19 Sep COPD, or chronic obstructive pulmonary disease, is a condition in which the lung airways (bronchial tubes) become inflamed and narrowed and the air sacs become. The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. 21 Nov The Medical Journal of Australia (MJA) recently published a summary of the internationally recognised COPD-X Guidelines to highlight the latest key clinical recommendations in the diagnosis and management of Chronic Obstructive Pulmonary Disease (COPD). Key evidence-based advances and. Read full-text medical journal articles from Medscape's COPD Journal Articles. Journal of the American Board of Family Medicine, January Treatment Effectiveness Medical Treatment of Pulmonary Arterial Hypertension Get up-to- date on the latest treatment strategies for pulmonary arterial hypertension. Seminars.
Clinical practice guidelines are ubiquitous and are developed to provide recommendations for the management of many diseases, including chronic obstructive pulmonary disease. The development of these guidelines is burdensome, demanding a significant investment of time and money. In Europe, the majority of countries develop their own national guidelines, despite the potential for overlap or duplication of effort.
A concerted effort and consolidation of resources between countries may alleviate the 2018 Guidelines For Copd Management Uptodate Medical Journal of maintaining individual national guidelines.
Despite significant resource investment into the development and maintenance of clinical practice guidelines, their implementation is suboptimal. Effective strategies of guideline dissemination must be given more consideration, to ensure adequate implementation and improved patient care management in the future. The ultimate treatment goals in chronic obstructive pulmonary disease COPD management remain uniform across the majority of national and international COPD clinical practice guidelines CPGsand include reduced symptoms, reduced exacerbation click at this page and improved quality of life [ 1 ].
To achieve these goals, CPGs require regular updates with recent and relevant state-of-the-art medical and scientific developments.
Guidelines strive to improve the quality of healthcare and to reduce variations in the treatment and management of COPD [ 2 ]. Clinical practice guidelines provide recommendations on patient management based on available evidence and, in certain cases, educated opinion where there is no direct evidence available [ 3 ].
The quality of the available evidence and the intended audience of CPGs remain core considerations for their development [ 4 ]. In recent years, CPGs have further evolved in response to an increasing recognition of the need for more stringent, systematic approaches when recommending specific therapeutic interventions or strategies [ 5 ].
The importance of rigorous processes to ensure that only accurate and appropriate treatment recommendations are made is see more well-accepted among professional scientific societies.
In fact, standards to guide the preparation of CPGs are now available [ 6 ]. However, little attention is afforded to the challenges and pitfalls associated with the development of such documents. A concerted effort between multiple stakeholders is needed to ensure precise, practical and up-to-date clinical recommendations for the diagnosis and optimal management of COPD.
Guidelines must be locally relevant; therefore local expert stakeholders should offer local proposals, while referring to global evidence-based documents. Important advances in the methodologies used for the development of CPGs have been made in recent years. GRADE provides a transparent, systematic approach to review available evidence and rate its quality, in order to make recommendations of graded strength based on the degree of confidence in the benefit-risk-cost ratio and applicability of the strategies of interest.
Evidence-based CPGs should require minimal interpretation by end-users, to reduce the risk of bias. However, this type 2018 Guidelines For Copd Management Uptodate Medical Journal CPG also carries inherent drawbacks and limitations, including a potential disconnection between the focus on high-quality scientific evidence and real-world clinical practice [ 10 ]. Evidence-based guidelines may not address areas where there is an insufficient number of well-designed clinical trials i.
While rigorous methodologies such as the GRADE strategy offer robust and less biased treatment recommendations, solely relying on such strict methodologies can also compromise the conclusions and external validity of CPGs. Using high-level, formal methodology to develop guidelines may exclude clinically relevant study results [ 12 ].
Evidence-based guidelines may reduce professional autonomy or clinical judgement [ 11 ]. Furthermore, the evidence included in these grading processes is primarily collected from specific subsets of patients who meet strict inclusion criteria for participation in large clinical trials: Consequently, often the results obtained do not allow determination of i the generalisability of results obtained in selected populations, or ii the most suitable target subgroups in terms of benefit-risk ratio.
Chronic obstructive pulmonary disease guidelines in Europe: a look into the future
However, it is well-recognised that significant heterogeneity exists among patients with COPD. A recent study by Halpin et al. Conversely however, guidelines which rely heavily on consensus opinion, rather than high-quality evidence, may be vulnerable to bias and individual interpretation [ 11 ].
To try to find the right balance, evidence from real-world effectiveness studies should be more heavily considered in CPGs. These could include the results of observational studies or source trials where appropriate [ 10 ], provided that they satisfy appropriate quality standards [ 14 ].
In light of this, CPGs should ideally combine both evidence- and opinion-based approaches in a complementary and transparent way. This can be achieved by clearly highlighting sections that are evidence-based, and addressing gaps in the knowledge by educated opinion or extrapolation from efficacy evidence in other disease areas.
Furthermore, of significant consideration is the use of single-disease guidelines for patients with multiple comorbidities. This may be particularly relevant in the case of COPD, because due to the advanced age of the majority of patients and the exposure to noxious particles or gases, especially tobacco smoking, the prevalence of comorbidities is substantial [ 15 ].
In addition, COPD and its respiratory consequences can exert direct deleterious effects on other systems; one example is the effect of lung hyperinflation on heart function [ 16 ]. Conversely, some comorbidities can increase the burden of COPD; e. The frequency and type of comorbidities presented may be different in patients in real life compared to those included in RCTs [ 18 ]; therefore, guidance on multimorbidity will need to be considered in the future [ 19 — 21 ].
Guidelines are time-consuming and expensive to produce. Extensive literature reviews and detailed analyses require more time and resources than clinical and academic experts can dedicate to the development and updates of national or international CPGs [ 1222 — 24 ].
Log in without password NEW! Recommendations that relieve the burden of disease e. New guidelines for acute COPD exacerbations.
This puts strain 2018 Guidelines For Copd Management Uptodate Medical Journal local and national societies with limited funding. Budget and available resources are important factors for most countries when developing and updating their national guidelines [ 22 ]. Financial support from private e. New simplified strategies for CPG development are being tested; they combine consensus through a Delphi methodology with strict application of GRADE in areas where consensus is not reached or that are subject source a high risk of bias [ 25 ].
If adequately validated, these strategies could save significant time and resources. Identifying the key target learn more here is a critical step in the development of CPGs. The audience is broad, and includes healthcare practitioners with varying levels of specialisation and expertise, as well as non-healthcare professionals [ 26 ]. Pulmonologists, general practitioners GPsother healthcare professionals, patients, payors and policy-makers are the primary audiences of COPD guidelines.
Although not directly involved in the delivery of patient care, healthcare payors, policy-makers and regulatory agencies also comprise the readership of CPGs. Recommendations that relieve the burden of disease e. Payors rely on CPGs and robust efficacy evidence in order to make informed decisions on funding and reimbursement policies of specific therapies [ 2728 ].
Stem Cells for COPD, Idiopathic Pulmonary Fibrosis, Emphysema Lung Stem Cell Therapy in 2018
Policy-makers also need CPGs to develop adequate prevention strategies and to build pathways of care [ 29 ]. Guidelines are heavily regarded by regulatory authorities, which may impact the design of clinical trials. This is of significant importance when regulatory authorities adopt the definition or diagnostic criteria used by a particular guideline when defining the requirements for novel drugs, thereby and perhaps inadvertently influencing the design of clinical trials [ 30 ].
Guidelines that are intended for widespread use in clinical practice should include relevant stakeholders at various and appropriate stages of the development process, which may encourage improved implementation and adherence of the recommendations through an increased sense of ownership [ 3132 ].
Although it may not be appropriate for all stakeholders to take an active role in the development process from the beginning, certain groups may participate in the drafting of recommendations or at the review stages. Academic or clinical expert involvement in guideline preparation should include GPs, pulmonologists, nurses and physiotherapists where appropriate [ 31 ].
As the majority of COPD care is administered by GPs, their involvement in guideline development may drive increased primary care physician-specialist communication and integration, which is crucial in the management of COPD, particularly when patient referral is necessary.
Input from nurses, cardiologists, physiotherapists and dieticians may also add value and go here expertise to guidelines in the pathways of care [ 26 ].
Critically, this may also help to incorporate patient preferences into the guidelines. Increased involvement may encourage patients to play a more active role in their healthcare management [ 33 ]. Duplicate efforts are made across Europe, with individual countries investing significant resources into the development of CPGs [ 34 ]. Institutional collaboration and consolidation of efforts may significantly reduce the cumbersome nature of guideline development and frequent updates [ 35 ].
Furthermore, variations in individual sets of guidelines will inevitably continue 2018 Guidelines For Copd Management Uptodate Medical Journal collaboration is encouraged and optimised between countries. These variations, however minor, have the potential to mislead or confuse practicing healthcare professionals [ 10 ]. The GOLD strategy also carries a major positive advantage in that the document is updated annually with the most recent and relevant literature and studies; however, no formal evaluation of evidence i.
GRADE more info similar is performed. In addition, since by its definition, GOLD aims to provide a global strategy document, some recommendations may not be directly i.
As most countries do not 2018 Guidelines For Copd Management Uptodate Medical Journal the resources to facilitate an annual update to their national guidelines, each country has the opportunity to adopt specific sections of GOLD that are locally relevant.
Clinical practice guidelines provide recommendations on patient management based on available evidence and, in certain cases, educated opinion where there is no direct evidence available [ 3 ]. Medscape App Get fast, accurate answers for point-of-care decision making. A recent study by Halpin et al. Budget and available resources are important factors for most countries when developing and updating their national guidelines [ 22 ].
Such processes could be facilitated by tighter collaboration between GOLD committees and regional, national or local initiatives. Owing to the importance of national guidelines, coupled with the international availability of the GOLD document, there may be potential for the development of an intermediary document between the two. Individual sensitivities could therefore be facilitated within this common adaptable template. In brief, first-line treatment recommendations at the class level and go here recommendations could be included within the common guideline, with local alternative suggestions added at a local level in line with local policy and scientific societies.
To support the introduction and implementation of a common, adaptable European guideline, a pan-European guideline development resource repository could be compiled as a support tool.
Moreover, different sections of a guideline dedicated to a specific healthcare practitioner role may boost implementation across clinical practice. There is potential for significant alleviation of time and budget constraints through a concerted, collaborative effort between European countries.
Who should take the lead during such a collaboration remains to be discussed, but it is likely that the European Respiratory Society ERS is in the best position to lead such a project.
Developing a European collaboration would be best achieved through click ERS and national societies, agreeing on a common methodology.
Tight links with the GOLD group could also be useful to share retrieved evidence and increase reactivity, allowing a continuous update and adaptation process. There is an apparent contradiction between the exponential increase in the scientific knowledge of COPD complexity phenotypes, endotypes, here etc. Complex raw data needs to be aggregated and translated into meaningful, useful information to support recommendations of new treatments [ 29 ].
Algorithms may be helpful to guide COPD therapy in a simple, stepwise and coordinated manner [ 40 ]. Such algorithms need to be flexible and continuously evolving in order to remain up-to-date and clinically relevant.
Importantly, the availability of algorithms does not negate the need for scientific principles, and the role of clinical judgement should always be acknowledged. Once finalised, the CPGs should be shared in 2018 Guidelines For Copd Management Uptodate Medical Journal ways to ensure optimal dissemination.
Freely accessible online publishing of the guidelines is important. A way forward could be to amalgamate CPGs on all diseases into one single portal that is accessible by all physicians, other healthcare professionals and the general public free of charge. This 2018 Guidelines For Copd Management Uptodate Medical Journal been done in Finland by the click Medical Society Duodecim Current Care Guideline system where guidelines on more than diseases are collated on a single online portal and used by most healthcare professionals [ 41 ].
Also, presenting the guidelines at local, national and international congresses may increase awareness amongst a myriad of healthcare practitioners. Furthermore, innovative methods to inform relevant end-users of CPGs could be considered e. Plain language summaries may also prove helpful to guide patients and their relatives on available treatments.
A short pocket version should be made available to all physicians to facilitate quick and easy access during patient consultations. Useful treatment algorithms should be available on an easily-navigable website. Using smart technology may also improve the implementation of guidelines. Such applications may also have a place within already-existing clinical integrated management systems such as GP practice computer software.
The final presentation of the recommendations should also be carefully considered. Succinct and concise recommendations presented in an easily-digestible format such as tables or charts should be considered for busy healthcare practitioners [ click ].
Evidence-based CPGs are rigorous by their very nature, but are difficult to implement in real-life clinical practice [ 11 ].