Management of Stable Chronic Obstructive Pulmonary Disease: A Systematic Review for a Clinical Practice Guideline

摘要

Chronic obstructive pulmonary disease (COPD) is a common and disabling condition in adults. Information about therapeutic effectiveness and adverse effects of common treatment options and how clinical and spirometric characteristics affect outcomes is not well known but is important for clinicians caring for patients with stable COPD. nnPurpose: To evaluate the effectiveness of COPD management strategies. nnData Sources: English-language publications in MEDLINE and the Cochrane Library through March 2007. nnStudy Selection: Randomized, controlled trials (RCTs) and previous systematic reviews of inhaled therapies, pulmonary rehabilitation, disease management, and supplemental oxygen in adults with COPD. nnData Extraction: Participant, study, and intervention characteristics; exacerbations; deaths; respiratory health status; exercise capacity; hospitalizations; and adverse effects. nnData Synthesis: Eight meta-analyses and 42 RCTs examined inhaled therapies: short-acting anticholinergics (n = 7), long-acting anticholinergics (n = 10), long-acting β2-agonists (n = 22), corticosteroids (n = 14), dual D2 dopamine receptor–β2-agonist (n = 3), or short-acting β2-agonist plus ipratropium (n = 3). Evidence for nonpharmacologic therapies included 3 reviews of 39 RCTs plus 6 additional RCTs of pulmonary rehabilitation, 2 reviews of 13 RCTs plus 2 additional RCTs of disease management, and 8 RCTs of oxygen. Overall, long-acting inhaled therapies, used alone or in combination, reduced exacerbations more than placebo by 13% to 25% and had similar effectiveness to each other. Average improvements in health status scores were less than what is considered to be clinically noticeable. Inhaled monotherapy did not reduce mortality rates. Inhaled corticosteroids plus long-acting β2-agonists reduced deaths in relative terms compared with placebo (relative risk, 0.82 [95% CI, 0.69 to 0.98]) and inhaled corticosteroids alone (relative risk, 0.79 [CI, 0.67 to 0.94]) but not compared with long-acting β2-agonists alone (relative risk, 0.82 [CI, 0.52 to 1.28]). Absolute reductions were 1% or less and were not statistically significant. Pulmonary rehabilitation improved health status and dyspnea but not walking distance. Neither disease management nor ambulatory oxygen improved measured outcomes. Supplemental oxygen reduced mortality rates among symptomatic patients with resting hypoxia (relative risk, 0.61 [CI, 0.46 to 0.82]). Insufficient evidence supports using spirometry to guide therapy. nnLimitations: Articles were limited to those in the English language. Treatment adherence, adverse effects, and effectiveness may differ among clinical settings. Short-acting inhalers for “rescue therapy” were not evaluated. nnConclusion: Long-acting inhaled therapies, supplemental oxygen, and pulmonary rehabilitation are beneficial in adults who have bothersome respiratory symptoms, especially dyspnea, and FEV1 less than 60% predicted. nnIn the United States, more than 5% of adults have symptomatic chronic obstructive pulmonary disease (COPD), which is a leading cause of morbidity and mortality (1, 2). Treatment options include inhaled pharmacologic therapy with short- or long-acting bronchodilators or corticosteroids, pulmonary rehabilitation, disease management, and supplemental oxygen (3). Long-acting inhaled bronchodilators and pulmonary rehabilitation have been recommended for patients with spirometrically detected obstruction, even without symptoms (3). Addition of inhaled corticosteroids to long-acting bronchodilators (combination therapy) has been recommended for individuals with repeated exacerbations and an FEV1 less than 50% predicted. Information about therapeutic effectiveness and adverse effects of common treatment options and how clinical and spirometric characteristics affect outcomes is not well known but is important for clinicians caring for patients with stable COPD. nnThis review updates a report prepared for the Agency for Healthcare Research and Quality (AHRQ) and serves as the background paper for an American College of Physician's Clinical Practice Guideline (4). It addresses the following questions: Which inhaled therapies are effective for treatment and maintenance of stable COPD? When should clinicians consider pulmonary rehabilitation and disease management? When should clinicians prescribe oxygen therapy? Should clinicians base treatment decisions on spirometric results, symptoms, or both? nnDetailed information on the use of spirometry for diagnosis and case finding is available in the original AHRQ report at http://www.ahrq.gov/clinic/tp/spirotp.htm. Spirometry for case finding and management would be useful if it identified individuals who were not clinically detected as candidates for COPD treatments, excluded individuals with false-positive clinical presentations for COPD, or independently identified thresholds to guide initiation or modification of therapies. Our previous report identified insufficient evidence to support these conditions.