Original Title: Guides et normes: Maladie pulmonaire obstructive chronique : repérage, diagnostic, usage optimal des médicaments et des dispositifs d’inhalation, et prise en charge globale

Authors' objectives: Chronic obstructive pulmonary disease (COPD) is characterized by expiratory airflow limitation causing persistent, progressive respiratory symptoms. The prevalence of COPD has been increasing over the past two decades. Given the challenges in recognizing this relatively underdiagnosed disease, together with the array of treatments and inhalation devices available to prescribers, the choice of which can influence the user's adherence to their medication, INESSS was asked to draft recommendations and develop an optimal use guide on the treatment of COPD to support front-line health professionals.

Authors' results and conclusions: RESULTS: From the analysis of the gathered data and the iterative process with the advisory committee’s members, the following key findings and messages were identified as necessary for enhancing practice and ultimately the care and service experience of people with COPD. (#1 RISK FACTORS ): Current or past smoking is the main risk factor for COPD. Although seldom mentioned in clinical practice guidelines, any other regular smoke inhalation habit deserves special attention, such as cannabis inhalation. Furthermore, current or past prolonged exposure to particulate matter or gases, such as second-hand tobacco smoke, cooking or heating biomass, occupational chemicals, are also major factors, especially in women and immigrants. Other factors related to genetics (e.g., alpha1-antitrypsin deficiency) or medical history (e.g., a history of asthma at a young age, prematurity, respiratory diseases at a young age) may also contribute to the development of this disease. (#2 CLINICAL PRESENTATION ): Although these symptoms are not exclusive, the presence of progressive and persistent dyspnea, chronic cough or chronic bronchial secretions points to the need, in a person 40 years of age or older who has at least one risk factor, to consider COPD. Dyspnea is the most common symptom, although it may sometimes go unrecognized because of lifestyle changes made to avoid shortness of breath. (#3 DIAGNOSTIC APPROACH): Spirometry, during a stable period, is essential for making a diagnosis of COPD. For atypical presentations or in case of doubt, a consultation with a specialist in respirology may be necessary. Dyspnea is a symptom common to other chronic diseases that often share the same risk factors as COPD, such as heart failure. Additional discriminating tests are sometimes necessary for making a diagnosis of COPD, even though concurrent diagnoses are also common. (#4 FUNCTIONAL AND CLINICAL EVALUATION): Assessing the severity of bronchial obstruction is useful for monitoring the course of COPD in the event of a rapid clinical deterioration. Assessing the severity of the symptoms and the risk of acute exacerbations at diagnosis and regularly thereafter helps guide therapeutic decision-making. Lastly, determining the blood eosinophil count by means of a complete blood count could add value to the decision to prescribe an inhaled corticosteroid in combination with a long-acting bronchodilator to individuals at risk for acute exacerbations. Determining the blood eosinophil count is also useful, when discontinuing an inhaled corticosteroid, for evaluating the risk of increased acute exacerbation severity and frequency. (#5 TREATMENT PRINCIPLES): Long-acting bronchodilators are the mainstay of COPD treatment. They limit symptoms, improve exercise tolerance and quality of life, and reduce the risk of acute exacerbations. The use of an inhaled corticosteroid can be added to help reduce the frequency of acute exacerbations. However, unlike in asthma, its use as monotherapy in COPD should be avoided. The decision to use or not use an inhaled corticosteroid in combination is based on the history of asthma and other comorbidities, the frequency and severity of the acute exacerbations, the blood eosinophil count, and the previous episodes of pneumonia. If the response to the current therapy is not meeting the objectives despite adherence to it and despite the appropriate use of inhalation devices, escalation can be undertaken according to a decision algorithm. However, de-escalation of the therapy is not encouraged, unless the risks outweigh the benefits. (#6 CHOICE OF INHALATION DEVICE): The criteria for selecting an inhalation device suited to the user are seldom discussed in the clinical practice guidelines, but this choice is crucial, especially for ensuring treatment adherence. At the heart of the decision are the individual's respiratory, cognitive and physical abilities for ensuring proper handling and coordination, and their preferences, based on the different characteristics of the inhalation devices available in Québec. Cost and drug insurance coverage are among the factors that influence people's preferences. To these factors one might add the devices’ environmental footprint, although the current state of knowledge of this subject is still limited. To promote treatment adherence and minimize waste, it is desirable to limit the number of inhalation devices, ideally by prescribing a combination of treatments in a single device, where possible, or treatments that involve similar devices. (#7 MANAGEMENT): Key steps to limit symptoms and prevent acute exacerbations include smoking cessation, reducing or eliminating exposure to irritants (e.g., pollution, smoke or biomass), and vaccination against respiratory infections. These measures help maintain the individual’s quality of life and autonomy. Support and education are also key elements. In fact, teaching the inhalation technique is considered to be the cornerstone of treatment adherence. Lastly, beyond an ordinary prescription for medication to be taken in the event of an acute exacerbation, drawing up a written action plan together with the patient is not a uniform practice at the provincial level. Having this action plan can help guide the individual to recognize a change in symptoms and, if applicable, to take the appropriate steps before a severe exacerbation. CONCLUSION: Undiagnosed or poorly controlled COPD has significant repercussions on the individual’s quality of life and that of their family, and can also lead to an increased risk of acute exacerbations. If severe, these episodes have a significant impact on resource utilization in terms of repeated emergency room visits or even stays in hospital or intensive care. While not a substitute for clinical judgment, this work should assist in the early detection and diagnosis of the disease, promote the optimal choice and use of medications and inhalation devices, and, ultimately, improve the care experience of those affected. However, improving practice will hinge on the dissemination of the clinical tools linked to this report, adherence to these changes, and the uptake of the recommendations by the health professionals concerned.

Authors' recommendations: Upon completion of this project, and following an iterative process with the members of the advisory committee, in which scientific data, information and recommendations from the literature consulted, contextual information and the perspectives of various stakeholders consulted were triangulated, a series of recommendations were drawn up. These recommendations are at the heart of this report and are also incorporated into the clinical tools stemming from this project, which are intended primarily for front-line clinicians, namely: • An optimal use guide - COPD; • A decision support tool - inhalation device; • A quick reference sheet for patient. UPDATE: The advisability of updating the recommendations will be assessed in four years from the date of publication on the basis of the advancement of the scientific data and changes in clinical practice, the listing of new drugs, or significant changes to the coverage criteria in the public

Authors' methods: A systematic search of the scientific literature was conducted, in collaboration with a scientific information specialist, in the PubMed, Embase, EBM Reviews and CINAHL databases, and the grey literature was manually searched by consulting, among others, the websites of learned societies specializing in the area of interest in this report. Document selection, extraction, and methodological quality assessment were carried out independently by two scientific professionals. The scientific evidence was assessed, and the contextual information gathered was analyzed by one professional and validated by another. To gather the stakeholders’ perspectives, an advisory committee consisting of clinicians from different specialties and areas of expertise, and a monitoring committee consisting of representatives from various Québec orders, federations and associations were created. In addition, people with COPD were consulted by means of a questionnaire. Lastly, the overall quality of this work, its acceptability and its applicability were assessed with the representatives on the monitoring committee, and with external reviewers specializing in the field of interest and future users who had not participated in the project.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/maladie-pulmonaire-obstructive-chronique.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/maladie-pulmonaire-obstructive-chronique.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)