The guidelines, published in the April 3 issue of the Annals of Internal Medicine and the April issue of CHEST, for the first time give doctors a list of what works -- and what doesn't -- for these devastating conditions.
Emphysema and chronic bronchitis -- known to doctors as chronic obstructive pulmonary disease or COPD -- make it very hard for a person to exhale. COPD usually begins with a morning cough and shortness of breath, and gradually gets worse -- much worse. It is the fourth-leading cause of death in the U.S. As many as nine out of 10 patients get COPD by smoking cigarettes.
COPD patients have recurring bouts of blocked air passages, extreme shortness of breath, coughing spells, and/or lung congestion with thick mucus. Doctors call these recurring bouts "exacerbations." Each bout takes its toll, significantly reducing a patient's life span and quality of life.
But doctors still don't know exactly what to tell patients who ask the big questions: What symptoms can I expect? What will my life be like? How long do I have before I have another relapse? How long do I have to live?
Vincenza T. Snow, MD, is senior medical associate for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), which developed the treatment guidelines together with the American College of Chest Physicians (ACCP). She is the lead author of the new guidelines.
"Our hope is that these guidelines will be widely read and that they will light a fire under researchers," Snow tells WebMD. "We support more studies that provide information patients can use."
Because the guidelines are based on existing research, they mostly apply to patients who are in the hospital -- even though 80% of COPD patients are treated in doctors' offices. Nevertheless, they make official several radical changes in treatment.
"I thing the biggest surprise is going to be the use of antibiotics," says Snow, who teaches at the Medical College of Pennsylvania in Philadelphia. "It was previously our impression that all acute exacerbations of COPD had to be treated with antibiotics. But the evidence shows that bacteria in the respiratory tract aren't playing much of a role, if any at all. The only time you see any benefit -- and it is a small one -- is in the most severe exacerbations. Hopefully, this means we won't give rise to antibiotic-resistant bugs in these patients who are treated over and over again."
Jan V. Hirschmann, MD, is professor of medicine at the University of Washington in Seattle and assistant chief of medicine at Seattle's Veterans Administration Medical Center. He did not help write the guidelines, but his research helped show that antibiotics don't help COPD patients.
The guidelines also would cut down on the amount of steroids a patient is given. Steroids commonly are given to people with COPD to improve the function of their lungs. The guidelines find no use at all for inhaled steroids and suggest that steroids taken orally or by injection should be taken for no more than two weeks. Steroids have a wide range of unwanted side effects -- and many doctors have routinely prescribed much longer courses of steroid treatment for their COPD patients.
Another change is in the use of bronchodilator inhalers.
"We doctors tend to hit these patients from all sides -- usually we give them two kinds of inhalers, a beta2 agonist [such as Proventil or Ventolin] and an anticholinergic [such as Atrovent]," Snow says. "Now we say start with the anticholinergics and then add beta2 agonists if more relief is needed."
The guidelines also advise against a category of bronchodilators known as methylxanthines, which already have been falling out of favor because of their high risk of dangerous side effects. And they say that mucus-dissolving drugs are no help at all.
So what can doctors do for hospitalized patients having severe COPD exacerbations? The guidelines recommend giving a short course of steroids as well as oxygen-enriched air through a mask that helps push air into the lungs.
This doesn't sound like much -- and the guidelines face this fact by calling for much more in-depth research into new treatments and better ways to take care of these severely ill patients.
Meanwhile, Snow has some advice for people who are still healthy: "The biggest message these guidelines have is that people should stop smoking."