Introduction

Chronic obstructive pulmonary disease (COPD) causes around 1 million deaths annually.1 Guidelines for the diagnosis, management, and prevention of COPD have been published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD)2 and regional bodies such as the American Thoracic Society and the European Respiratory Society (ATS/ERS),3 the United Kingdom's National Institute for Clinical Excellence (NICE),4 and the Canadian Thoracic Society.5 Although such guidelines are updated regularly, they lag behind developments in clinical research. Furthermore, adherence to guidelines by practising doctors is often poor.6

On the basis of a review of recent medical developments, we describe a practical, patient oriented approach to the hierarchical implementation of pharmacotherapy in COPD. Published guidelines and many recent articles have acknowledged that modern management should embrace long acting bronchodilators and consider the potential role of inhaled corticosteroids and the stage at which they should be introduced. We have developed an algorithm that includes these important treatments.

Sources and search criteria

We reviewed the most recent guidelines from GOLD (August 2004), NICE (February 2004), and ATS/ERS (June 2004), and supplemented these by searching PubMed, using the criteria (“COPD” or “chronic obstructive pulmonary disease”) and “bronchodilator” for publications between January 2002 and March 2004. We found 21 recent clinical trials not cited in the GOLD guidelines, which covered combination therapy (inhaled corticosteroid plus β₂ agonist), the anticholinergic tiotropium taken once daily, and several meta-analyses of use of inhaled corticosteroid.7^–10 ^w1-w17

Diagnosis and staging

Since therapeutic strategies in COPD and asthma differ markedly, differential diagnosis is key to optimal management. Asthma should be suspected in patients with a childhood history of asthma, recurrent respiratory infections or episodes of “bronchitis,” or a family history of asthma or atopy (hay fever, allergic rhinitis, and eczema). COPD should be suspected in patients with a history of …