VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

Department of Veterans Affairs

Department of Defense

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management.

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendations.

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor.

Version 3.0 2014

December 2014 Page 1 of 94

Prepared by:

The Management of Chronic Obstructive Pulmonary Disease Working Group

With support from:

The Office of Quality, Safety and Value, VA, Washington, DC &

Office of Evidence Based Practice, US Army Medical Command

Version 3.0 2014

Based on evidence reviewed through February 2014

December 2014 Page 2 of 94

Table of Contents Table of Contents ...............................................................................................................................3

Background .......................................................................................................................................5

Chronic Obstructive Pulmonary Disease (COPD) ...................................................................................... 5

Pathology .................................................................................................................................................. 5

Etiology ..................................................................................................................................................... 5

Epidemiology and Impact ......................................................................................................................... 5

Progress in COPD ...................................................................................................................................... 6

About this Clinical Practice Guideline (CPG) ........................................................................................6

Scope of this CPG ...................................................................................................................................... 7

Population ............................................................................................................................................. 7

Interventions and Management Methods ............................................................................................ 7

Methods .................................................................................................................................................... 7

Reconciling 2007 CPG Recommendations ................................................................................................ 9

Conflict of Interest .................................................................................................................................... 9

Patient-Centered Care ............................................................................................................................ 10

Implementation ...................................................................................................................................... 10

Limitations .............................................................................................................................................. 10

Guideline Working Group ................................................................................................................. 11

Algorithms ....................................................................................................................................... 12

Algorithm Format .................................................................................................................................... 12

Algorithm A: Management of COPD in Primary Care ............................................................................. 13

Algorithm B: Management of Acute Exacerbations of COPD ................................................................. 14

Algorithm C: Management of COPD in the Hospital or Emergency Department ................................... 15

Recommendations ........................................................................................................................... 16

Diagnosis and Assessment of COPD .................................................................................................. 22

Management of Patients with COPD in the Outpatient Setting .......................................................... 26

Pharmacologic Therapy .......................................................................................................................... 26

Oxygen Therapy ...................................................................................................................................... 36

Exercise Hypoxemia ............................................................................................................................ 37

Air Travel ............................................................................................................................................. 37

Nocturnal Hypoxemia ......................................................................................................................... 38

December 2014 Page 3 of 94

Stable Hypercapnea ................................................................................................................................ 38

Supported Self-Management .................................................................................................................. 38

Telehealth ............................................................................................................................................... 39

Pulmonary Rehabilitation ....................................................................................................................... 39

Breathing Exercise ................................................................................................................................... 40

Nutrition Referral .................................................................................................................................... 40

Lung Volume Reduction Surgery and Lung Transplantation .................................................................. 41

Management of Patients in Acute Exacerbation of COPD .................................................................. 41

Management of Patients with COPD in the Hospital or Emergency Department ................................ 45

Future Research ............................................................................................................................... 47

Appendix A: Evidence Review Methodology ..................................................................................... 50

Formulating Evidence Questions ............................................................................................................ 50

Population ........................................................................................................................................... 50

Interventions ....................................................................................................................................... 50

Outcomes ............................................................................................................................................ 51

Conducting the Systematic Review ......................................................................................................... 53

Convening the Face-to-Face Meeting ..................................................................................................... 64

Grading Recommendations .................................................................................................................... 64

Drafting and Submitting the Final CPG ................................................................................................... 67

Appendix B: Evidence Table.............................................................................................................. 68

A