugular pressure. Recommendation 31 Long-term oxygen therapy (IV) Long-term oxygen therapy is indicated for patients who have: PaO2 equal or below 7.3 kpa (55 mmhg) or SaO2 equal or below 88%, with or without hypercapnia confirmed twice over a three week period or PaO2 between 7.3 kpa (55 mmhg) and 8.0 kpa (60 mmhg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (hematocrit > 55%) Recommendation 32 - Long-term oxygen therapy and air travel (IV) All patients on long-term oxygen therapy planning air travel should be assessed according to the British Thoracic Society (BTS) recommendations. Recommendation 33 Smoking cessation counseling (I) Smoking cessation counseling delivered by physicians and other health professionals is recommended. Recommendation 34 Self-management counseling (I) Patients at risk of having an exacerbation of COPD should be offered self-management advices that encourage them to respond promptly to the exacerbations symptoms. Recommendation 35 Lifestyle counseling (IV) It is recommended that patients should receive advices on healthy living including diet, physical exercise and risk factors avoidance. Recommendation 36 Diet advices (IV)

5 Patients with abnormal BMI, high (ΒΜΙ>25) or low (ΒΜΙ<18.5), should be referred for diet advices. Recommendation 37 Participation in pulmonary rehabilitation programs (I) Pulmonary rehabilitation programs are recommended to improve quality of life and reduce healthcare costs for all individuals with COPD regardless of COPD staging. Recommendation 38 - Pulmonary rehabilitation programs interventions (IV) Pulmonary rehabilitation programs should include physical training, disease education, nutritional, psychological and behavioural interventions. Recommendation 39 Palliative care (IV) Opioids, benzodiazepines, tricyclic anti-depressants and major tranquilizers could be used in COPD end stages patients. Recommendation 40 Considerations for age population groups (III-2) Modification of the diagnosis of COPD is recommended for the elderly because the use of the fixed ratio FEV1/FVC may lead to COPD overdiagnosis in older adults with mild COPD and underdiagnosis in adults younger than 45 years. Disease prevention Recommendation 41 Community based interventions (III-1) Community based interventions are recommended for the COPD prevention and management. Recommendation 42 Smoking cessation (III-1) All COPD patients who smoke should be encouraged to quit. Recommendation 43 Risk factors avoidance (IV) Avoidance of occupational exposures and risk factors should be recommended to all COPD patients. Recommendation 44 - Reduce exposure to risk factors (III-1) Efficient ventilation, non-polluting cooking stoves and chimneys use should be recommended in COPD patients. Recommendation 45 Influenza vaccination (III-1) Influenza vaccination should be recommended to all patients with COPD. Recommendation 46 Pneumococcal vaccination (III-2) Pneumococcal vaccination should be recommended to all patients with COPD.

6 Referral Recommendation 47 COPD patients referral (IV) Referrals for specialist s advices should be recommended when clinically indicated (diagnostic uncertainty, suspected severe COPD, rapid decline in FEV1, assessments for oxygen therapy, onset of symptoms in patients under 40 years or a family history of alpha 1-antitrypsin deficiency, hemoptysis, etc.) regardless the disease staging. Health professionals and healthcare units Recommendation 48 COPD multidisciplinary s team responsibilities (IV) It is recommended that the multi-disciplinary team that manage COPD patients (doctors, nurses, physiotherapists, occupational therapists, pharmacists) assess patients needs, advise them on self-management strategies, identify and monitor patients at high risk of exacerbations, advice them on exercise techniques and educate patients and other health care professionals. Recommendation 49 Multidisciplinary team for patients with severe COPD (IV) In patients with more severe COPD stages the multidisciplinary team should also include a: dietician, social worker, mental health trained worker, behavior nurse therapist, clinical psychologist or psychiatrist. Recommendation 50 Specialized nurses (IV) Specialized lung nurses should be included in the multidisciplinary COPD team. Recommendation 51 Contribution of nurses to patients participating in pulmonary rehabilitation programs and exercises (IV) Nurses should promote patients with COPD to participate in pulmonary rehabilitation programs and exercises. Recommendation 52 - Contribution of nurses in patients self-management and patient education (IV) Nurses should support disease self-management strategies, assess patients compliance to inhaler devices to ensure accurate technique and train patients with sub-optimal technique. Recommendation 53 - Physiotherapy techniques and COPD (III-1) In COPD patients with excessive sputum, training in the use of positive expiratory pressure nasal or oronasal masks by a physiotherapist should be recommended. Recommendation 54 Physiotherapy techniques and COPD (IV) In COPD patients with excessive sputum, training in the active cycle of breathing techniques by a physiotherapist should be recommended.

7 Recommendation 55 Social services and COPD (IV) Patients disabled by COPD should be considered for referral for assessment to social services. Recommendation 56 Telehealthcare and COPD (I,III-1) Telehealthcare for COPD is recommended as improves quality of life, reduces the number of the emergency department visits (I) and it is cost-effective (III-1).

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