Guía de Práctica Clínica: Enfermedad Pulmonar Obstructiva Crónica

Objectives

The guideline aims to provide evidence-based recommendations for the prevention, diagnosis, treatment, referral and continuing management of chronic obstructive pulmonary disease (COPD) in Chile, supporting clinical decisions across public and private services at primary, secondary and tertiary levels.[1][2]It addresses COPD as a major public-health concern associated with mortality, morbidity, impaired quality of life, underdiagnosis and diagnostic error.[3]

• Promote smoking cessation, influenza and pneumococcal vaccination, pulmonary rehabilitation and physical activity as core non-pharmacological components of COPD care.[4][3]
• Confirm diagnosis through post-bronchodilator spirometry, exclude alternative diagnoses and assess lung function annually.[2]
• Individualise inhaled pharmacological treatment according to symptoms, exacerbation history, clinical evolution, personal characteristics, tolerability, accessibility and cost.[4][3]
• Manage stable COPD, acute exacerbations, frequent exacerbations and advanced or terminal disease, including palliative care where appropriate.[4][5]
• Support smoking cessation for people who actively smoke, preferably through comprehensive structured programmes incorporating nicotine replacement therapy where available.[6]
• Use long-acting bronchodilator therapy for persistent symptoms, with conditional recommendations favouring long-acting muscarinic antagonist (LAMA) monotherapy over long-acting beta agonist (LABA) plus LAMA, and over LABA monotherapy in the specified comparisons.[7]
• Consider LAMA, LABA and inhaled corticosteroid triple therapy for frequent exacerbations, balancing possible exacerbation reductions against increased pneumonia and minor adverse effects.[6]
• Provide physical activity, respiratory physiotherapy, pulmonary rehabilitation and non-invasive ventilation for relevant patient groups, including people with acute hypercapnic respiratory failure.[4][5]
• Address tobacco exposure as the principal risk factor while recognising occupational dust exposure, household pollution and potential genetic factors, including alpha-1 antitrypsin deficiency.[8][1]

Implementation

The guideline combines person-centred, evidence-based clinical recommendations with service delivery close to patients’ homes, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to consider benefits, harms, certainty of evidence, patient values, feasibility, resource use and cost-effectiveness.[9][10]Its development involved Ministry of Health, National Health Fund, methodological, clinical and primary-care contributors, alongside evidence-synthesis organisations and, where possible, patients.[2][11]

• Deliver most routine care through local health centres, enabling medicine collection and participation in muscle-reconditioning and smoking-cessation programmes.[2][12]
• Use the Adult Respiratory Disease programme and primary-care respiratory disease rooms as established service platforms for COPD management; 295,031 people with COPD were recorded as under control in 2018.[1]
• Strengthen diagnosis through wider spirometry use, as limited access to spirometry and non-specific early symptoms contribute to underdiagnosis and diagnostic error.[3]
• Review stable COPD every six months when there has been no more than one outpatient exacerbation in the previous year, and every three months after more than one outpatient exacerbation or an exacerbation-related hospital admission.[5]
• Use follow-up to review treatment, assess inhaler technique, identify destabilising factors and add pharmacological or non-pharmacological interventions where needed.[5]
• Offer structured and supervised physical-activity programmes where feasible, and provide chest respiratory techniques for hypersecretory patients with frequent exacerbations following appropriate assessment and dosing.[4]
• Deliver pulmonary rehabilitation for exacerbated COPD in hospital-linked rehabilitation facilities, and provide non-invasive ventilation for acute hypercapnic respiratory failure in continuously monitored critical-care or acute medical settings with secretion management.[4][5]
• Support shared decision-making for conditional recommendations, taking account of expected effects, preferences, costs and available resources.[10]
• Address medicine-access constraints, as LAMA treatments, some recommended inhaled options and nicotine replacement therapy were not generally included in the Garantías Explícitas en Salud benefits package or routinely available in health-centre formularies.[7][6][4]
• Encourage health establishments to expand COPD treatment options and establish tobacco-cessation programmes.[6]
• Maintain recommendation validity through a periodic alert system for new relevant studies, while using GRADE certainty categories and evidence reviews to inform future updates.[10][13]

Monitoring & Evaluation

Monitoring and evaluation are primarily embedded in clinical follow-up, evidence assessment and routine health information rather than in a formal implementation-performance framework. The guideline supports treatment review, assessment of disease stability and escalation of care according to exacerbation history, while acknowledging that the extracts do not define a comprehensive indicator set, reporting chain, audit process or accountability system.[5][3][1][9]

• Review treatment, consider additional pharmacological and non-pharmacological therapies, check inhaler technique, and assess factors that could destabilise chronic obstructive pulmonary disease (COPD) during follow-up contacts.[5]
• Provide six-monthly follow-up for people with stable COPD and no more than one outpatient exacerbation in the preceding year, and three-monthly follow-up for those with more than one outpatient exacerbation or an exacerbation-related hospital admission in the preceding year.[5]
• Recognise uncertainty about the optimum follow-up interval, while considering more frequent contact for people with greater respiratory impairment or recurrent exacerbations.[5]
• Monitor people receiving non-invasive ventilation continuously in acute hypercapnic respiratory failure, including management of secretions and clinical surveillance in an appropriately monitored care setting.[4][5]
• Use post-bronchodilator spirometry to confirm diagnosis and assess lung function annually, while strengthening spirometry use to address underdiagnosis and diagnostic error.[3][2]
• Use the Adult Respiratory Disease programme and Monthly Statistical Summary to track the number of people with COPD under primary-care control; the cited 2018 caseload was 295,031 people, including 116,457 classified as type A or B.[1]
• Interpret mortality and burden estimates cautiously because COPD may be under-recognised, omitted from death certificates, or recorded only as a contributing cause.[3]
• Use epidemiological and service data to characterise disease burden, including the reported adjusted COPD prevalence of 14.5% among people aged over 40 years in Santiago.[3]
• Review the continuing validity of recommendations as evidence changes; the 2019 update reassessed key recommendations from the 2013 guideline, and a periodic alert system was established to identify new studies addressing formulated questions.[2][10]
• Apply the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess certainty of evidence and recommendation strength, including consideration of desirable and undesirable effects, patient values and preferences, feasibility, resource use and, where available, cost-effectiveness.[9][10][13]

Evidence certainty is categorised as high, moderate, low or very low, and recommendations may be strong, conditional or based on good clinical practice. These classifications guide clinical decision-making but are not implementation indicators.[10][13]The extracts do not specify targets, indicator definitions, data-collection frequencies, reporting responsibilities, public performance reporting, audit arrangements, sanctions or other formal accountability mechanisms.[14][7][6][15][16][17]

Costing & Financing

Cost, accessibility, resource availability and cost-effectiveness are recognised as relevant considerations in selecting and recommending COPD interventions, but the supplied extracts provide no monetary budgets, unit costs, financing allocations, funding sources, quantified funding gaps or economic assumptions.[3][10][11]

• Consider accessibility, affordability, individual characteristics and tolerability when selecting inhaled pharmacological treatment for persistent symptoms or rescue treatment needs.[3]
• Incorporate intervention and comparator costs, resource use, availability of resources and cost-effectiveness into the formulation of recommendations, particularly where conditional recommendations require individualised and shared decision-making.[10]
• Recognise that economic evaluations, Chilean intervention-cost assessments and cost reports were assigned to specialist contributors, although the extracts do not report their findings or monetary values.[11]
• Address access constraints affecting long-acting muscarinic antagonist treatment, recommended inhaled options for frequent exacerbations and nicotine replacement therapy, which were not generally included in the Garantías Explícitas en Salud benefits package or routinely available in health-centre formularies at the time described.[7][6][4]
• Develop smoking-cessation support programmes through health establishments because nicotine replacement therapy was not included in the benefits package and was not usually available through health-centre formularies.[4]
• Use care close to people’s homes where possible, enabling medicine collection and participation in muscle-reconditioning and smoking-cessation programmes, although no associated service-delivery costs are specified.[2][12]
• Recognise resource implications for supervised physical-activity programmes, pulmonary rehabilitation linked to a hospital rehabilitation gym, and continuously monitored non-invasive ventilation, while noting that no cost estimates or financing mechanisms are supplied.[4][5]

No resource-mobilisation plan, procurement mechanism, budget timetable, public or private funding split, reimbursement arrangement, cost threshold, or estimate of the financial consequences of expanding medicines, spirometry, rehabilitation, ventilation capacity or cessation services is specified in the extracts.[14][7][6][2][12][9][15][16][17]