COPD guidelines: still room for improvement in practice


By Mardi Chapman

19 Sep 2022

There’s new evidence to back up existing recommendations regarding the management of COPD but it’s putting the fundamentals into practice that still needs attention.

Speaking to the limbic about the 2022 update of the COPD-X guidelines, first author Associate Professor Eli Dabscheck said there was good quality evidence now for doing what was done five years ago but without much evidence.

“So there is evidence for triple inhaled therapy in patients with frequent exacerbations. That’s now well established,” he said.

“And there were some concepts that were emerging five years ago that have now had level one evidence emerge, such as prophylactic macrolides for patients with frequent exacerbations that are otherwise optimised and where there are no drug interactions.”

Associate Professor Dabscheck, from the Alfred Hospital, said the role of home bilevel ventilation in stable COPD with hypercapnia had also been confirmed with pooled data in the last few years showing a reduction in mortality.

Similarly, regarding lung volume reduction surgery, a meta-analysis has shown an improvement in lung function, six-minute walk and quality of life, which is however offset by a high risk of complications and 45-day mortality.

“So it’s not new information, but it’s been presented in very neat level one meta-analysis recently. So that remains a vexed question to the clinician because there is some risk with potential significant symptomatic and exercise benefits.”

He said there was concern about implementation of the fundamentals of COPD management – spirometry to confirm the diagnosis and pulmonary rehabilitation to improve quality of life, exercise capacity and reduce exacerbations.

“There are issues accessing spirometry… 20-30% of patients admitted with COPD don’t actually have evidence of COPD. So I think we could do the most fundamental things better and same with pulmonary rehab. We know it’s safe. We know it’s super effective. Yet, there’s limited access and limited referrals.”

In other areas requiring improvement, he said local and international data suggested overprescription of antibiotics, particularly IV antibiotics, and corticosteroids, particularly IV corticosteroids.

“There’s probably a lack of adherence to guidelines with regards to acute exacerbation care. That’s not uniquely Australian; that’s been described across the world.”

Associate Professor Dabscheck said the guidelines were a useful resource for all healthcare providers including nurses, specialists and GPs.

Solutions to some of the identified challenges in guideline implementation may be addressed in a Lung Foundation Australia blueprint strategy for COPD, expected to be launched later this year.

The updated guidelines were published in The MJA [link].

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