Chronic obstructive pulmonary disease (COPD) – Related resources

Cochrane reviews

Drug therapy

• Tiotropium treatment for COPD is associated with fewer exacerbations compared with ipratropium bromide. It also appears to be associated with improved lung function, fewer hospital admissions, and improved quality of life .
• Inhaled short-acting beta2-agonists are effective in most but not all patients with moderate to severe COPD .
• Anti-cholinergic bronchodilatators appear to have similar efficacy as beta-2-sympathomimetic agents for acute exacerbations of chronic obstructive pulmonary disease .
• Both long-acting beta-agonist and inhaled corticosteroid therapy confer similar benefits across the majority of outcomes in patients with stable chronic obstructive pulmonary disease .
• Combination of a corticosteroid and a long-acting beta-agonist in one inhaler is effective in reducing acute exacerbations in adults with chronic obstructive pulmonary disease when compared to placebo, to mono-component steroid or to mono-component long-acting beta-agonists. As compared to placebo or mono-component steroid, the combination also reduces mortality. Pneumonia is more common with combined inhalers as compared to options not including steroids.
• The addition of inhaled corticosteroid (ICS) and long-acting beta2-agonist (LABA) combination treatment to tiotropium may improve health-related quality of life and lung function in chronic obstructive pulmonary disease. If the combination tiotropium + LABA is already in use, the addition of ICS may not bring additional benefit. There is uncertainty regarding the effects on mortality, hospitalisation, exacerbations of COPD and pneumonia. In patients with stable COPD, pMDI produce similar outcomes to dry powder devices for delivering beta-2 agonist .
• Cardioselective beta-blockers do not produce significant short-term reduction in airway function when given to patients with COPD .
• Oral steroids appear to improve lung function and symptoms more than placebo in stable chronic obstructive pulmonary disease, but not all people benefit equally. Long-term use does not slow the decline in lung function and there is an increased risk of side-effects .
• Use of continuous prophylactic antibiotics are effective in reducing exacerbations in patients with at least moderately severe COPD .
• PDE4 inhibitors (roflumilast, cilomilast) appear to improve lung function and reduce likelihood of exacerbations in people with stable COPD regardless of the severity of the disease .

Surgery

• Stapling is more effective than laser resection for lung volume reduction in diffuse emphysema, but there is no evidence from randomized trials comparing surgery with optimal conservative treatment .

Physiotherapy and rehabilitation

• Water-based exercise training compared with no exercise training improves exercise capacity and may improve health-related quality of life in COPD. Water-based exercise training appears to improve endurance exercise capacity compared with land-based exercise training .
• Breathing exercises appear to improve functional exercise capacity in patients with severe COPD .
• There is little evidence on the effectiveness of ambulatory domiciliary oxygen therapy on exercise capacity in patients with COPD .
• Nocturnal positive pressure ventilation appears not to improve the condition of patients with COPD .
• Patients with COPD may exercise longer and have less shortness of breath when using oxygen during an exercise-training program .Breathing training, walking aids, neuro-electrical muscle stimulation (NMES) and chest wall vibration (CWV) appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of chronic obstructive pulmonary disease (COPD). The evidence on their effectiveness in other conditions is very limited .
• Pulmonary rehabilitation including exercise therapy after a recent exacerbation appears to reduce hospital admissions and mortality .

Lifestyle and counselling

• Nutritional support has no significant effect on anthropometric measures, lung function or exercise capacity in patients with stable COPD .
• Self-management interventions appear to be associated with a reduction in respiratory-related hospital admissions, improved health-related quality of life, and improvement in dyspnoea in patients with chronic obstructive pulmonary disease (COPD) .

Prevention and screening

• Vaccinating patients who have recurrent acute exacerbations of chronic bronchitis with oral H. influenzae vaccine in the autumn may reduce the number and severity of exacerbations over the following winter .

Others

• Treatment of acute exacerbations of COPD in hospital at home with support from respiratory nurses appears to lead to fewer readmissions in comparison with conventional hospital treatment.
• Action plans may aid people with COPD in recognising and reacting appropriately to an exacerbation of their symptoms via the self-initiation of antibiotics or steroids, but these changes appear not to translate into a reduction in healthcare utilisation or improvement in patient well being .
• Outreach nursing programmes for COPD may improve health-related quality of life but may not affect mortality or the number of hospitalisations .
• Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital .

There is no clear evidence supporting vibration for clearing bronchial secretions . N-acetylcysteine appears to reduce the risk of exacerbation in patients with chronic obstructive pulmonary disease (COPD). The effects may be less in patients taking inhaled corticosteroids .

Clinical guidelines

• Qaseem A, Wilt TJ, Weinberger SE et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011;155(3):179-91.
• Chronic obstructive pulmonary disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007.
• Chronic obstructive pulmonary disease (updated). Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). This guideline partially updates and replaces NICE clinical guideline 12. National Institute for Health and Clinical Excellence (NICE), CG101, June 2010 .

Decision support

• Antibiotics for COPD exacerbation
• Cardioselective beta-blockers for patients with asthma/COPD
• Drugs for preventing frequent exacerbations in COPD

Literature

Clinical practice reviews

• Celli BR. Update on the management of COPD. Chest 2008 Jun;133(6):1451-62.
• Niewoehner DE. Clinical practice. Outpatient management of severe COPD. N Engl J Med 2010 Apr 15;362(15):1407-16.
• O'Reilly J, Jones MM, Parnham J, Lovibond K, Rudolf M, Guideline Development Group. Management of stable chronic obstructive pulmonary disease in primary and secondary care: summary of updated NICE guidance. BMJ 2010 Jun 25;340():c3134.
• Siafakas NM (Ed.). Management of chronic obstructive pulmonary disease. European Respiratory Monograph 2006;11(38):i–ix, 1–475.
• Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med 2004 Jun 24;350(26):2689-97.

Other literature

• Loke YK, Cavallazzi R, Singh S. Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies. Thorax 2011;66(8):699-708.
• McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest 2001 Apr;119(4):1190-209.
• Wijkstra PJ, Lacasse Y, Guyatt GH, Casanova C, Gay PC, Meecham Jones J, Goldstein RS. A meta-analysis of nocturnal noninvasive positive pressure ventilation in patients with stable COPD. Chest 2003 Jul;124(1):337-43.
• Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004 Jun;23(6):932-46.
• Snow V, Lascher S, Mottur-Pilson C, Joint Expert Panel on Chronic Obstructive Pulmonary Disease of the American College of Chest Physicians and the American College of Physicians-American Society of Internal Medicine. Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2001 Apr 3;134(7):595-9.
• Bach PB, Brown C, Gelfand SE, McCrory DC, American College of Physicians-American Society of Internal Medicine, American College of Chest Physicians. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med 2001 Apr 3;134(7):600-20.
• Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS, GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001 Apr;163(5):1256-76.