Inhaled treatment of COPD: a Delphi consensus statement

Figures & data

Table 1 Definition of levels of consensus

Perfect consensus	All respondents agree on an answer
Very good consensus	Median and 50% of respondents at one integera or 80% of respondents within one integer of the medianb
Good consensus	50% of respondents within one integer of the median or 80% of respondents within two integers of the median
Some consensus	50% of respondents within two integers of the median or 80% of respondents within three integers of the median
No consensus	All other cases

Notes: Adapted from Chest, 119, Baumann M, Strange C, Heffner J., Management of spontaneous pneumothorax an American College of Chest Physicians Delphi consensus statement, 590–602. Copyright (2001), with permission from Elsevier.⁷

a For example, median and 50% of respondents are both at 7 (integer = point on the Likert scale);

b For example, median is 7 and 80% of respondents are between 6 and 8.

Table 2 Central trends and degree of consensus reached after the second round

	Group	Q1	Median (Q2)	Q3	Consensus
1.1 Do you think it is useful to start therapy with long-acting bronchodilators in COPD patients with FEV1≥50%, in the absence of symptoms?
0= NO; 10= YES	BE	6	7	8	Good consensus
	EU	2	8	8	Good consensus
2.1 If a symptomatic COPD patient with FEV1≥50% is treated with one long-acting bronchodilator, what should be the first choice?
0= LABA; 10= LAMA	BE	5	7	8	Good consensus
	EU	5	8	10	Some consensus
2.2 What should be the first choice when treating a symptomatic COPD patient with FEV1≥50%? Single or dual bronchodilation?
0= LABA/LAMA; 10= LABA/LAMA	BE	2	4	5	Some consensus
	EU	1	2	2	Good consensus
2.3 When a COPD patient with FEV1≥50% remains symptomatic despite treatment with a single bronchodilator, a treatment with a combination of LABA/LAMA is the best choice
0= total disagreement; 10=complete agreement	BE	8	9	10	Very good consensus
	EU	10	10	10	Very good consensus
2.4 When a COPD patient with FEV1≥50% had one exacerbation (requiring treatment with oral corticosteroids and/or antibiotics, but no hospitalization) in the previous 12 months despite treatment with a LAMA, a combination of LABA/LAMA is the best choice
0= total disagreement; 10=complete agreement	BE	3	5	7	Some consensus
	EU	8	9	10	Very good consensus
2.5 When a COPD patient with FEV1≥50% had one exacerbation (requiring treatment with oral corticosteroids and/or antibiotics, but no hospitalization) in the previous 12 months despite treatment with a LABA, a combination of LABA/LAMA is the best choice
0= total disagreement; 10=complete agreement	BE	5	7	8	Good consensus
	EU	7	8	10	Good consensus
2.6 When a COPD patient with FEV1≥50% had one exacerbation (requiring treatment with oral corticosteroids and/or antibiotics, but no hospitalization) in the previous 12 months, an ICS should be added
0= total disagreement; 10= complete agreement	BE	2	3	4	Good consensus
	EU	0	2	3	Good consensus
3.1 COPD patient with FEV1<50%, but not symptomatic. What should be the first choice when treating this patient? (0 = total disagreement; 10= complete agreement)
a) SABA/SAMA	BE	1	2	5	Good consensus
	EU	0	0	0	Very good consensus
b) LABA	BE	3	6	7	Good consensus
	EU	1	1.5	4	Some consensus
c) LAMA	BE	5	7	8	Good consensus
	EU	7	8	10	Good consensus
d) LABA/ICS	BE	0	1	3	Good consensus
	EU	0	0.5	2	Good consensus
e) LABA/LAMA	BE	5	6	8	Good consensus
	EU	5	5	6	Very good consensus
f) LABA/LAMA/ICS	BE	0	1	2	Very good consensus
	EU	0	0	3	Very good consensus
4.1 What should be the first choice when treating a symptomatic COPD patient, with FEV1<50%, but no exacerbations in the previous 12 months? (0= total disagreement; 10 = complete agreement)
a) LAMA	BE	5	6	8	Some consensus
	EU	0	5	10	No consensus
b) LABA/ICS	BE	1	2	4	Good consensus
	EU	0	0.5	3	Good consensus
c) LABA/LAMA	BE	7	8	9	Very good consensus
	EU	8	9	10	Very good consensus
d) LABA/LAMA/ICS	BE	1	2	3	Good consensus
	EU	0	2	5	Some consensus
4.2 If the same patient, with FEV1<50%, but no exacerbations in the previous 12 months remains symptomatic after initial treatment with a LAMA, what should be the most appropriate treatment? (0 = total disagreement; 10 = complete agreement)
a) LABA	BE	1	2	2	Good consensus
	EU	0	0.5	2	Good consensus
b) LABA/ICS	BE	1	1	3	Good consensus
	EU	0	0.5	1	Very good consensus
c) LABA/LAMA	BE	9	9	10	Very good consensus
	EU	10	10	10	Very good consensus
d) LABA/LAMA/ICS	BE	1	1	3	Good consensus
	EU	0	2	5	Some consensus
4.3 If the same patient, with FEV1<50%, but no exacerbations in the previous 12 months remains symptomatic after initial treatment with a LABA, what should be the most appropriate treatment? (0 = total disagreement; 10 = complete agreement)
a) LAMA	BE	3	4	5	Good consensus
	EU	0	0.5	4	Good consensus
b) LABA/ICS	BE	1	1	3	Good consensus
	EU	0	0.5	2	Good consensus
c) LABA/LAMA	BE	8	9	10	Very good consensus
	EU	10	10	10	Very good consensus
d) LABA/LAMA/ICS	BE	1	2	3	Good consensus
	EU	0	1.5	4	Some consensus
4.4 If a symptomatic COPD patient has an FEV1<50% but only one exacerbation (requiring treatment with oral corticosteroids and/or antibiotics, but no hospitalization) in the previous 12 months, what should be the first-choice treatment? (0 = total disagreement; 10 = complete agreement)
a) LAMA	BE	4	5	7	Good consensus
	EU	2	7.5	10	No consensus
b) LABA/ICS	BE	1	2	4	Good consensus
	EU	0	0.5	2	Good consensus
c) LABA/LAMA	BE	8	9	9	Very good consensus
	EU	8	9	10	Very good consensus
d) LABA/LAMA/ICS	BE	2	3	5	Good consensus
	EU	0	0.5	4	Good consensus
4.5 If a COPD patient has an FEV1<50% and two exacerbations (requiring treatment with oral corticosteroids and/or antibiotics) or one hospitalization for an exacerbation in the previous 12 months, what should be the first-choice treatment? (0 = total disagreement; 10 = complete agreement)
a) LAMA	BE	2	3	5	Good consensus
	EU	0	0	3	Very good consensus
b) LABA/ICS	BE	4	6	8	Some consensus
	EU	5	6	8	Good consensus
c) LABA/LAMA	BE	4	5	7	Good consensus
	EU	6	8	8	Good consensus
d) LABA/LAMA/ICS	BE	8	9	9	Good consensus
	EU	6	8	8	Good consensus
4.6 An ICS should always be added to the treatment if a COPD patient had two or more exacerbations (requiring treatment with oral corticosteroids and/or antibiotics, but no hospitalization) in the previous 12 months
(0= total disagreement; 10= complete agreement)	BE	6	7	8	Good consensus
	EU	5	6.5	8	Some consensus
4.7 An ICS should always be added to the treatment if a COPD patient had an exacerbation requiring a hospitalization in the previous 12 months
(0= total disagreement; 10= complete agreement)	BE	5	6	6	Good consensus
	EU	5	6	8	Good consensus

Abbreviations: BE, Belgium pneumologists (n=31); COPD, chronic obstructive pulmonary disease; EU, European experts (n=10); FEV₁, forced expiratory volume in 1 second; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; Q1, first quartile; Q2, second quartile or median; Q3, third quartile.

Figure 1 Overview of expert’s consensus on first-choice treatment for COPD patients.

Notes: This figure gives a schematic overview of experts consensus on first-choice treatment for COPD patients with FEV₁≥50% (A) and FEV₁<50% (B). *The preference for a LAMA or a LABA was not investigated for patients with FEV₁<50% who are not symptomatic. **According to the Belgian consensus, switch to LABA/LAMA is only needed if patients have one exacerbation (requiring treatment with oral corticosteroids and/or antibiotics), despite treatment with a LABA, and not despite treatment with LAMA. ***Belgian consensus was only reached for LABA/LAMA/ICS; European consensus was reached for both LABA/LAMA/ICS and LABA/LAMA.¹ Moderate exacerbation = exacerbations requiring treatment with oral corticosteroids and/or antibiotics in the previous 12 months. ²≥2 moderate exacerbations or 1 severe exacerbation =≥2 exacerbations (requiring treatment with oral corticosteroids and/or antibiotics) or 1 hospitalization for an exacerbation in the previous 12 months.
Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist.

BaumannMStrangeCHeffnerJManagement of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statementChest2001119259060211171742

 PubMed Web of Science ®Google Scholar

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 Google Scholar

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