Do not do in COPD: consensus statement on overuse

Figures & data

Figure 1 Summary of the methodology used in the study, including the number of ideas identified, selection criteria, and procedure used to screen “do not do” recommendations in COPD.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 2 Description file for each “do not do” recommendation in COPD.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 1 Practices in diagnosis, therapy, and self-care determined to be ill-advised for COPD patients following a consensus conference

Group	“Do not do” recommendations	F		I		F × I
		Mean	Level of agreement	Mean	Level of agreement	Mean
Patients with stable COPD	Do not administer inhaled corticosteroids as routine treatment for patients with FEV1 >60% and <2 acute exacerbations in the previous year or in patients without an overlapping COPD–asthma phenotype.	8.6	0.10	8.3	0.10	72.2
	Do not neglect to perform spirometry as part of the diagnostic work-up in patients with a past history of smoking and symptoms of COPD.	8.3	0.21	8.3	0.11	68.9
	Do not assume that patients correctly administer inhaled medication in the absence of proper confirmation.	8.0	0.13	8.5	0.15	68.0
	Do not initiate treatment without previously confirming the diagnosis by spirometry.	8.0	0.24	8.4	0.17	67.2
	Do not change inhaled treatment without first assessing treatment compliance.	7.9	0.26	7.7	0.12	60.8
	Do not perform pulmonary function testing systematically at each follow-up visit if there is no change in symptoms, in the number of previous acute exacerbations, or in treatment.	7.6	0.27	7.7	0.25	58.5
Patients with exacerbated COPD	Do not prescribe antibiotic treatment in all cases of acute exacerbation.	8.8	0.19	8.2	0.15	72.2
	Do not prescribe nebulized medication in all cases of acute exacerbation.	8.1	0.21	7.8	0.19	63.2
	Do not administer high-flow oxygen if oxygen saturation is >90% or if PaO2 is ≥60 mmHg.	7.0	0.20	9.0	0.12	63.0
	Do not prescribe home oxygen therapy following an acute exacerbation if PaO2 is ≥60 mmHg.	7.5	0.31	8.2	0.19	61.5
	Do not prescribe corticosteroid therapy for periods of >14 days or with progressive reduction in therapy.	8.2	0.16	7.4	0.22	61.2
	Do not perform spirometry in patients with known COPD.	6.9	0.38	8.4	0.13	58.0
Self-care in patients with COPD	Do not discontinue taking inhaled medication because an improvement in clinical symptoms has taken place.	7.7	0.21	9.0	0.07	69.3
	Do not use the inhaler incorrectly.	7.2	0.18	9.0	0.12	64.8
	Do not stop walking due to feelings of dyspnea.	7.9	0.15	7.8	0.22	61.6
	Do not take unprescribed treatments.	7.1	0.10	8.5	0.16	60.3

Notes: F, frequency of occurrence of the discouraged practice; I, degree of inappropriateness of the discouraged practice; F × I, frequency of occurrence of the practice multiplied by its degree of inappropriateness. Mean, average value from 0 to 10. This is estimated using the coefficient of variation obtained when each recommendation is evaluated. Lower coefficients of variation indicate greater degrees of homogeneity of assessments and thus greater degrees of consensus.

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; PaO₂, partial pressure of oxygen.

Table 2 Level of evidence and grade of recommendation as indicated in SIGN²⁴ including bases that justify the “do not do” recommendations

Group	Name of the practice with level of evidence and grade of recommendation	Bases that justify the recommendation (References)
Patients with stable COPD	Do not administer inhaled corticosteroids as routine treatment in patients with FEV1 >60% and <2 acute exacerbations in the previous year or in patients without an overlapping COPD-asthma phenotype. Level of evidence: 1++ Grade of Recommendation: A	GOLD^Citation13 Miravitlles et al^Citation32 Vogelmeier et al^Citation33 Zhong et al^Citation34 Price et al^Citation35 Vestbo et al^Citation36 Suissa et al^Citation37 Wedzicha et al^Citation38
	Do not neglect to perform spirometry as part of the diagnostic work-up in patients with a past history of smoking and symptoms of COPD. Level of evidence: 2++ Grade of Recommendation: B	Zwar et al^Citation39 Dirven et al^Citation40 GOLD^Citation13 EPOC^Citation41
	Do not assume that patients correctly administer inhaled medication in the absence of proper confirmation. Level of evidence: 2+ Grade of Recommendation: C	Sriram and Percival^Citation42 Ingebrigtsen et al^Citation43 Plaza et al^Citation44 Vestbo et al^Citation45 Alexopoulos et al^Citation46 Wei et al^Citation47 Tommelein et al^Citation48 Leiva-Fernández et al^Citation49 Bryant et al^Citation50
	Do not initiate treatment without previously confirming the diagnosis by spirometry. Level of evidence: 2++ Grade of Recommendation: B	Fernández Villar et al^Citation51 Buffels et al^Citation52 Hardie et al^Citation53 Jones et al^Citation54 Miravitlles et al^Citation55 Miller and Levy^Citation56
	Do not change inhaled treatment without first assessing treatment compliance. Level of evidence: 2+ Grade of Recommendation: C	Sriram and Percival^Citation42 Ingebrigtsen et al^Citation43 Melani and Paleari^Citation57 Braido et al^Citation58 Plaza et al^Citation44
	Do not perform pulmonary function testing systematically at each follow-up visit if there is no change in symptoms, in the number of previous acute exacerbations, or in treatment. Level of evidence: 4 Grade of Recommendation: D	Kohansal et al^Citation59 Donaldson et al^Citation60 GOLD^Citation13 Miravitlles et al^Citation32 EPOC^Citation61 Peces-Barba et al^Citation62
Patients with exacerbated COPD	Do not prescribe antibiotic treatment in all cases of acute exacerbation. Level of evidence: 1+ Grade of Recommendation: A	Sapey and Stockley^Citation63 Vollenweider et al^Citation64 Soler et al^Citation65 Miravitlles et al^Citation66 Boixeda et al^Citation67
	Do not prescribe nebulized medication in all cases of acute exacerbation. Level of evidence: 1++ Grade of Recommendation: A	Turner et al^Citation68 Brocklebank et al^Citation69 Dolovich et al^Citation70 Tashkin et al^Citation71
	Do not administer high- flow oxygen if oxygen saturation is >90% or if PaO2 is ≥60 mmHg. Level of evidence: 1++ Grade of Recommendation: A	Royal United Hospital Bath^Citation72 Driscoll et al^Citation73 Rachmale et al^Citation74 Miravitlles et al^Citation75 American Thoracic Society^Citation76 BTS^Citation77 Barberá et al^Citation78 Siafakas et al^Citation79 Pauwels et al^Citation80
	Do not prescribe home oxygen therapy following an acute exacerbation if PaO2 is ≥60 mmHg. Level of evidence: 1++ Grade of Recommendation: A	Cranston et al^Citation81 Nocturnal Oxygen Therapy Trial^Citation82 Medical Research Council Working Party^Citation83 Croxton and Bailey^Citation84 Güell Rous^Citation85 Peces-Barba et al^Citation62 Task Force of GesEPOC^Citation86 GOLD^Citation13 Qaseem et al^Citation87 Stoller et al^Citation88
	Do not prescribe corticosteroid therapy for periods of >14 days or with progressive reduction in therapy. Level of evidence: 1++ Grade of Recommendation: A	Leuppi et al^Citation89 McCrory et al^Citation90 Singh et al^Citation91 Walters et al^Citation92 Albert et al^Citation93 Task Force of GesEPOC^Citation86 Miravitlles et al^Citation32 GOLD^Citation13
	Do not perform spirometry in patients with known COPD. Level of evidence: 4 Grade of Recommendation: D	GOLD^Citation13 Task Force of GesEPOC^Citation86 COPD^Citation94
Self-care in patients with COPD	Do not discontinue taking inhaled medication because an improvement in clinical symptoms has taken place. Level of evidence: 1++ Grade of Recommendation: A	Ingebrigtsen et al^Citation43 Restrepo et al^Citation95 Ágh et al^Citation96 Van Boven et al^Citation97 Vestbo et al^Citation45
	Do not use the inhaler incorrectly. Level of evidence: 4 Grade of Recommendation: D	Cecere et al^Citation98 Vestbo et al^Citation45 SEPAR^Citation99 Plaza et al^Citation100 Calle Rubio et al^Citation101 Giner et al^Citation102 Sánchez^Citation103 Plaza et al^Citation44
	Do not stop walking due to feelings of dyspnea. Level of evidence: 2++ Grade of Recommendation: B	Álvarez-Gutiérrez et al^Citation104 García-Río^Citation105 GOLD^Citation13 Miravitlles et al^Citation32 Watz et al^Citation106
	Do not take unprescribed treatments. Level of evidence: 1++ Grade of Recommendation: A	GOLD^Citation13 Miravitlles et al^Citation32 Tashkin et al^Citation107 Vogelmeier et al^Citation108 Wise et al^Citation109 Decramer et al^Citation110 Celli et al^Citation111 Vestbo et al^Citation45

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; PaO₂, partial pressure of oxygen.

Table 3 Indicators used for assessment of “do not do” recommendations

Group	“Do not do” recommendations	Indicators
Patients with stable COPD	Do not administer inhaled corticosteroids as routine treatment for patients with FEV1 >60% and <2 acute exacerbations in the previous year or in patients without an overlapping COPD-asthma phenotype.	Number of patients with FEV1 >60% and with 0–1 acute exacerbations in the previous year and who receive inhaled corticosteroids as routine treatment (exclusive of patients with an overlapping COPD–asthma phenotype)/number of patients diagnosed with COPD who receive inhaled corticosteroids as routine treatment.
	Do not neglect to perform spirometry as part of the diagnostic work-up in patients with a past history of smoking and symptoms of COPD.	Number of patients who are smokers (at least 10 pack-years) over age 35 presenting respiratory symptoms and who have not received spirometry/number of patients who are smokers and have a diagnosis of COPD.
	Do not assume that patients correctly administer inhaled medication in the absence of proper confirmation.	Number of patients for whom the patient chart contains references to inhaled therapy (direct observation or as obtained through compliance questionnaires such as Test of Adherence to Inhalers [TAI])/total number of patients with COPD and inhaled treatment.
	Do not initiate treatment without previously confirming the diagnosis by spirometry.	Number of COPD patients undergoing treatment with inhalants/number of patients with spirometry-confirmed COPD diagnosis.
	Do not change inhaled treatment without first assessing treatment compliance.	Number of patients with a justified change in inhaled treatment appearing in their patient chart/number of patients in whom treatment has changed over the previous year.
	Do not perform pulmonary function testing systematically at each follow-up visit if there is no change in symptoms, in the number of previous acute exacerbations, or in treatment.	Number of spirometry studies performed in a given period of time/number of follow-up consultations undertaken in the same period.
Patients with exacerbated COPD	Do not prescribe antibiotic treatment in all cases of acute exacerbation.	Number of COPD patients with acute exacerbations treated with antibiotic therapy/number of COPD patients with acute exacerbations.
	Do not prescribe nebulized medication in all cases of acute exacerbation.	Number of COPD patients with acute exacerbations treated with nebulized medication/number of COPD patients with acute exacerbations.
	Do not administer high-flow oxygen if oxygen saturation is >90% or if PaO2 is ≥60 mmHg.	Number of patients receiving high-flow oxygen therapy who have oxygen saturation >90% or PaO2 ≥60 mmHg/number of patients undergoing this therapy throughout a given period of time.
	Do not prescribe home oxygen therapy following an acute exacerbation if PaO2 is ≥60 mmHg.	Number of patients prescribed home oxygen therapy following an acute exacerbation with PaO2 ≥60 mmHg/total number of cases prescribed home oxygen therapy following an acute exacerbation.
	Do not prescribe corticosteroid therapy for periods of >14 days or with progressive reduction in therapy.	Number of patients prescribed with long-term (>14 days) treatment with corticosteroids/total number of patients undergoing corticosteroid therapy.
		Number of patients prescribed to receive progressive reduction of corticosteroid therapy/total number of patients undergoing corticosteroid therapy.
	Do not perform spirometry in patients with known COPD.	Number of spirometry studies performed during acute exacerbations in patients with previously known COPD/number of COPD patients with acute exacerbations.
Self-care in patients with COPD	Do not discontinue taking inhaled medication because an improvement in clinical symptoms has taken place.	Number of consultations assessing degree of compliance and proper therapy administration/total number of consultations.
	Do not use the inhaler incorrectly.	Number of consultations assessing errors in dosage or inhaler use/total number of consultations.
	Do not stop walking due to feelings of dyspnea.	Daily/weekly/monthly log of distance walked compared to the results of the individual 6-minute walking test. Improved score on surveys and rating scales for physical activity or activities of daily living.
	Do not take unprescribed treatments.	Total number of COPD patients receiving unprescribed therapy/total number of patients with COPD.

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; PaO₂, partial pressure of oxygen.

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