Title: Management of Chronic Obstructive Pulmonary Disease in
Primary Care
|
Citation
|
|
Management of Chronic Obstructive
Pulmonary Disease. Washington, DC: VA/DoD Clinical Practice Guideline
Working Group, Veterans Health Administration, Department of Veterans
Affairs and Health Affairs, Department of Defense, August 1999. Office
of Quality and Performance publication 10Q-CPG/COPD-01.
|
Completion Date:
|
|
August 1999
|
Release Date:
|
|
April 2000
|
Source(s):
|
|
Washington (DC): The COPD Guideline
was developed by and for clinicians from the Department of Veterans
Affairs (VA) and the Department of Defense (DoD); 1999. Various Pages.
|
Adaptation:
|
|
The guideline was based in part on
the 1997 Clinical Practice Guideline for the Management of Persons
with Chronic Obstructive Pulmonary Disease or Asthma.
|
Guideline Status:
|
|
This is the current version of the
guideline. An update is targeted for late 2001.
|
Developer(s):
|
|
Veterans Health Administration (VHA),
Department of Veterans Affairs (VA)- Federal Government Agency [U.S.]
Department of Defense - Federal Government Agency [US]
|
Funding Source:
|
|
United States Government
|
Committee:
|
|
The Chronic Obstructive Pulmonary
Disease Workgroup
|
Group Composition:
|
|
The list
of contributors to this guideline includes nurses, respiratory
therapists, pulmonologists, intensivists, internal medicine and primary
care physicians, and experts in the field of guideline and algorithm
development.
|
Disease/Condition:
|
|
COPD
|
Category:
|
|
Diagnosis, Treatment, Management
|
Intended Users:
|
|
Clinician staff including Physicians;
Nurses; Nurse Practitioners; Physician Assistants; Respiratory Care
Practitioners
|
Target Population:
|
|
Any person with suspected or confirmed
COPD who is eligible for care in the VA or DoD health care delivery
system.
|
Contact Person(s):
|
|
VA:
Peter Almenoff, MD
National Program Director, Pulmonary/Critical Care
VISN 15
4801 Linwood Blvd, Bldg. 2
Kansas City, MO 64128
Phone: 816.861.4700
Email: peter.almenoff@med.va.gov
DoD:
John P. Mitchell, Lt. Col., MC, USAF
Consultant to Air Force Surgeon General
David Grant Medical Center
60 MDOS/SGOMP
101 Bodin Circle, Suite 1C508
Travis AFB, CA 94535-1800
Phone: (707) 423-5008
Email: john.mitchell@60mdg.travis.af.mil
|
GOALS/OBJECTIVES
- To describe the critical decision points in outpatient, emergency,
and inpatient management of chronic obstructive pulmonary disease
(COPD)
- To provide a clear and comprehensive guideline incorporating
current information and practices for practitioners throughout
the DoD and Veterans Health Administration systems.
- To improve local management of patients with COPD and improve
patient outcome
|
INTERVENTIONS
AND PRACTICES
The Guideline consists of a Core Module and 6 modules that cover
outpatient management:
- Acute Exacerbation (A1)
- Pharmacotherapy (A2)
- Long-Term Oxygen Therapy (A3)
- Preoperative Evaluation and Management (A4)
- Management of Air Travel (5)
- Insomnia (6)
In addition, 3 algorithms address inpatient management:
- Emergency Room and Hospital Ward (B1)
- Pharmacotherapy (B2)
- Oxygen Therapy (B3)
|
|
OUTCOMES CONSIDERED
- Change in pulmonary function (FEV1 - peak expiratory flow rate)
- Symptom control
|
MAJOR
RECOMMENDATIONS
This guideline was formatted as 9 algorithms, with annotations.
Presentation of the algorithms is intended to assist the clinician
in reviewing and identifying key points that are comprehensively
discussed in the guideline document.
|
CLINICAL
ALGORITHM ARE PROVIDED FOR:
Algorithms are provided for:
|
TYPE OF
EVIDENCE
The guideline is supported by the literature in a majority of areas,
with evidence-based tables and references throughout the document.
The evidence consists of key clinical randomized controlled trials
and longitudinal studies in the area of COPD. Where existing literature
is ambiguous or conflicting, or where scientific data are lacking
on an issue, recommendations are based on the expert panel's opinion
and clinical experience. The guideline contains a bibliography and
discussion of the evidence supporting each recommendation.
|
DESCRIPTION
OF METHODS TO COLLECT EVIDENCE
The algorithm and annotations are in part based on the COPD guideline
developed in 1997. Additional literature related to the population
being studied (adult) and the treatment setting (primary care) was
provided on an adhoc basis by Birch and Davis Associates, Inc., to
supplement the original search.
The Medical Subject Headings (MeSH) include: (Diseases; Respiratory
Tract Diseases; Lung Diseases; Lung Diseases - Obstructive, Atelectasis,
Bronchopulmonary Dysplasia; Asthma, Bronchitis, Pulmonary Emphysema).
Selection of articles was then based on key therapies in COPD, study
characteristics, and study design. In this search, "study characteristics"
are those of analytic studies, case-control studies, retrospective
studies, cohort studies, longitudinal studies, follow-up studies,
prospective studies, cross-sectional studies, clinical protocols,
controlled clinical trials, randomized clinical trials (RCT)s, intervention
studies, and sampling studies. Study design includes crossover studies,
double-blind studies, matched pair analysis, meta-analysis, random
allocation, reproducibility of results, and sample size.
|
METHODS
TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE
Evidence-based practice involves integrating clinical expertise
with the best available clinical evidence derived from systematic
research. The working group reviewed the articles for relevance
and graded the evidence using the rating scheme published in the
U.S. Preventive Services Task Force (U.S. PSTF) Guide to Clinical
Preventive Services, Second Edition (1996), displayed in Table
1. The experts themselves formulated Quality of Evidence (QE)
ratings after an orientation and tutorial on the evidence grading
process. Each reference was appraised for scientific merit, clinical
relevance, and applicability to the populations served by the
Federal health care system. The QE rating is based on experimental
design and overall quality. Randomized controlled trials (RCT)
received the highest ratings (QE=I), while other well-designed
studies received a lower score (QE=II-1, II-2, or II-3). The QE
ratings are based on the quality, consistency, reproducibility,
and relevance of the studies.
The Grading Scheme Used for the Guideline
|
Quality of Evidence (QE)
|
| |
Level
of Evidence
Grading = A |
Level
of Evidence
Grading = B |
Level
of Evidence
Grading = C |
| Primary Evidence |
Randomized clinical trials |
Well-designed clinical studies |
Panel consensus |
| Secondary Evidence |
Other clinical
studies |
Clinical studies
related to topic but not in this clinical population |
Clinical studies
related to
topic but not in this clinical population
|
| |
|
Strength of Recommendation (SR)
|
| Grade |
Description |
| I |
Usually indicated, always acceptable,
and considered useful and effective. |
| IIa |
Acceptable, of uncertain effectiveness,
and may be controversial. Weight of evidence in favor of usefulness/effectiveness. |
| IIb |
Acceptable, of uncertain effectiveness,
and may be controversial. Not well established by evidence,
can be helpful and probably not harmful. |
|
REVIEW
METHODS
Peer Review
|
QUALIFYING
STATEMENTS
Clinical practice guidelines, which are increasingly being used in
health care, are seen by many as a potential solution to inefficiency
and inappropriate variations in care. Guidelines should be evidenced-based
as well as based upon explicit criteria to ensure consensus regarding
their internal validity. However, it must be remembered that the use
of guidelines must always be in the context of a health care provider's
clinical judgment in the care of a particular patient. For that reason,
the guidelines may be viewed as an educational tool analogous to textbooks
and journals, but in a more user-friendly format.
|
GUIDELINE
AVAILABILITY
Electronic copies available from:
The Office of Quality and Performance web site.
Print copies available from:
The Office of Quality and Performance (10Q)
Veterans Health Administration, Department of Veterans Affairs
810 Vermont, NW
Washington, DC 20420 |
|
Copy Statement: No copyright restrictions apply
|
Click to return to the home page of COPD-CPG
