Sections

Chronic Obstructive Pulmonary Disease (COPD)

Guidelines

Guidelines Summary

Guidelines related to chronic obstructive pulmonary disease (COPD) screening have been issued by the US Preventive Services Task Force (USPSTF).^[104]Additionally, this organization published guidelines on preventing tobacco use and smoking cessation.^[105]

Other guidelines include general COPD management guidelines (eg, GOLD guidelines)^{[4, 106]}and US Department of Veterans Affairs/Department of Defense (VA/DoD) guidelines.^[107]Joint guidelines for stable COPD management have been issued by the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.^[34]

Finally, the Canadian Critical Care Trials Group and the Canadian Critical Care Society Noninvasive Ventilation Guidelines Group issued guidelines on noninvasive positive-pressure ventilation (NIPPV),^[108]and the American College of Chest Physicians and Canadian Thoracic Society released guidelines on COPD exacerbation prevention.^[109]

Screening Guidelines

In 2016, the USPSTF retained its 2008 recommendation against screening for COPD in individuals who do not have related symptoms.^[104]The task force found inadequate evidence in support of the value of questionnaires or spirometry in improving health outcomes (quality of life, morbidity, or mortality) of asymptomatic individuals. It found the screening procedures not overtly harmful, but costly in terms of time and expense. Moreover, the task force concluded that because screening and available drug treatments do not alter the course of the disease, screening offers no net benefit. This recommendation does not apply to adults who present with symptoms, such as chronic cough or dyspnea.

Tobacco Use Guidelines

According to the USPSTF guidelines on preventing tobacco use and tobacco-caused disease, clinicians should ask all adult patients about their use of tobacco products and provide cessation interventions to current users.^[105]The guideline engages a "5-A" approach to counseling that includes the following:

Ask about tobacco use
Advise to quit through personalized messages
Assess willingness to quit
Assist with quitting
Arrange follow-up care and support

Brief behavioral counseling (< 10 min) and pharmacotherapy are each effective alone—although they are most effective when used together. The USPSTF also advises clinicians to ask all pregnant women, regardless of age, about tobacco use. Those who currently smoke should receive pregnancy-tailored counseling supplemented with self-help materials.

GOLD guidelines

The 2018 clinical practice guidelines from the GOLD report on COPD are summarized.^{[106, 110]}

Diagnosis and initial assessment recommendations are as follows:

COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors.
Spirometry is required to make the diagnosis; a postbronchodilator FEV ₁/FVC ratio of less than 0.70 confirms the presence of persistent airflow limitation.
COPD assessment goals are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (eg, exacerbations, hospital admissions, death) to guide therapy.
Concomitant chronic diseases occur frequently in COPD patients and should be treated because they can independently affect mortality and hospitalizations.

Prevention and maintenance therapy recommendations are as follows:

Smoking cessation is key. Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates, as do legislative bans on smoking. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain.
Pharmacologic therapy can reduce the symptoms of COPD, can reduce the severity and frequency of exacerbations, and can improve exercise tolerance and health status.
Pharmacologic treatment regimens should be individualized. They should be guided by symptom severity; exacerbation risk; adverse effects; comorbidities; drug availability and cost; and patient response, preference, and ability to utilize the various drug delivery devices.
Inhaler technique should be assessed regularly.
Pneumococcal and influenza vaccinations decrease the incidence of lower respiratory tract infections.
Pulmonary rehabilitation improves symptoms, physical and emotional participation in everyday activities, and quality of life.
Patients with severe resting chronic hypoxemia have improved survival with long-term oxygen therapy.
In patients with stable COPD and resting or exercise-induced moderate desaturation, routine long-term oxygen treatment is not recommended; however, consider individual patient factors regarding the need for supplemental oxygen.
With severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term noninvasive ventilation may prevent rehospitalization and decrease mortality.
Select patients with advanced emphysema refractory to optimized medical care may benefit from surgical or bronchoscopic interventional treatments.
In advanced COPD, palliative approaches are effective in controlling symptoms.

Stable COPD recommendations are as follows:

In stable COPD, base the management strategy on an individualized assessment of the symptoms and risk of exacerbations.
Strongly urge smoking cessation in patients who smoke.
Treatment goals are symptom reduction and reduction in future exacerbations. Pharmacologic treatments should be complemented by nonpharmacologic interventions.

Exacerbation recommendations are as follows:

A COPD exacerbation is defined as acute respiratory symptom worsening with the need for additional therapy. Several factors can lead to an exacerbation, the most common being respiratory tract infections.
The recommended initial bronchodilators to treat an exacerbation are short-acting beta2-agonists, with or without short-acting anticholinergics.
As soon as possible before hospital discharge, initiate maintenance therapy with a long-acting bronchodilator.
Systemic corticosteroids can improve lung function and oxygenation. They also shorten recovery time and hospital duration. The duration of systemic corticosteroid therapy should not exceed 5-7 days.
If indicated, antibiotic therapy can shorten recovery time, reduce the risk of early relapse and treatment failure, and reduce hospitalization duration. The duration of antibiotic therapy should not exceed 5-7 days.
Owing to increased adverse effect profiles, methylxanthines are not recommended.
The first mode of ventilation used in COPD with acute respiratory failure and without contraindications is noninvasive mechanical ventilation. It improves gas exchange, reduces the work of breathing, decreases the need for intubation, decreases hospitalization duration, and improves survival.

COPD and comorbidity recommendations are as follows:

Treat COPD comorbidities with the usual standard of care, regardless of the presence of COPD. COPD treatment should not be altered by the presence of comorbidities.
Lung cancer is a common comorbidity with COPD and is a main cause of mortality.
Cardiovascular disease is an important frequent COPD comorbidity, as are osteoporosis and anxiety/depression. The latter two are underdiagnosed and associated with poor health status and prognosis.
Gastroesophageal reflux disease can increase the risk of exacerbations and poor health status.
Simplicity of treatment and minimization of polypharmacy are emphasized in a multimorbidity and COPD treatment plan.

In the 2016 update of the GOLD guidelines, a rubric is used that assesses symptoms, breathlessness, spirometric classification, and risk of exacerbations to classify patients according to the following groups^[4]:

Group A (low risk/less symptoms): Stage I or II, 1 or fewer exacerbation per year no hospitalization, modified Medical Research Council (mMRC) 0-1 or COPD Assessment Test (CAT) less than 10
Group B (low risk/more symptoms): Stage I or II, 1 or fewer exacerbation per year no hospitalization, mMRC 2 or higher or CAT 10 or higher
Group C (high risk/less symptoms): Stage III or IV, 2 or more per year 1 or more exacerbation with hospitalization, mMRC 0-1 or CAT less than 10
Group D (high risk/more symptoms): Stage III or IV, 2 or more per year 1 or more exacerbation with hospitalization, mMRC 2 or higher or CAT 10 or higher

The GOLD patient group-based management recommendations include the following^[4]:

Group A-D: Reduction of risk factors (influenza and pneumococcal vaccine); smoking cessation; physical activity; short-acting anticholinergic or short-acting beta-adrenergic agonists as needed
Group B: Long-acting anticholinergics or long-acting beta-adrenergic agonists; cardiopulmonary rehabilitation
Group C: Inhaled corticosteroid and long-acting beta-adrenergic agonists or long-acting anticholinergics; cardiopulmonary rehabilitation
Group D: Inhaled corticosteroid and long-acting beta-adrenergic agonists and/or long-acting anticholinergics; cardiopulmonary rehabilitation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery (LVRS)

VA/DoD guidelines

In 2014, the VA/DoD released updated guidelines for the management of COPD.^[107]These guidelines were endorsed with qualifications by the Institute of Clinical Systems Improvement (ICSI) in 2016.^[111]The VA/DoD guidelines classify patients with COPD into the following two groups:

Patients who experience frequent exacerbations (two or more/year, defined as prescription of corticosteroids, prescription of antibiotics, hospitalization, or emergency department visit)
Patients without frequent exacerbations

Major management recommendations include the following:

Prevention and risk reduction efforts include smoking cessation and vaccination
Short-acting beta-adrenergic agonists as needed for rescue therapy
Long-acting bronchodilators to patients with stable COPD who continue to have respiratory symptoms (eg, dyspnea, cough)
Inhaled long-acting antimuscarinic agent (LAMA) tiotropium as first-line maintenance therapy in patients with stable COPD respiratory symptoms (eg, dyspnea, cough) and as first-line therapy for patients with severe airflow obstruction (ie, post bronchodilator FEV₁< 50%) or a history of COPD exacerbations
For clinically stable patients who have not had exacerbations on short-acting antimuscarinic agents (SAMA), continue treatment rather than switch to long-acting bronchodilators (Note: ICSI qualifies this guidance and recommends offering first-line therapy of LAMA but allows for continuance of SAMA if patient preference or cost considerations make it preferred.)
Inhaled corticosteroid should not be used as a first-line monotherapy in symptomatic patients with stable COPD
Combination therapy with long-acting antimuscarinic agent and long-acting beta-adrenergic agonists for patients who have persistent dyspnea on monotherapy; inhaled corticosteroid may be added as a third medication if dyspnea persists or patient experiences exacerbations
Offer pulmonary rehabilitation to stable patients with exercise limitation despite pharmacologic treatment and to patients who have recently been hospitalized for an acute exacerbation

ACP, ACCP, ATS, and ERS joint guidelines

In 2011, the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society issued joint guidelines for the diagnosis and management of stable COPD. The major recommendations include the following^[34]:

In symptomatic patients, use of spirometry to diagnose airflow obstruction; spirometry should not be used to routinely screen for airflow obstruction in asymptomatic individuals (strong recommendation)
Inhaled bronchodilators may be used to treat symptomatic patients with FEV ₁ between 60% and 80% predicted (weak recommendation) and for symptomatic patients with FEV ₁ less than 60% predicted (strong recommendation)
Monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled beta-adrenergic agonists for symptomatic patients with FEV ₁ less than 60% predicted (strong recommendation); choice of specific monotherapy should be based on patient preference, cost, and adverse effect profile
Combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled beta-adrenergic agonists, or inhaled corticosteroids) may be considered for symptomatic patients with FEV ₁ less than 60% predicted (weak recommendation)
Pulmonary rehabilitation for symptomatic patients with an FEV ₁ less than 50% predicted (strong recommendation); pulmonary rehabilitation may be considered for symptomatic or exercise-limited patients with an FEV ₁ greater than 50% predicted (weak recommendation)
Continuous oxygen therapy in patients who have severe resting hypoxemia (PaO ₂ ≤55 mm Hg or SpO ₂ ≤88%) (strong recommendation)

NIPPV Guidelines

In 2011, the Canadian Critical Care Trials Group and the Canadian Critical Care Society Noninvasive Ventilation Guidelines Group issued guidelines encouraging the use of noninvasive ventilation (NIPPV or continuous positive airway pressure [CPAP]) to avoid intubation for patients in acute care with respiratory failure. Key recommendations relevant to COPD include the following^[108]:

NIPPV should be the first-line choice for supporting patients with a severe exacerbation of COPD.
In facilities with extensive NIPPV experience, patients with COPD can be considered for a trial of early extubation to NIPPV.
Patients with hypoxemia or acute respiratory distress after undergoing surgery or in immunosuppression can be considered for a trial of NIPPV.
Routine use of helium-oxygen is not recommended with NIPPV in patients with severe exacerbation of COPD

Commentary accompanying the Canadian Critical Care guideline urges close patient monitoring and 24-hour availability of an experienced rescue team in case noninvasive ventilation fails and rapid intervention is required.^[108]

Acute Exacerbation Guidelines

In 2015, the American College of Chest Physicians and Canadian Thoracic Society released guidelines on the prevention of acute exacerbations of COPD.^[109]

Major recommendations include the following:

The 23-valent pneumococcal vaccine is recommended; however, evidence is insufficient that pneumococcal vaccination prevents COPD acute exacerbations
Administer the influenza vaccine annually
Provide smoking cessation counseling and treatment
Provide pulmonary rehabilitation for those with moderate, severe, or very severe COPD who have had a recent exacerbation
Provide education with a written action plan and case management
For patients with a history of COPD acute exacerbations, education and case management should include direct access to a healthcare specialist at least monthly
Telemonitoring is not beneficial compared with usual care

In patients with moderate-to-severe COPD, recommendations are as follows:

Long-acting beta-2 agonists are beneficial, but LAMAs are superior to prevent moderate-to-severe acute exacerbations
Use a SAMA rather than a short-acting beta2-agonist as monotherapy to prevent acute mild-to-moderate exacerbations
Use a SAMA plus a short-acting beta2-agonist to prevent acute moderate exacerbations of COPD
Use long-acting beta2-agonist monotherapy rather than SAMA monotherapy to prevent acute exacerbations of COPD
Use a LAMA instead of a SAMA to prevent acute moderate-to-severe exacerbations
A combination of a SAMA plus a long-acting beta2-agonist is better than long-acting beta2-agonist monotherapy to prevent acute mild-to-moderate exacerbations

In patients with stable, moderate, severe, and very severe COPD, recommendations are as follows:

A maintenance combination of inhaled corticosteroid and long-acting beta2-agonist therapy is better than corticosteroid monotherapy or beta2-agonist monotherapy to prevent acute exacerbations of COPD

In patients with stable COPD, recommendations are as follows:

Use a maintenance combination of inhaled corticosteroid and long-acting-beta2 agonist therapy or inhaled long-acting anticholinergic monotherapy for acute exacerbations
A maintenance combination of inhaled long-acting anticholinergic, corticosteroid, and long-acting beta2-agonist therapy or inhaled long-acting anticholinergic monotherapy are both effective to prevent acute exacerbations

In patients aged 40 years who are smokers or have a history of smoking, recommendations are as follows:

Use a long-term macrolide to prevent acute exacerbations in patients with moderate-to-severe COPD with a history of one or more moderate or severe exacerbations in the prior year despite optimal maintenance inhaler therapy
In patients with an acute exacerbation, systemic corticosteroids should be given orally or intravenously to prevent hospitalization for subsequent acute exacerbations of COPD in the first 30 days (only) after the initial exacerbation
For patients with moderate-to-severe COPD and chronic bronchitis and a history of at least one exacerbation in the last year, use roflumilast to prevent acute exacerbations
For stable patients, use an oral slow-release theophylline twice daily to prevent acute exacerbations
For patients with moderate-to-severe COPD and two or more exacerbations in the last 2 years, use oral N-acetylcysteine to prevent acute exacerbations
For stable patients who continue to have acute exacerbations in spite of maximal therapy to reduce them, oral carbocysteine should be used to prevent acute exacerbations if available
For those with moderate-to-severe COPD at risk for exacerbations, statins are not recommended to prevent exacerbations

Medication

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Media Gallery

Venn diagram of chronic obstructive pulmonary disease (COPD). Chronic obstructive lung disease is a disorder in which subsets of patients may have dominant features of chronic bronchitis, emphysema, or asthma. The result is airflow obstruction that is not fully reversible.
Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells.
Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells (high-powered view).
Gross pathology of advanced emphysema. Large bullae are present on the surface of the lung.
Gross pathology of a patient with emphysema showing bullae on the surface.
At high magnification, loss of alveolar walls and dilatation of airspaces in emphysema can be seen.
Posteroanterior (PA) and lateral chest radiograph in a patient with severe chronic obstructive pulmonary disease (COPD). Hyperinflation, depressed diaphragm, increased retrosternal space, and hypovascularity of lung parenchyma are demonstrated.
A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on lateral chest radiograph.
A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph.
Severe bullous disease as seen on a computed tomography (CT) scan in a patient with chronic obstructive pulmonary disease (COPD).
Pressure volume curve comparing lungs with emphysema, lungs with restrictive disease, and normal lungs.
Flow volume curve of a patient with emphysema shows marked decrease in expiratory flow, hyperinflation, and air trapping (patient B) compared with a patient with restrictive lung disease, who has reduced lung volumes and preserved flow (patient A).
Forced expiratory volume in 1 second (FEV1) can be used to evaluate the prognosis in patients with emphysema. The benefit of smoking cessation is shown here because the deterioration in lung function parallels that of a nonsmoker, even in late stages of the disease. Redrawn from Fletcher C, Peato R. The natural history of chronic airflow obstruction. Br Med J 1977; 1: 1645-1648.
Oxygen therapy via nasal cannula.
Home supplemental oxygen.
Bilevel positive airway pressure (BiPAP).
Pulmonary rehabilitation.
Chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation.
Chest radiograph of an emphysematous patient shows hyperinflated lungs with reduced vascular markings. Pulmonary hila are prominent, suggesting some degree of pulmonary hypertension (Correa da Silva, 2001).
Schematic representation of another sign of emphysema on the lateral chest radiograph. When the retrosternal space (defined as the space between the posterior border of the sternum and the anterior wall of the mediastinum) is larger than 2.5 cm, it is highly suggestive of overinflated lungs. This radiograph is from a patient with pectus carinatum, an important differential diagnosis to consider when this space is measured (Correa da Silva, 2001).
Close-up image shows emphysematous bullae in the left upper lobe. Note the subpleural, thin-walled, cystlike appearance (Correa da Silva, 2001).
A, Frontal posteroanterior (PA) chest radiograph shows no abnormality of the pulmonary vasculature, with normal intercostal spaces and a diaphragmatic dome between the 6th and 7th anterior ribs on both sides. B, Image in a patient with emphysema demonstrating reduced pulmonary vasculature resulting in hyperlucent lungs. The intercostal spaces are mildly enlarged, and the diaphragmatic domes are straightened and below the extremity of the seventh rib (Correa da Silva, 2001).
A, Lateral radiograph of the chest shows normal pulmonary vasculature, a retrosternal space within normal limits (< 2.5 cm), and a normal angle between the diaphragm and the anterior thoracic wall. B, Lateral view of the chest shows increased pulmonary transparency, increased retrosternal space (>2.5 cm), and an angle between the thoracic wall and the diaphragm >90 degrees. Straightening of the diaphragm can be more evident in this projection than on others (Correa da Silva, 2001).
High-resolution CT (HRCT) in a patient after viral bronchiolitis obliterans demonstrates areas of airtrapping, which is predominant in the inferior lobes and associated with bronchiectasis in the left lower lobe. Note that the decreased attenuation caused by the airtrapping can simulate emphysema (Correa da Silva, 2001).
Pediatric high-resolution CT (HRCT) shows a hyperinflated right lung with large pulmonary bullae due to congenital lobar emphysema (Correa da Silva, 2001).
High-resolution CT (HRCT) demonstrates areas of centriacinar emphysema. Note the low attenuation areas without walls due to destruction of the alveoli septae centrally in the acini. Red element shows the size of a normal acinus (Correa da Silva, 2001).
High-resolution CT (HRCT) shows large bullae in both inferior lobes due to uniform enlargement and destruction of the alveoli walls causing distortion of the pulmonary architecture (Correa da Silva, 2001).
Panacinar emphysema of the left lung in a patient with a right lung transplant. Note the red element showing the size of a normal acinus and its discrepancy with the destroyed and enlarged airspaces of the left lower lobe (Correa da Silva, 2001).
High-resolution CT (HRCT) shows subpleural bullae consistent with paraseptal emphysema. Red mark shows the size of a normal acinus (Correa da Silva, 2001).
High-resolution CT (HRCT) shows enlarged air-spaces or bullae adjoining pulmonary scars, consistent with paracicatricial emphysema. Red mark shows the size of a normal acinus (Correa da Silva, 2001).
CT densitovolumetry of a nonsmoker, healthy young patient shows normal lungs. Less than 0.35% of lungs have attenuations below -950 HU (Correa da Silva, 2001).
Expiratory CT densitovolumetry shows no areas of airtrapping (Correa da Silva, 2001).
CT densitovolumetry in a patient with lung cancer. Three-dimensional (3D) image shows that the cancer is in the portion of the right lung that was less affected by emphysema in a patient with poor pulmonary function (Correa da Silva, 2001).
CT densitovolumetry shows the attenuation mask. Green areas are those with attenuation below the selected threshold (here, -950 HU to evaluate emphysema), and pink areas are those with attenuations above the threshold. Area outside the patient is highlighted in green because of air (Correa da Silva, 2001).
CT densitovolumetry demonstrates irregular distribution of the emphysema, with substantial predominance in the left lung (Correa da Silva, 2001).

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Author

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Annie Harrington, MD Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians

Disclosure: Nothing to disclose.

Nidhi S Nikhanj, MD Fellow, Department of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles

Nidhi S Nikhanj, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

John J Oppenheimer, MD Clinical Professor, Department of Medicine, Rutgers New Jersey Medical School; Director of Clinical Research, Pulmonary and Allergy Associates, PA

John J Oppenheimer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, New Jersey Allergy, Asthma and Immunology Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Amgen; GSK; Aquestive; Aimmune<br/>Clinical Adjudication/Data Safety Monitoring Board for AZ, GSK, Abbvie, Sanofi; Executive Editor for Annals of Allergy, Asthma & Immunology; Editor for Medscape; Reviewer for UpToDate; Honoraria from American Board of Allergy and Immunology.

Acknowledgements

Ryland P Byrd Jr, MD Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, East Tennessee State University, James H Quillen College of Medicine; Medical Director of Respiratory Therapy, James H Quillen Veterans Affairs Medical Center

Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment