Scope and Purpose
This guideline was mainly intended to update the existing 2007 ACP guidelines that address the diagnosis and management of stable chronic obstructive pulmonary disease (COPD). The update would provide new scientific evidence on how to diagnose and manage stable COPD. The four joint organizations, namely; ACP, ATS, ACCP, and ERS, who updated the guidelines jointly, rephrased and provided clarification of the 2007 recommended guidelines. Besides, the updates were aimed at providing recommendations on when a stable COPD patient should be considered for pharmacotherapy. Therefore, the authors provided an elaborate clarification on how to select a particular monotherapy that is most effective among various available therapies. The recommendations give reaffirmation concerning when to use spirometry, as well as provide a more detailed recommendation concerning pulmonary rehabilitation (Qaseem et al., 2011).
The primary target for the procedures included health professionals, particularly clinicians handling patients affected by COPD. The recipients of the services outlined in the guidelines are the patients suspected to be suffering from stable COPD or those diagnosed with COPD. In terms of their scope, the recommendations do not address all the areas of COPD patient management. The strategies are limited to pulmonary rehabilitation, pharmacological management, and oxygen therapy (Qaseem et al., 2011).
Stakeholders’ Involvement
The success of developing the recommendations can be highly attributed to the developers and authors of the guidelines. The panel that developed the strategies was comprised of representatives from each of the organizations that participated. The balanced representation made it possible for the final recommendations to be adopted as the formal position of the four collaborating organizations. All the participating organizations were represented by medical doctors, most of who had attained Ph.D. qualifications in their fields of study. Also, some of the organizations presented research scientists who had attained at least a Master’s of Science (MSC) qualification in their areas of study (Qaseem et al., 2011).
The panelists communicated through a well-established e-mailing and conference call system to ensure inclusiveness, particularly the opinions of the primary target. The panelists reached a consensus through communication. If a disagreement occurred, then the discussion would be used to resolve the dispute and the final recommendation would arrive through a unanimous vote. All the elements of the guidelines were developed based on the input from all the panelists. Any evidence reviews identified by any of the panelists were presented to the entire panel for review and comment; such evidence than provided the basis for guideline development. There was no provision for the special involvement of the target population as any information provided was treated with equal weight by the panelists (Qaseem et al., 2011).
Rigor of Development
The panelists developed three main questions that formed the baseline for their literature search. The questions included: What is the significance of physical examination and patient history in the diagnosis of COPD? What is the significance of spirometry in the diagnosis of asymptomatic adults with an elevated risk of developing COPD? What are the available effective COPD management strategies? The literature that was considered focused on the significance of spirometry in the diagnosis and screening of COPD, comparative effectiveness, the efficacy of management strategies, pulmonary rehabilitation strategies, and combination therapies (Qaseem et al., 2011).
The strength of such evidence was that it was possible to develop guidelines that were highly specific to the problem of study. The specificity of the scope and questions that guided the literature search and the specificity of selection criteria for the included evidence helped in addressing the study question comprehensively (van Wetering, Hoogendoorn, Mol, Rutten-van Mo¨lken, & Schools, 2010; Vogelmeier et al., 2011). The limitation of such evidence was that the guidelines developed would not address other areas of the study question, which would also contribute to the ineffective management of the disease (Pesek & Lockey, 2011). The authors considered the health benefits, side effects, and associated risk factors associated with each recommendation. Based on this analysis, it was clear that the recommendations provided were solely based on the retrieved and analyzed evidence. As a quality measure, the guidelines were first reviewed by Dr. Vincenza Snow before publication (Qaseem et al., 2011). The major limitation of this update was that there was no laid mechanism for the review of the recommendations.
Clarity and Presentation
Seven recommendations were made from the retrieved evidence. It was strongly recommended that spirometry should be used for the diagnosis of airflow obstruction, particularly in patients presenting with respiratory symptoms. However, spirometry should be applied as a screening test in persons without respiratory symptoms (MininËśo, Xu & Kochanek, 2010). It was weakly recommended that inhaled bronchodilators can be used as a treatment strategy for patients with stable COPD, who present with 60-80% FEV1 and respiratory symptoms. It was strongly recommended that inhaled bronchodilators could be used for patients with FEV1 and respiratory symptoms. The panelists recommended strongly that clinicians should prescribe monotherapy using either long-acting inhaled-agonists or anticholinergics in COPD symptomatic patients who have a predicted FEV1 of 60%. Moreover, the selected monotherapy ought to be based on the preference of the patient, the associated drug side effects, and the cost.
It was also weakly recommended that clinicians have the liberty to administer inhaled therapies in combination for stable COPD symptomatic patients who have a predicted FEV1 of 60%. Pulmonary rehabilitation was weakly recommended for exercise-limited or symptomatic patients with a predicted FEV1 of 50%. The panel recommended that clinicians should prescribe continuous oxygen therapy as a remedy for COPD patients with severe resting hypoxia (Michele, Pinheiro, & Iyasu, 2010). These proposals were presented and could be identified with ease, both in the abstract of the guidelines, as well as the article proper. The ease of retrieval was enhanced by listing each of the recommendations individually.
Applicability
The possible main facilitator of the recommendations is the fact that they were agreed upon by all panelists accrued from multiple and dynamic organizations that focused on the same area of study. The major setback may be the financial implications and the lack of political willpower of the member states to adopt the strategies as a basis for COPD treatment.
To apply these guidelines, the authors advised that the guidelines should be treated only as suggestions that do not apply to all clinical situations and patients. As such, the recommendations should not be used as a replacement for clinicians’ judgment. The panelists also stated clearly that the guidelines expire after five years or when other updates are published before the expiry of the five years. The major limitation of these recommendations concerning applicability was the fact that the authors did not provide any possible resource implications. Furthermore, the authors did not provide any mechanism for auditing and monitoring the application of the recommended strategies. These limitations affect the scope of the guidelines.
Editorial Independence
The funding of this update was done solely by the operating budget of the ACP; therefore, there was a possibility of bias due to fear of funding withdrawal if the views of ACP were not given more weight. However, the situation was avoided by ensuring the views of the panelists were considered equal and the discussions were used to resolve any dispute. Furthermore, any conflict of interest was declared, analyzed, and resolved before the onset of the discussions. As such, all the potential sources of bias were avoided.
The views of the funding body were kept from influencing the outcome by ensuring that all the recommendations were agreed unanimously. Moreover, the funding body did not have a primary interest in the guidelines, as it was simply a body of professionals focusing on cardiovascular disease and not a pharmaceutical company. Any competing interests from the panelists or the participating organizations were documented and published on a website for easy access.
Summary
The guidelines sufficiently provided an update on the 2007 ACP guidelines as expected. As stated in their objectives, the authors demonstrated the value of physical examination and patient history in the diagnosis of airflow obstruction. The authors also showed the significance of spirometry in screening and diagnosing COPD. Finally, the panelists effectively described the recommended strategies for the management of COPD, including the degree of recommendation. The study question was, therefore, answered comprehensively. The method employed in the literature search was also ideal, as it contributed to the success of the study.
The guidelines are highly applicable to the entire health profession. Though the primary target of the recommendations is clinicians, nurses, particularly Advanced Practice Nurse (APN), can contribute to the application of the recommendations. As an APN, I will provide a model of care for others by embracing and applying evidence-based recommendations. I will also participate in screening and diagnosing COPD as recommended by the guidelines. I will provide patient education to empower the patients to make informed decisions concerning the choice of a treatment strategy for COPD. With such information, the clinical outcome will be improved.
References
Michele, T. M., Pinheiro, S., & Iyasu, S. (2010). The safety of tiotropium—the FDA’s conclusions. New England Journal of Medicine, 363, 1097-1097.
MininËśo, A. M., Xu, J. Q., & Kochanek, K. (2010). Deaths: preliminary data for 2008. National Vital Statistics Reports, 59(2), 1-60. Web.
Pesek, R., & Lockey, R. (2011). Vaccination of adults with asthma and COPD. Allergy, 66(1), 25-31.
Qaseem, A., Wilt, T. J., Weinberger, S. E., Hanania, N. A., Criner, D., Molen, T…, Shekelle, P. (2011). Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Annals of Internal Medicine, 155(3), 179-191. Web.
van Wetering, C. R., Hoogendoorn, M., Mol, S. J., Rutten-van Mo¨lken, M. P., & Schols, A. M. (2010). Short- and long-term efficacy of a community-based COPD management programme in less advanced COPD: a randomised controlled trial. Thorax, 65(1), 7-13. Web.
Vogelmeier, C., Hederer, B., Glaab, T., Schmidt, H., Rutten-van Mo¨lken, M. P., & Beeh, K. M.,… Fabbri, L. M. (2011). POET-COPD Investigators. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. New England Journal of Medicine, 364, 1093-1103. Web.