International Journal of Noncommunicable Diseases

EDITORIAL
Year
: 2022  |  Volume : 7  |  Issue : 2  |  Page : 53--54

The 2022 update of the Global Initiative for Chronic Obstructive Lung Disease guidelines for chronic obstructive pulmonary disease: Implications for primary health care


Ashutosh Nath Aggarwal 
 Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Ashutosh Nath Aggarwal
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India




How to cite this article:
Aggarwal AN. The 2022 update of the Global Initiative for Chronic Obstructive Lung Disease guidelines for chronic obstructive pulmonary disease: Implications for primary health care.Int J Non-Commun Dis 2022;7:53-54


How to cite this URL:
Aggarwal AN. The 2022 update of the Global Initiative for Chronic Obstructive Lung Disease guidelines for chronic obstructive pulmonary disease: Implications for primary health care. Int J Non-Commun Dis [serial online] 2022 [cited 2022 Oct 5 ];7:53-54
Available from: https://www.ijncd.org/text.asp?2022/7/2/53/351746


Full Text



The scientific committee of the Global Initiative for Chronic Obstructive Lung Disease has periodically updated their global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). These guidelines provide an evidence-based framework for evaluating, treating, and preventing COPD at all levels of health care. The most recent version for the year 2022 was recently released.[1] Although this update broadly reiterates the principles outlined in the previous reports, there are a few subtle but important changes. Health-care workers and health managers need to be aware of these modifications, especially in the primary care setting where the vast majority of COPD patients are likely to be evaluated and managed.

The 2022 update provides additional new data on COPD prevalence and its economic burden, as well as on the association of COPD with exposure to high doses of pesticides and ambient particulate matter.[1] This information should prove useful to health managers in implementing population-based chronic respiratory disease (CRD) programmes in their countries and regions. New definitions have been provided for four distinct entities: (a) early COPD, (b) mild COPD, (c) COPD in young people, and (d) Pre-COPD. Early COPD is defined by the presence of biological mechanisms underlying COPD, and should not be considered equivalent to mild COPD, which is a clinical entity that relates more to the severity of airflow obstruction and may or may progress further with time. COPD in young people is more of an operational subset of patients in the 20–50-year age group, in many of whom COPD may have early-life origins. Pre-COPD refers to people of any age having respiratory symptoms in the absence of airflow limitation, some of whom may not progress to airway obstruction over time. This last group is particularly interesting and is likely to be the focus of major research in future. As of now, such grouping may not have any impact on CRD services at the primary health-care level but may assume importance as more data emerges, especially in terms of preventive activities and personalized therapy.

There are no major alterations in the strategies for diagnosis and initial assessment of COPD, except that fatigue has been included and defined as a new symptom.[1] New evidence has however been cited regarding the potential benefit of maintenance pharmacotherapy in reducing the rate of deterioration in pulmonary function. This is based on a recent systematic review of nine randomized clinical trials including 33,051 COPD patients, that reported a reduction in the decline of forced expiratory volume 1 by 5 mL/year in patients receiving active treatment as compared to those receiving placebo.[2] This should provide extra impetus to our efforts in recognizing COPD patients early, and initiating treatment as soon as feasible, for improving clinical outcomes. In addition, further data have been provided in relation to blood eosinophil counts. Blood eosinophilia has been proposed as a biomarker to identify frequently exacerbating patients likely to benefit from the addition of inhaled corticosteroids. The current guidelines suggest that blood eosinophil count may also serve as a prognostic marker for a decline in pulmonary function.[3] Till now, blood eosinophil counts are not routinely advised in primary care settings. Moreover, their threshold and utility are also not clear in tropical countries with a high community burden of parasitic infections. Still, one might need to consider this investigation in selected patients. New data also suggest that inhaled corticosteroids in higher, but not lower, doses may improve survival in comparison to bronchodilator therapy alone.[4] Again, these data may not radically shift treatment practices as of now, but certainly point to gradual refining of our understanding in tailoring treatment to specific patient needs.

No significant changes have been made to the recommendations on nonpharmacological treatment, which has always been a vital component of overall COPD management. Smoking cessation and structured pulmonary rehabilitation, both of which can be encouraged early in varying measures at primary health-care setups, may sometimes benefit the patient far more than drug therapy. The present update specifically outlines options for pulmonary rehabilitation in rural, remote, domiciliary, or other resource-limited settings.[1] For the first time, the document incorporates a section on telerehabilitation, which is safe and confers similar benefits as center-based pulmonary rehabilitation.[1] These recommendations should prove useful in the primary care setting, especially during the ongoing COVID-19 pandemic when frequent interactions with patients may not be desirable.

The list of vaccines suggested for COPD patients has also been expanded. Till now, influenza and pneumococcal vaccinations were recommended. The current update adds (a) Tdap vaccination to protect against pertussis among those not vaccinated in adolescence, (b) Zoster vaccine for those aged 50 years or more, and (c) COVID-19 vaccination in line with prevalent national guidelines.[1] Although COVID-19 vaccination has been administered to a large proportion of the adult population having comorbidities (including COPD), the other vaccines are still not part of the universal immunization protocols for adults in most developing countries. The actual clinical utility of these vaccines, as well as the cost–benefit advantage, is also not clear. More data are needed from resource-constrained settings before these recommendations can be successfully implemented.

Another new recommendation in the current update is regarding the annual screening for lung cancer using low-dose computed tomography scan in patients with smoking-related COPD.[1] Lung cancer screening has always remained a controversial issue, and although recent data suggests its utility among smokers, the high cost and limited infrastructure at the primary care level are major roadblocks. It is unlikely that routine and universal lung cancer screening can be implemented in the near future.

References

1Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2022 Report). Available from: https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf. [Last accessed on 2022 Jun 22].
2Celli BR, Anderson JA, Cowans NJ, Crim C, Hartley BF, Martinez FJ, et al. Pharmacotherapy and lung function decline in patients with chronic obstructive pulmonary disease. A systematic review. Am J Respir Crit Care Med 2021;203:689-98.
3Tan WC, Bourbeau J, Nadeau G, Wang W, Barnes N, Landis SH, et al. High eosinophil counts predict decline in FEV1: Results from the CanCOLD study. Eur Respir J 2021;57:2000838.
4Martinez FJ, Rabe KF, Ferguson GT, Wedzicha JA, Singh D, Wang C, et al. reduced all-cause mortality in the ETHOS trial of budesonide/glycopyrrolate/formoterol for chronic obstructive pulmonary disease. A randomized, double-blind, multicenter, parallel-group study. Am J Respir Crit Care Med 2021;203:553-64.