Chronic obstructive pulmonary disease Management and Follow up.

This guideline offers evidence-based recommendations on the management of COPD. The recommendations are intended to provide healthcare professionals with practical guidance on diagnosis and treatment guidelines of COPD and improving health outcomes for people living with COPD.

1-   Risk factors Recommendations

·  1a. We recommend Smoking cessation interventions as the most important intervention to prevent worsening and reduces mortality in COPD patients, as smoking is the most important risk factor for COPD development (Strong recommendation)

2-   Diagnosis

·  2a. We recommend using pragmatic case-finding algorithm (annex 1,2) to enable accurate COPD diagnoses for most populations with a thorough history and examination for COPD as the first step to diagnosis. (Strong recommendation)

·  2b. We recommend using spirometry results showing post-bronchodilator FEV1/FVC ratio <0.7 for COPD diagnosis.  (annex 3) (Strong recommendation)

·  2c. We recommend regular comprehensive assessment of functional status and impact of COPD as validated assessment tools such as: COPD Assessment Test (CAT) and mMRC (Modified Medical Research Council) Dyspnea Scale to measure dyspnea. (annex  4) (Strong recommendation)

·  2d. In cases with a large increase in post-bronchodilator FEV1 (with greater confidence if increase is >15% and >400 mL) that suggests asthma or coexisting asthma and COPD, We recommend considering patient history, pattern of symptoms, and investigations like eosinophils level to confirm diagnosis of COPD. (Strong recommendation)

·  2e. We advise using a person-centered systematic approach rather than a single-disease approach based on the ‘4Ms’ for elderly patients with chronic non-communicable diseases: Mentation, Mobility, Medications, and Morbidities, to manage patients with COPD. (annex 5,6) (Conditional recommendation)

·  2f. We strongly recommend Regular assessment of COPD symptoms and exacerbation risk by Combined initial COPD assessment (ABE GOLD) (annex 7) (strong recommendation)     

3-   Treatment

A.   Pharmacological Treatment Recommendations (annex 11)

·      3Aa. We strongly recommend using a stepwise approach using initial therapy revised by management cycle then follow up treatment if needed to Optimize COPD treatment pharmacotherapy. (annex  8,9,10) (Strong recommendation)

·      3Ab: In COPD patients who complain of dyspnea or exercise intolerance, we strongly recommend LABA/LAMA combination therapy over LABA or LAMA monotherapy (strong recommendation).

·      3Ac: In COPD patients who complain of dyspnea or exercise intolerance despite dual therapy with LABA/LAMA, We strongly recommend use of triple therapy with ICS/LABA/LAMA over dual therapy with LABA/LAMA in those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization. (strong recommendation).

·      3Ad: In COPD patients who are receiving triple therapy (ICS/LABA/LAMA), we suggest withdrawing ICS if the patient has had no exacerbations in the past year. (conditional recommendation).

·      3Ae: In COPD patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, we suggest ICS as an additive therapy on a LABA+LAMA combination . (Strong recommendation).

·      3Af. We strongly recommend Regularly check inhaler technique and adherence.  (Strong recommendation)

·      3Ag. we suggest using long-term macrolide antibiotics in people with moderate to severe COPD and frequent exacerbations (Conditional recommendation)

·      3Ah.  We suggest considering biological therapy in COPD people with frequent exacerbations (annex  15) (Conditional recommendation)

B.   Nonpharmacological Treatment Recommendations

·                 3Ba. We strongly recommend non-pharmacological strategies such as pulmonary rehabilitation and regular exercise to anyone with COPD to improve quality of life, exercise capacity, and reduce COPD exacerbations. (annex  16) (Strong recommendation

·      3Bb. we suggest using Lung volume reduction (surgical and endobronchial) to enhance lung function, exercise capacity, and quality of life. (annex  17) (Conditional recommendation)

·      3Bc. we suggest encouraging vaccination to reduce risks associated with influenza, Streptococcus pneumoniae, respiratory syncytial virus (RSV), severe acute respiratory syndrome coronavirus (SARS-CoV2), pertussis, and varicella zoster (annex  18) (Conditional recommendation)

·      3Bd.  We strongly recommend using long-term oxygen therapy (>18 hours) for COPD patients with resting hypoxemia. (Strong recommendation)

·      3Be. We strongly recommend using long-term non-invasive ventilation in people with stable COPD and hypercapnia to reduce mortality and hospital admissions. (Strong recommendation)

·      3Bf. Patient self-management programs incorporating multicomponent interventions (such as education, exercise training and psychosocial support) can improve health outcomes, quality of life and decrease healthcare utilization (Good Practice Statement)

4-   Follow up and home care arrangements: (annex 19)

4a. Coordinate multidisciplinary support for patients who are receiving home management, implement systems for planned transfers of care to ensure patients receive continuous and coordinated primary care from their general practice or primary healthcare team. (Good Practice Statement)

4b.  Arrange follow-up visit within 1-4 weeks to

·      Evaluate ability to cope in his/her usual environment.

·      Review and ensure patients understand treatment regimen.

·      Re-assessment of inhaler techniques.

·      Re- assessment of need for long term oxygen.

·      Document the capacity to do physical activity and daily living. activities

·      Document symptoms: CAT or mMRC.

·      Determine status of comorbidities.

(Good Practice Statement)

4c. Arrange follow-up visit within 12-16 weeks to Measure FEV1.  (Good Practice Statement)