Bronhopneumopatia obstructivă cronică

Objectives

The national clinical protocol establishes a comprehensive framework for preventing, screening, diagnosing, classifying, treating and following up chronic obstructive pulmonary disease (COPD), including stable disease, exacerbations, complications and patient education.[1][2]It provides the basis for institution-specific protocols that retain the national structure while adapting delivery to local service capacity.[3]

• Increase COPD screening among people aged over 40 who are registered with family doctors.[3][4]
• Improve early identification of people at increased risk through assessment of smoking, occupational and household exposures, air pollution, and selected genetic susceptibility, including alpha-1 antitrypsin deficiency.[5][6][7]
• Confirm airflow obstruction and assess severity, symptoms, exacerbation risk, comorbidities and prognosis in order to develop individual treatment algorithms.[8][9]
• Reduce exposure to tobacco smoke, workplace dusts and toxic gases, household pollutants and ambient air pollution as primary prevention priorities.[10][5][11]
• Strengthen secondary prevention through smoking cessation, patient and family education, annual influenza vaccination, pneumococcal vaccination, risk-factor reduction and maintenance treatment during remission.[10][6][12]
• Improve symptoms, exercise tolerance, pulmonary function, health status and quality of life while preventing disease progression, exacerbations, complications, hospitalisations and mortality.[13][14][15]
• Expand access to physician-indicated medicinal and non-medicinal maintenance treatment, documented counselling on modifiable risk factors, pulmonary rehabilitation, nutritional support and physical activity.[3][12][16]
• Reduce complications among patients supervised by family doctors, including acute pulmonary heart disease and pneumothorax, and reduce deaths attributable to COPD.[3][16][17]

Implementation

Delivery is organised across primary medical care, specialist outpatient consultation and hospital services, linking family doctors, phthisiopneumologists, diagnostic institutions, therapy departments, pneumology departments and intensive-care services according to clinical severity and required capacity.[1][3][18]The Ministry of Health, Labour and Social Protection approves the protocol and may recommend additional institutional monitoring forms; professional development and endorsement involved the Chiril Draganiuc Institute of Phthisiopneumology, the State University of Medicine and Pharmacy Nicolae Testemițanu, the National Health Insurance Company and the Medicines and Medical Devices Agency.[1][3][19]

• Screen high-risk groups annually in primary care through history-taking, smoking-index assessment and peak expiratory flow measurement, with targeted alpha-1 antitrypsin assessment for younger patients or those with a relevant family history.[20][6]
• Confirm diagnosis through clinical examination and spirometry, supplemented where indicated by pulse oximetry, laboratory tests, imaging, exercise testing, sputum examination, blood-gas analysis, electrocardiography, echocardiography, computed tomography, bronchoscopy and specialist functional investigations.[20][18][21][22]
• Use combined clinical assessment of lung function, symptom burden measured with the modified Medical Research Council dyspnoea scale or COPD Assessment Test, exacerbation history, smoking exposure and comorbidities to stratify patients and select treatment.[8][23][9]
• Provide pharmacological treatment according to disease group, severity, treatment response and exacerbation risk, using short- or long-acting bronchodilators, combination inhalers, selected inhaled corticosteroid combinations and, for specified patients, triple therapy or other adjunctive medicines.[24][13][25][15]
• Prioritise inhaled therapy and select inhaler devices according to the patient’s ability and consent, while teaching correct use, supporting adherence and explaining treatment benefits, adverse effects and warning signs.[26][25]
• Deliver non-pharmacological care through smoking-cessation counselling at every visit, reduction of occupational and household pollutants, vaccination, pulmonary rehabilitation, nutrition support, breathing exercises and individually adapted physical activity.[11][26][27][28]
• Manage mild and moderate exacerbations principally in ambulatory care with intensified bronchodilator treatment and, where indicated, antibiotics and oral corticosteroids; manage severe exacerbations in hospital with oxygen, intensified medicines, treatment of associated conditions and ventilatory support where required.[29][30][31][32]
• Apply hospital and intensive-care admission criteria based on worsening symptoms, respiratory failure, treatment response, comorbidities, home support, oxygenation, blood gases, mental status and haemodynamic stability.[23][33][30]
• Use non-invasive ventilation as the preferred initial ventilatory method for acute respiratory failure when indicated, escalating to invasive ventilation where non-invasive ventilation fails or specific severe clinical circumstances arise.[31][32]
• Support discharge through spirometry where required, restoration of maintenance bronchodilator treatment, review of inhaler technique and oxygen needs, written clinical information, and recommendations shared with the family doctor and patient.[34][35]
• Equip primary, specialist and hospital services with trained clinical staff, peak-flow meters, pulse oximetry, spirometry, electrocardiography, radiology, bronchoscopy, laboratory and microbiological capacity, oxygen therapy, and the specified respiratory medicines.[36][37][38][39]
• Monitor implementation through percentage indicators covering screening among people over 40, adherence to prescribed maintenance treatment, documented education on modifiable risks, acute pulmonary heart disease, pneumothorax and COPD mortality among family-doctor-supervised patients.[4][16][17]
• Reassess patients after exacerbations and during continuing follow-up, including at 1–4 weeks and 12–16 weeks, through symptom scores, spirometry, inhaler technique, oxygen requirements, comorbidities, exercise capacity and BODE prognostic parameters.[29][35][40]
• Use standardised family-doctor consultation records and protocol-based audit forms to document repeated clinical assessment, investigations, treatment and compliance with required care processes.[41][42][43]

Monitoring & Evaluation

The protocol combines implementation monitoring, clinical follow-up, standardised documentation and audit tools for chronic obstructive pulmonary disease (COPD). Its explicit implementation indicators cover screening, maintenance treatment, patient education, complications and mortality among patients supervised by family doctors.[4][16][17]

• Measure screening coverage as the proportion of people aged over 40 registered with a family doctor who received COPD screening.[4]
• Measure maintenance-treatment coverage as the proportion of supervised patients with stable COPD who followed prescribed medicinal and non-medicinal treatment during the preceding 12 months.[4][16]
• Measure documented education as the proportion of registered patients receiving information on modifiable risk factors during the preceding six months.[16]
• Monitor complications through the proportions of family-doctor-supervised patients developing acute pulmonary heart disease or pneumothorax during the preceding year.[16][17]
• Monitor COPD mortality as the proportion of supervised COPD patients who died from the disease during the preceding 12 months.[17]

Clinical assessment supports monitoring at diagnosis, during stable disease, through exacerbations and after discharge. Spirometry confirms obstruction and is used for follow-up; symptom burden may be assessed with the modified Medical Research Council dyspnoea scale or COPD Assessment Test, while exacerbation history, comorbidities and hospital or intensive-care admission requirements inform risk assessment.[8][20][18]

• Monitor patients after an exacerbation at 1–4 weeks and again at 12–16 weeks, including after every hospital discharge.[29][35]
• Reassess treatment understanding, inhaler technique, symptoms, spirometry, comorbidities, physical activity and the ongoing need for long-term oxygen therapy at follow-up.[35][40]
• Assess prognosis using BODE index parameters and identify mortality risk factors, including severe respiratory impairment, rapid decline in forced expiratory volume in one second, low body mass index, prolonged smoking and advanced age.[35][40]
• Use pulse oximetry, blood-gas measurements, acid-base assessment, peak-flow measurement and spirometry to assess respiratory impairment, treatment response and deterioration.[34][44][22]
• Record clinical status, exacerbation severity, risk factors, treatments, discharge or death dates and in-hospital death within 30 days through structured data-capture fields.[45]

The protocol includes a family-doctor consultation record that permits repeated date-based documentation of symptoms, smoking exposure, examination findings, functional measures, laboratory tests, imaging, sputum investigations and cardiac findings.[42][46]A standardised audit form records institution, auditor, patient and clinician details, admission information, diagnosis, clinical assessment and completion of protocol-based diagnostic checks.[41][43]

Institution-specific protocols may introduce additional monitoring forms when recommended by the Ministry of Health, Labour and Social Protection, and the national protocol was prepared in 2019 with review scheduled for 2025.[3][19]The supplied material does not specify data custodians, routine reporting procedures, a reporting timetable, performance targets, surveillance governance or formal accountability arrangements beyond the indicators, clinical records and audit mechanisms described.[4][16][43]

Costing & Financing

The protocol identifies substantial service, workforce, diagnostic and medicine requirements across primary care, specialist consultation and hospital settings, but it provides no monetary costing or financing framework.[2][40][38]

• Provide primary-care capacity through family doctors, nurses and laboratory staff, supported by blood-pressure measurement, stethoscopes, peak-flow meters, microscopy, laboratory services and electrocardiography.[40][36]
• Equip specialist diagnostic services with phthisiopneumologists, imaging specialists, endoscopists, laboratory doctors and nurses, alongside pulse oximetry, spirometry, radiology, electrocardiography, fibrobronchoscopy and microbiological laboratory capacity.[37]
• Maintain hospital respiratory-care capacity through internists, phthisiopneumologists, functional diagnostics, imaging, endoscopy, laboratory staff, nursing staff and access to relevant specialist consultations.[38][39]
• Make available bronchodilators, inhaled corticosteroids, combination inhalers, antibiotics, expectorants, anticoagulants, oxygen therapy and other listed treatments according to the relevant level of care.[37][47][48]
• Support ambulatory and hospital treatment, rehabilitation, vaccination, long-term oxygen therapy, non-invasive ventilation and selected advanced emphysema interventions where clinically indicated.[30][12][49]

Protocol development received external support funded by the United States Government through the Millennium Challenge Corporation and administered by the United States Agency for International Development, but no financial amount is given.[50]Roflumilast was identified as not registered in the Republic of Moldova at the time of the source.[37][51]

The supplied material does not specify unit costs, total budgets, budget allocations, domestic financing sources, resource-mobilisation arrangements, funding gaps, cost-effectiveness evidence or economic assumptions for implementation.[2][52][53]