Chronic Obstructive Pulmonary Disease (COPD) and Emphysema in Emergency Medicine Guidelines

GOLD general clinical practice guidelines

The 2018 the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines on COPD are summarized. ^{[8, 9]}

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.

GOLD classification

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 ^[10] :

• 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

GOLD patient grouping

The GOLD patient group-based management recommendations include the following ^[10] :

• 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)