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

6 November 2007 | Volume 147 Issue 9 | Pages 639-653

Background: 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.

Purpose: To evaluate the effectiveness of COPD management strategies.

Data Sources: English-language publications in MEDLINE and the Cochrane Library through March 2007.

Study Selection: Randomized, controlled trials (RCTs) and previous systematic reviews of inhaled therapies, pulmonary rehabilitation, disease management, and supplemental oxygen in adults with COPD.

Data Extraction: Participant, study, and intervention characteristics; exacerbations; deaths; respiratory health status; exercise capacity; hospitalizations; and adverse effects.

Data Synthesis: Eight meta-analyses and 42 RCTs examined inhaled therapies: short-acting anticholinergics (n = 7), long-acting anticholinergics (n = 10), long-acting ß₂-agonists (n = 22), corticosteroids (n = 14), dual D₂ dopamine receptor–ß₂-agonist (n = 3), or short-acting ß₂-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 ß₂-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 ß₂-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.

Limitations: 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.

Conclusion: 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.

Author and Article Information

From the Minnesota Agency for Healthcare Research and Quality Evidence-based Practice Center, Minneapolis Veterans Affairs Medical Center, and University of Minnesota, Minneapolis, Minnesota.

Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the AHRQ or the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank Indy Rutks, who assisted in the literature search and creation of some figures.

Grant Support: Prepared by the Minnesota AHRQ Evidence-based Practice Center, Minneapolis, Minnesota, under AHRQ contract no. 290-02-0009 and a contract with the American College of Physicians.

Potential Financial Conflicts of Interest: Consultancies: D. Niewoehner (Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Sanofi Aventis, Schering-Plough, Adams Respiratory Therapeutics). Honoraria: D. Niewoehner (Pfizer Inc., Boehringer Ingelheim). Grants received: D. Niewoehner (Boehringer Ingelheim, GlaxoSmithKline).

Requests for Single Reprints: Timothy J. Wilt, MD, MPH, Veterans Affairs Medical Center (111-0), Minneapolis, MN 55417; e-mail, tim.wilt{at}med.va.gov.

Current Author Addresses: Dr. Wilt and Mr. MacDonald: University of Minnesota School of Medicine, Center for Chronic Disease Outcomes Research (111-0), Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417.

Dr. Niewoehner: University of Minnesota School of Medicine, Pulmonary Section (111A), Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417.

Dr. Kane: Clinical Outcomes Research Center, School of Public Health, Health Policy and Management, University of Minnesota, Minneapolis, MN 55455.

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