The COPD-X Plan: Australian And New Zealand Guidelines For The .

The COPD-X Plan:Australian and New Zealand Guidelinesfor the management ofChronic Obstructive Pulmonary Disease2021Current COPD Guidelines CommitteeProfessor Ian Yang, MBBS(Hons), PhD, FRACP, Grad Dip Clin Epid, FAPSR, FThorSoc,Thoracic Physician, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD (CoChair)Associate Professor Eli Dabscheck, MBBS, M Clin Epi, FRACP, Staff Specialist, Department ofRespiratory Medicine, The Alfred Hospital, Melbourne, VIC (Co-Chair)Dr Johnson George, BPharm, MPharm, PhD, Grad Cert Higher Education, Senior Lecturer,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VICDr Sue Jenkins, OAM, GradDipPhys, PhD, Physiotherapy Department, Sir Charles GairdnerHospital; School of Physiotherapy and Exercise Science, Curtin University; Institute for RespiratoryHealth, Perth, WAProfessor Christine McDonald, AM, FAHMS, MBBS(Hons), PhD, FRACP, FThorSoc, Director,Department of Respiratory and Sleep Medicine, The Austin Hospital, Melbourne, VICProfessor Vanessa McDonald DipHlthScien (Nurs), BNurs, PhD, FThorSoc, Professor ofChronic Disease and Academic Clinical Nurse Consultant, The University of Newcastle and JohnHunter Hospital, Newcastle, NSWProfessor Brian Smith, MBBS, Dip Clin Ep & Biostats, PhD, FRACP, Staff Specialist, BendigoHospital (VIC)Professor Nick Zwar, MBBS, MPH, PhD, FRACGP, Executive Dean, Faculty of Health Sciences andMedicine, Bond University (QLD)Lung Foundation Australia Secretariat SupportMs Mearon O’Brien, BPubH, Guidelines Manager, Lung Foundation Australia, Brisbane; AdjunctFellow, The University of Queensland, BrisbaneMs Kelcie Herrmann, BSpPath, General Manager Clinical Programs, Research and Innovation, LungFoundation Australia, BrisbaneWebsite Updates: Ms Mearon O’Brien, Guidelines Manager, Lung Foundation Australia, BrisbaneLiterature Searches: Literature search strategy provided by Megan Neumann, Client ServicesLibrarian at The Prince Charles Hospital, BrisbaneThese guidelines have been developed and revised by Lung Foundation Australia and theThoracic Society of Australia and New Zealand as part of a national COPD program.Correspondence: Lung Foundation Australia, PO Box 1949, Milton QLD 4064. copdx@lungfoundation.com.auThe COPD-X Plan – Version 2 63 (February 2021)1

Past Committee MembersPast ChairpersonsProfessor Michael Abramson, MBBS, BMedSc(Hons), PhD, FRACP, FAFPHM, Deputy Head,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (Principal Author)(Chair: 2004-2014)Professor Alan J Crockett, PSM, MPH, PhD, FANZSRS Professor of Clinical Respiratory Physiology,Division of Health Sciences, University of South Australia; Emeritus Fellow, Discipline of GeneralPractice, School of Population Health, University of Adelaide, Adelaide, SA (Chair: 2003-2004)Past Committee MembersProfessor Michael Abramson, MBBS, BMedSc(Hons), PhD, FRACP, FAFPHM, Deputy Head,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (Principal Author)(Chair: 2004-2014)Professor Alan J Crockett, PSM, MPH, PhD, FANZSRS Professor of Clinical Respiratory Physiology,Division of Health Sciences, University of South Australia; Emeritus Fellow, Discipline of GeneralPractice, School of Population Health, University of Adelaide, Adelaide, SA (Chair: 2003-2004)Associate Professor David K McKenzie, PhD, FRACP, Director of Cardiac and Respiratory Services,South East Sydney Local Health District and Head of Department, Respiratory and Sleep Medicine,Prince of Wales Hospital, Randwick, NSW (Principal author)Professor Peter A Frith, MBBS, FRACP, Professor in Respiratory Medicine, Flinders University andRepatriation General Hospital, Daw Park, SAProfessor Norbert Berend, MD, FRACP, Director, Woolcock Institute of Medical Research, RoyalPrince Alfred Hospital, Sydney, NSWMs Jenny Bergin, BPharm, MPS, Pharmacist Consultant, Pharmacy Guild of AustraliaDr Jonathan G W Burdon, MD, FRACP, Respiratory Physician, Department of Respiratory Medicine,St Vincent’s Hospital, Melbourne, VICAssociate Professor Stephen Cala, PhD, FRACP, Respiratory Physician, and Head, RespiratoryInvestigation Unit, Gosford Hospital and University of Newcastle, NSWProfessor Peter Gibson, MBBS, FRACP, Respiratory Specialist, John Hunter Hospital, Newcastle,NSWProfessor Nicholas Glasgow, MBChB, MD, FRNZGP, FRACGP, FAChPM, Dean, Medicine andHealth Sciences, College of Medicine, Biology and Environment, the Australian National University,Canberra, ACTProfessor Christine Jenkins, AM, MD, FRACP, Thoracic Physician, Concord Hospital, Sydney, NSWMr Ross Lisle, Consumer Representative, Toowoomba, QLDProfessor Guy Marks, Australian Centre for Asthma Management, Sydney, NSWDr Jitendra Parikh, MD, MPM, Royal Australian College of General PractitionersProfessor Harold H Rea, MD, FRACP, Academic Head of Medicine, South Auckland Clinical School,University of Auckland, New ZealandMrs Marilyn Robinson, RN, Respiratory/Asthma Educator, Townsville Community Health Service,Townsville Health Services District, QLDProfessor Julian A Smith, MS, FRACS, Professor, and Head, Department of Surgery, MonashUniversity, and Head, Cardiothoracic Surgery Unit, Monash Medical Centre, Clayton, VICAssociate Professor Greg. Snell, MBBS, FRACP, Respiratory and Lung Transplant Physician,Department of Respiratory Medicine, Alfred Hospital, Melbourne, VICAssociate Professor Robin D Taylor, MD, FRCPC, Department of Respiratory Medicine, DunedinSchool of Medicine, University of Otago, Dunedin, NZProfessor G Ian Town, DM, FRACP, Dean, Christchurch School of Medicine and Health Sciences,New ZealandMr Marcus Weidinger, Pharmaceutical Society of AustraliaDr Richard Wood-Baker, MBBS, DM, FRACGP, FRCP, MRCP[I], MEd, Director of CardiorespiratoryMedicine, Royal Hobart Hospital; Honorary Fellow, Menzies Research Institute, Hobart, TASThe COPD-X Plan – Version 2 63 (February 2021)2

Other contributors – Past and PresentAssociate Professor Jenny Alison, PhysiotherapistDr Guy Bannink, Staff Specialist Palliative MedicineMs Kate Baumwol, Senior Speech PathologistMr Paul Cafarella, PsychologistAssociate Professor Donald Campbell, Respiratory PhysicianMs Nola Cecins, PhysiotherapistDr Belinda Cochrane, Staff Specialist Respiratory and Sleep PhysicianDr Karen Detering, Respiratory PhysicianDr Tanja Effing, Respiratory Scientist/ EpidemiologistDr Michael Epton, Respiratory PhysicianDr Nichola Gale, Senior Lecturer: Physiotherapy/ ResearcherProfessor Charles Gilks, International Public Health SpecialistDr David Hart, Respiratory PhysicianAssociate Professor Peter Holmes, Respiratory PhysicianAssociate Professor Kylie Hill, PhysiotherapistDr Alice YM Jones, Physiotherapist; Honorary Professor; Adjunct ProfessorMs Kim Jones, Research AssistantDr Kirk Kee, Respiratory PhysicianDr Jun (JK) Khoo, Specialist Respiratory and Sleep Disorders PhysicianMs Leona Knapman, Exercise PhysiologistAssociate Professor John Kolbe, Respiratory PhysicianMs Zoe Kopsaftis, Research OfficerDr Tom Kotsimbos, Respiratory PhysicianDr Nicole Livermore, Senior Clinical PsychologistMs Maria Loder, Respiratory NurseDr James Markos, Respiratory PhysicianDr R Doug McEvoy, Respiratory and Sleep PhysicianDr Renae McNamara, PhysiotherapistDr Ruth McKenzie, General PractitionerAssociate Professor Lucy Morgan, Respiratory PhysicianDr Shirley PC Ngai, Physiotherapist; Assistant ProfessorDr Cristino C Oliveira, PhysiotherapistDr Matthew Peters, Respiratory PhysicianProfessor Philippa Poole, Senior LecturerProfessor Robert Pierce, Respiratory Physician (deceased)Associate Professor Robyn Richmond, ResearcherDr Jonathan Rutland, Respiratory PhysicianProfessor Paul Seale, Respiratory PhysicianAssociate Professor Natasha Smallwood, Respiratory PhysicianMs Laura Smith, PhD StudentMs Sheree Smith, Respiratory NurseProfessor Greg Snell, Lung Transplant PhysicianMs Gillian Syres, Research FellowMr Pieter Walker, PsychologistConjoint Professor Peter Wark, Senior Staff SpecialistProfessor Trevor Williams, Respiratory & Sleep Medicine PhysicianMr Jamie Wood, Senior Physiotherapist – Cystic FibrosisProf Lisa Wood, Nutritional BiochemistAssociate Professor Iven Young, Respiratory PhysicianMs Juliet L Brown, BA(Hons), MLib, Former COPD Project and Guidelines Manager, LungFoundation Australia, BrisbaneThe COPD-X Plan – Version 2 63 (February 2021)3

Table of ContentsCurrent COPD Guidelines Committee .1Past Committee Members .2Other contributors – Past and Present .3Foreword . 10The origins of the COPD-X guidelines . 11COPD-X Methodology . 12Support for COPD-X . 12Levels of evidence . 13Box 1: Levels of evidence . 13Key Recommendations of the COPD-X Guidelines. 14C: Case finding and confirm diagnosis . 17Figure 1: COPD Phenotypes . 18C1. Aetiology and natural history . 19Figure 2: Time-course of chronic obstructive pulmonary disease (COPD)(Fletcher 1977) . 20Figure 3: Risk of occupational exposure for COPD from selected studies . 21Box 2: Risk Factors for COPD (Global Initiative for Chronic Obstructive LungDisease (GOLD) 2018) . 22C1.1 Natural history . 23C2. Diagnosis . 24C2.1 History . 24Box 3: Modified Medical Research Council (mMRC) Dyspnoea Scale for gradingthe severity of breathlessness during daily activities . 25C2.2 Physical examination . 25C2.3 Spirometry . 26Figure 4: Comparison of flow-volume curves for spirometry . 27C2.4 Flow volume tests . 28C2.5 COPD case finding . 28C3. Assessing the severity of COPD . 29Box 4: Classification of severity of chronic obstructive pulmonary disease(COPD) . 30C4. Assessing acute response to bronchodilators . 30Box 5: Assessment of acute response to inhaled beta-agonist at diagnosis . 31C4.1 Confirm or exclude asthma . 31C5. Specialist referral . 32Box 6: Indication for referral to specialist respiratory outpatient services . 32C5.1 Complex lung function tests . 32C5.2 Exercise testing . 33C5.3 Sleep studies . 33The COPD-X Plan – Version 2 63 (February 2021)4

C5.4 Chest x-rays . 33C5.5 High resolution computed tomography . 33C5.6 Ventilation and perfusion scans . 33C5.7 Transcutaneous oxygen saturation . 34C5.8 Arterial blood gas measurement . 34C5.9 Sputum examination . 34C5.10 Haematology and biochemistry . 34C5.11 Electrocardiography and echocardiography . 35C5.12 Trials of Therapy . 35O: Optimise function . 36O1. Inhaled bronchodilators . 37O1.1 Short-acting bronchodilators . 37O1.1.1 Short-acting beta2-agonists (SABA) . 37O1.1.2 Short-acting muscarinic antagonists (SAMA) . 38O1.1.3 Short-acting bronchodilator combinations . 38O1.2 Long-acting bronchodilators . 39O1.2.1 Long-acting muscarinic antagonists (LAMA) . 39O1.2.2 Long-acting beta2-agonists (LABA) . 40O1.2.3 Long-acting bronchodilator combinations (LAMA/LABA) . 41O1.3 Assessment of response and continuation of bronchodilator therapy . 43O2. Oral bronchodilators . 43O2.1 Methylxanthines . 43O2.2 Phosphodiesterase type-4 inhibitors . 44O3. Corticosteroids . 44O3.1 Oral corticosteroids . 44O3.2 Inhaled corticosteroids (ICS) . 44O3.3 Inhaled corticosteroids (ICS) versus long-acting beta2-agonists (LABA) . 47O4. Inhaled combination therapy . 47O4.1 Inhaled corticosteroids and long-acting beta2-agonists in combination(ICS/LABA) . 47O4.2 Inhaled corticosteroids and long-acting beta2-agonists and long-actingantimuscarinics in combination (ICS/LABA/LAMA) . 50O4.2.1 Eosinophil count and inhaled corticosteroids . 54O4.3 Biologic therapies . 56O5. Inhaler technique and adherence . 56O5.1 Inhaler technique . 56O5.2 Inhaler adherence. 58O6. Non-pharmacological interventions . 59O6.1 Pulmonary rehabilitation . 60O6.2 Exercise training . 62The COPD-X Plan – Version 2 63 (February 2021)5