Dr David Bellamy, GP, Bournemouth, and a BTS member

Since publication of the British Thoracic Society (BTS) Guid-lines on Chronic Obstructive Pulmonary Disease in 1997 there have been new developments in a number of therapeutic areas.

The BTS is updating its guidelines. The revised version should be available towards the end of 2002. In the past few months, publication of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and a Consensus Statement on the management of aspects of COPD from the RCP in Edinburgh have brought a welcome current perspective of evidence-based management of COPD.

COPD affects at least 1-2% of the UK population, increasing to 7% in the over-65s; 30 000 people die annually from the disease. Worldwide it is likely to become the fifth most common cause of chronic disability by 2020.

The GOLD guidelines were written by experts from around the world, with the aim of increasing awareness of COPD and its management to both clinicians and policy makers.

COPD should be considered in any patient with:

  • a chronic cough
  • chronic sputum production
  • syspnoea that is persistent, progressive (usually slowly), worse on exercise and worse with respiratory infections
  • plus a history of exposure to risk factors for COPD such as tobacco smoke or occupational dusts.

GOLD emphasises that spirometry should be used to confirm the diagnosis. Airflow obstruction is defined as a post-bronchodilator FEV1 <80% predicted and a FEV1/FVC <70%.

Classification of COPD severity in GOLD differs in many respects from the BTS guidelines, and in parts seems overcomplicated for primary care use. However, the 'Stage 0 – At Risk' category (Table 1) is an excellent addition that helps GPs to identify and concentrate on early disease.

Table 1: Classification of COPD severity

Stage Characteristics
0 At Risk

Normal spirometry
Chronic symptoms – cough, sputum production

1 Mild COPD FEV1/FVC <70%: FEV1 >80% predicted
With or without chronic cough or sputum
2 Moderate COPD

FEV1/FVC <70%
FEV1 between 30% and 80% predicted
With or without chronic symptoms of dyspnoea,
cough, or sputum production

3 Severe COPD

FEV1/FVC <70%
FEV1 <30% predicted or FEV1 <50% predicted
plus respiratory failure or signs of cardiac failure

Therapeutically, smoking cessation remains the single most important means of preventing the disease and its progression. Management has been helped by greater use of nicotine replacement therapy and bupropion.

Bronchodilators remain the cornerstone of symptomatic therapy but there is now more evidence that long-acting beta-agonists have a useful role in improving both dyspnoea and health status.

Inhaled corticosteroid use has been clarified by four major trials, and both GOLD and the Edinburgh Consensus have agreed the following:

  • Inhaled steroids do not affect the rate of decline of FEV1
  • Long-term inhaled steroids are applicable only for more severe, symptomatic patients (FEV1 <50% predicted) who have regular exacerbations, where they may reduce exacerbations and slow decline in health status
  • Optimum dose, delivery system and the merits of different products are unknown
  • Chronic use of oral steroids is not recommended.

Both documents emphasise the proven value of regular exercise and rehabilitation, and both are very relevant to primary care.

  • The GOLD guidelines are available on the GOLD website at www.goldcopd.com The Consensus Statement is available in full on the Royal College of Physicians of Edinburgh website at www.rcpe.ac.uk

Guidelines in Practice, June 2001, Volume 4(6)
© 2001 MGP Ltd
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