Management of stable chronic obstructive pulmonary disease: a systematic review for a clinical practice guideline.
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.


OBJECTIVE
To evaluate the effectiveness of COPD management strategies.


METHODS
English-language publications in MEDLINE and the Cochrane Library through March 2007.


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


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


RESULTS
Eight meta-analyses and 42 RCTs examined inhaled therapies: short-acting anticholinergics (n = 7), long-acting anticholinergics (n = 10), long-acting beta2-agonists (n = 22), corticosteroids (n = 14), dual D2 dopamine receptor-beta2-agonist (n = 3), or short-acting beta2-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 beta2-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 beta2-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.


CONCLUSIONS
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.


CONCLUSIONS
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.
Wilt
Timothy J
TJ
Minnesota Agency for Healthcare Research and Quality Evidence-based Practice Center, Minneapolis Veterans Affairs Medical Center, and University of Minnesota, Minneapolis, Minnesota 55417, USA. tim.wilt@med.va.gov
Niewoehner
Dennis
D
MacDonald
Roderick
R
Kane
Robert L
RL
D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000009:adverse effects / Q000627:therapeutic use; D058666:Adrenergic beta-2 Receptor Agonists; D018680:Cholinergic Antagonists / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D010102:Oxygen Inhalation Therapy; D011379:Prognosis; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D016032:Randomized Controlled Trials as Topic; D018343:Receptors, Adrenergic, beta-2 / Q000627:therapeutic use; D013147:Spirometry
D000305:Adrenal Cortex Hormones; D058666:Adrenergic beta-2 Receptor Agonists; D018680:Cholinergic Antagonists; D018343:Receptors, Adrenergic, beta-2