REVIEW Open Access
Ch onic obs uc i e pulmona y disease
guidelines in Eu ope: a look in o he u u e
Ma c Mi a i lles
1*
, Nicolas Roche
2
, João Ca doso
3
, Da id Halpin
4
, Zau bek Aisano
5
, Hannu Kankaan an a
6,7
,
Vladimi Kobližek
8
, PawełŚliwiński
9
, Lei Bje me
10
, Michael Tamm
11
, F ancesco Blasi
12
and Claus F. Vogelmeie
13
Abs ac
Clinical p ac ice guidelines a e ubiqui ous and a e de eloped o p o ide ecommenda ions o he managemen o
many diseases, including ch onic obs uc i e pulmona y disease. The de elopmen o hese guidelines is bu densome,
demanding a signi ican in es men o ime and money. In Eu ope, he majo i y o coun ies de elop hei own na ional
guidelines, despi e he po en ial o o e lap o duplica ion o e o . A conce ed e o and consolida ion o esou ces
be ween coun ies may alle ia e he esou ce-in ensi y o main aining indi idual na ional guidelines. Despi e signi ican
esou ce in es men in o he de elopmen and main enance o clinical p ac ice guidelines, hei implemen a ion is
subop imal. E ec i e s a egies o guideline dissemina ion mus be gi en mo e conside a ion, o ensu e adequa e
implemen a ion and imp o ed pa ien ca e managemen in he u u e.
Keywo ds: Ch onic obs uc i e pulmona y disease, Clinical p ac ice guidelines, T ea men ecommenda ions
Backg ound
The ul ima e ea men goals in ch onic obs uc i e pul-
mona y disease (COPD) managemen emain uni o m
ac oss he majo i y o na ional and in e na ional COPD
clinical p ac ice guidelines (CPGs), and include educed
symp oms, educed exace ba ion isk and imp o ed
quali y o li e [1]. To achie e hese goals, CPGs equi e
egula upda es wi h ecen and ele an s a e-o - he-a
medical and scien i ic de elopmen s. Guidelines s i e o
imp o e he quali y o heal hca e and o educe a ia-
ions in he ea men and managemen o COPD [2].
Clinical p ac ice guidelines p o ide ecommenda ions
on pa ien managemen based on a ailable e idence and,
in ce ain cases, educa ed opinion whe e he e is no di -
ec e idence a ailable [3]. The quali y o he a ailable
e idence and he in ended audience o CPGs emain
co e conside a ions o hei de elopmen [4]. In ecen
yea s, CPGs ha e u he e ol ed in esponse o an
inc easing ecogni ion o he need o mo e s ingen ,
sys ema ic app oaches when ecommending speci ic
he apeu ic in e en ions o s a egies [5]. The impo ance
o igo ous p ocesses o ensu e ha only accu a e and ap-
p op ia e ea men ecommenda ions a e made is now
well-accep ed among p o essional scien i ic socie ies. In
ac , s anda ds o guide he p epa a ion o CPGs a e now
a ailable [6]. Howe e , li le a en ion is a o ded o he
challenges and pi alls associa ed wi h he de elopmen o
such documen s.
A conce ed e o be ween mul iple s akeholde s is
needed o ensu e p ecise, p ac ical and up- o-da e
clinical ecommenda ions o he diagnosis and op imal
managemen o COPD. Guidelines mus be locally
ele an ; he e o e local expe s akeholde s should o e
local p oposals, while e e ing o global e idence-based
documen s.
This e iew a icle highligh s he challenges associa ed
wi h he de elopmen and implemen a ion o na ional
CPGs o COPD in Eu ope and Russia.
Cu en challenges associa ed wi h he de elopmen o
guidelines
Impo an ad ances in he me hodologies used o he
de elopmen o CPGs ha e been made in ecen yea s.
These include he G ading o Recommenda ions Assess-
men , De elopmen and E alua ion (GRADE) guides [7].
GRADE p o ides a anspa en , sys ema ic app oach o
e iew a ailable e idence and a e i s quali y, in o de o
* Co espondence: [email p o ec ed]
1
Pneumology Depa men , Uni e si y Hospi al Vall d’Heb on, Cibe de
En e medades Respi a o ias (CIBERES), Ba celona, Spain
Full lis o au ho in o ma ion is a ailable a he end o he a icle
© The Au ho (s). 2018 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0
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ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o
he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e
(h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed.
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11
DOI 10.1186/s12931-018-0715-1
make ecommenda ions o g aded s eng h based on he
deg ee o con idence in he bene i - isk-cos a io and ap-
plicabili y o he s a egies o in e es . GRADE is bes used
in esponse o de ined key clinical (popula ion/in e en-
ion/compa a o /ou come [PICO]) ques ions [5, 8, 9].
E idence-based CPGs should equi e minimal in e -
p e a ion by end-use s, o educe he isk o bias.
Howe e , his ype o CPG also ca ies inhe en d aw-
backs and limi a ions, including a po en ial disconnec-
ion be ween he ocus on high-quali y scien i ic
e idence and eal-wo ld clinical p ac ice [10]. E idence-
based guidelines may no add ess a eas whe e he e is
an insu icien numbe o well-designed clinical ials
(i.e. e idence), bu ye clinicians s ill equi e guidance
in hese a eas [11].
While igo ous me hodologies such as he GRADE
s a egy o e obus and less biased ea men ecom-
menda ions, solely elying on such s ic me hodologies
can also comp omise he conclusions and ex e nal alid-
i y o CPGs. Using high-le el, o mal me hodology o de-
elop guidelines may exclude clinically ele an s udy
esul s [12]. E idence-based guidelines may educe p o-
essional au onomy o clinical judgemen [11]. Fu he -
mo e, he e idence included in hese g ading p ocesses
is p ima ily collec ed om speci ic subse s o pa ien s
who mee s ic inclusion c i e ia o pa icipa ion in
la ge clinical ials: speci ically, egis a ion andomised
con olled ials (RCTs) ec ui pa ien s in whom he e
is he highes chance o demons a e he e icacy o
es ed agen s [10]. Consequen ly, o en he esul s ob-
ained do no allow de e mina ion o (i) he gene alis-
abili y o esul s ob ained in selec ed popula ions, o (ii)
he mos sui able a ge subg oups in e ms o bene i -
isk a io. Howe e , i is well- ecognised ha signi ican
he e ogenei y exis s among pa ien s wi h COPD. Olde
o e y se e e COPD pa ien s, pa ien s wi h a his o y o
as hma and/o alle gy, ne e smoke s o pa ien s wi h
mul iple como bidi ies may no mee inclusion c i e ia
and he e o e may no be ep esen ed by he e idence
used o suppo mos ecommenda ions wi hin guide-
lines [3, 11]. A ecen s udy by Halpin e al. epo ed
ha only 27% o COPD pa ien s a e eligible o RCTs
[13]. Unde - ep esen a ion o “challenging pa ien s”(i.e.
hose who do no mee s ic eligibili y c i e ia, pa icu-
la ly he elde ly, hose wi h signi ican como bidi ies and
hose equi ing long- e m oxygen he apy) in RCTs
esul s in e idence-based CPGs ha may no be ully
adequa e o ensu e he op imal managemen o a signi i-
can numbe o pa ien s.
Con e sely howe e , guidelines which ely hea ily on
consensus opinion, a he han high-quali y e idence,
may be ulne able o bias and indi idual in e p e a ion
[11]. To y o ind he igh balance, e idence om eal-
wo ld e ec i eness s udies should be mo e hea ily
conside ed in CPGs. These could include he esul s o
obse a ional s udies o p agma ic ials whe e app op i-
a e [10], p o ided ha hey sa is y app op ia e quali y
s anda ds [14]. In ligh o his, CPGs should ideally
combine bo h e idence- and opinion-based app oaches
in a complemen a y and anspa en way. This can be
achie ed by clea ly highligh ing sec ions ha a e e idence-
based, and add essing gaps in he knowledge by educa ed
opinion o ex apola ion om e icacy e idence in o he
disease a eas. Fu he mo e, o signi ican conside a ion is
he use o single-disease guidelines o pa ien s wi h mul-
iple como bidi ies. This may be pa icula ly ele an in
he case o COPD, because due o he ad anced age o he
majo i y o pa ien s and he exposu e o noxious pa icles
o gases, especially obacco smoking, he p e alence o co-
mo bidi ies is subs an ial [15]. In addi ion, COPD and i s
espi a o y consequences can exe di ec dele e ious e -
ec s on o he sys ems; one example is he e ec o lung
hype in la ion on hea unc ion [16]. Con e sely, some
como bidi ies can inc ease he bu den o COPD; e.g., anx-
ie y and dep ession can inc ease he pe cep ion o dyspnea
h ough a ious mechanisms including hype en ila ion
and psychological dis ess [17]. The equency and ype o
como bidi ies p esen ed may be di e en in pa ien s in
eal li e compa ed o hose included in RCTs [18]; he e-
o e, guidance on mul imo bidi y will need o be consid-
e ed in he u u e [19–21].
Guidelines a e ime-consuming and expensi e o p o-
duce. Ex ensi e li e a u e e iews and de ailed analyses
equi e mo e ime and esou ces han clinical and aca-
demic expe s can dedica e o he de elopmen and up-
da es o na ional o in e na ional CPGs [12, 22–24].
This pu s s ain on local and na ional socie ies wi h lim-
i ed unding. Budge and a ailable esou ces a e impo -
an ac o s o mos coun ies when de eloping and
upda ing hei na ional guidelines [22]. Financial suppo
om p i a e (e.g. pha maceu ical) companies may aise
issues a ound po en ial con lic s o in e es [24]. New
simpli ied s a egies o CPG de elopmen a e being
es ed; hey combine consensus h ough a Delphi me h-
odology wi h s ic applica ion o GRADE in a eas whe e
consensus is no eached o ha a e subjec o a high
isk o bias [25]. I adequa ely alida ed, hese s a egies
could sa e signi ican ime and esou ces. An o e iew
o he de elopmen al p ocesses o na ional CPGs in
Eu ope and Russia is p esen ed in Table 1.
The key a ge audiences o na ional and in e na ional
guidelines
Iden i ying he key a ge audience is a c i ical s ep in
he de elopmen o CPGs. The audience is b oad, and
includes heal hca e p ac i ione s wi h a ying le els o
specialisa ion and expe ise, as well as non-heal hca e
p o essionals [26]. Pulmonologis s, gene al p ac i ione s
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 2 o 9
Table 1 The de elopmen o na ional guidelines in Eu ope and Russia: pa icipan s and in ended audiences
Coun y E idence sys em used O ganisa ion in ol ed in he de elopmen Pa icipan s in ol ed in he
de elopmen
In ended audience Re e ence
Czech Republic Consensus The Czech Pneumological and Ph hisiological
Socie y (CPPS) commissioned an expe
g oup o d a ecommended guidelines
o he managemen o s able COPD.
Subsequen e isions we e u he discussed
a he Na ional Consensus Con e ence.
Re iewe s’commen s con ibu ed o he
es ablishmen o he inal e sion.
Pulmonologis s and
pha macologis s
Pulmonologis s ( ull e sion),
in e nis s, GPs, and eme gency
physicians ( educed e sion). The
Czech na ional ecommenda ion
was ully accep ed by he S a e
Ins i u e o D ug Con ol (SUKL).
[43]
England NICE echnical manual
me hodology (includes
GRADE)
Na ional Ins i u e o Heal h and Ca e
Excellence (NICE)
Pulmonologis s, GPs, espi a o y
nu ses, physio he apis s pa ien s,
NICE echnical eam (including
heal h economis s), eedback
om egis e ed s akeholde s
(payo s, p o essional bodies,
hospi als e c.)
Pulmonologis s, GPs, o he
specialis s, all o he heal hca e
p o essionals in ol ed in ca ing
o people wi h COPD, payo s
and manage s
h ps://www.nice.o g.uk/p ocess/
pmg20/chap e /in oduc ion-
and-o e iew [44]
Finland E idence-based
medicine and GRADE
me hodology
The Cu en Ca e Guidelines we e de eloped
by he Finnish Medical Socie y Duodecim in
associa ion wi h a ious medical specialis
socie ies. The guidelines we e p oduced wi h
public unding and a e open o all heal hca e
p o essionals and he gene al public, and
include pa ien e sions. A la ge e iewing
g oup including GPs was asked o commen
on he guideline.
Pulmonologis s, GPs and
in e nis s
Pulmonologis s, GPs, o he
specialis s, all o he heal hca e
p o essionals (including nu ses,
physio he apis s, pha macis s)
and ci izens
www.kaypahoi o. i/web/english/
home [41,45]
F ance (A) Posi ion pape /
s a emen on
pha macological
ea men op imisa ion
o s able COPD
A es ic ed expe g oup was commissioned
by he na ional socie y (SPLF) o p oduce an
ini ial p oposi ion. A la ge e iewing g oup
including GPs was asked o commen .
Pulmonologis s and GPs Pulmonologis s and GPs [46]
(B) GRADE me hod o
guidelines on
exace ba ions
An ex ensi e mul idisciplina y g oup o
expe s and end-use s was commissioned
o p oduce he ini ial documen , which was
commen ed on by a panel o ex e nal e iewe s.
Pulmonologis s, GPs, in ensi is s,
eme gency physicians,
physio he apis s and nu ses
Pulmonologis s, GPs, in ensi is s,
eme gency physicians,
physio he apis s and nu ses
[47]
Ge many Consensus The Ge man Respi a o y Socie y (DGP) and he
Ge man Ai way League (AWL) commissioned an
expe g oup o de elop a guideline o he
diagnosis, assessmen and managemen o COPD.
Pulmonologis s Pulmonologis s, GPs, in ensi is s,
eme gency physicians,
physio he apis s, nu ses and
pa ien s
Vogelmeie CF e al.
Pneumologie 2017; in
p epa a ion
I aly Consensus The documen was p epa ed by a wo king
g oup appoin ed by he h ee majo na ional
espi a o y socie ies (AIMAR, AIPO and SIMeR)
and he I alian Socie y o Gene al Medicine
(SIMG). Rep esen a i es o he I alian Minis y
o Heal h and AGE.NA.S. we e in ol ed as
ex e nal independen obse e s o ensu e
e hical, social and solida i y p inciples.
Pulmonologis s and GPs Pulmonologis s and o he
specialis s wo king ei he inside
o ou side he hospi al se ing,
GPs, o he heal hca e p o essionals,
pa ien associa ions, and ins i u ions
a na ional, egional, o local le el
[48]
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 3 o 9
Table 1 The de elopmen o na ional guidelines in Eu ope and Russia: pa icipan s and in ended audiences (Con inued)
Coun y E idence sys em used O ganisa ion in ol ed in he de elopmen Pa icipan s in ol ed in he
de elopmen
In ended audience Re e ence
Poland Consensus Polish Respi a o y Socie y Pulmonologis s Pulmonologis s and a sho
e sion o GPs
[49]
Po ugal Consensus Na ional Heal h Au ho i y (DGS)
commissioned an expe g oup, including
Na ional Physicians O ganiza ion (OM)
and Po uguese Respi a o y Socie y (SPP)
ep esen a i es, o p oduce a guidance
documen .
Pulmonologis s All Physicians o he Na ional
Heal h Se ice (SNS)
[50]
Russia E idence-based
medicine and
consensus
Russian Respi a o y Socie y and Russian
Minis y o Heal h.
Pulmonologis s Pulmonologis s, GPs, o he
heal hca e p o essionals, pa ien
associa ions, and ins i u ions a
na ional, egional, o local le el
[51]
Spain GRADE and
consensus
11 medical scien i ic socie ies and he
Na ional Associa ion o Pa ien s.
Pulmonologis s, GPs, in e nal
medicine, ehabili a o s, nu ses,
physio he apis s, ge ia icians,
eme gency specialis s and
pa ien s
Pulmonologis s, GPs, in e nal
medicine and eme gency
specialis s
[52]
Sweden (A) E idence-based
medicine and
consensus
Swedish Medical P oduc s Agency (MPA) Pulmonologis s, GPs,
alle gologis s and
physio he apis s
Pulmona y specialis s, GPs and
in e nal medicine specialis s
h ps://lakemedels e ke .se/
upload/halso-och-sjuk a d/be
handlings ekommenda ione /
K onisk _obs uk i _lungsjukdom
_KOL_behandlings ekommen
da ion.pd [53]
(B) E idence-based
medicine and GRADE
The Swedish Na ional Boa d o Heal h
and Wel a e
Pulmonologis s, GPs,
alle gologis s and
physio he apis s
Pulmona y specialis s, GPs and
in e nal medicine specialis s
[54]
Swi ze land Consensus The Swiss Socie y o Pneumology (SGP)
commissioned an expe g oup including
pulmonologis s om all i e Uni e si y
Hospi als in Swi ze land, a ep esen a i e
om a REHAB Clinic and a leas one
ep esen a i e om each Language Region
in Swi ze land
Swiss medical doc o s
(membe s o he Foede a io
Medico um Hel e ico um
[FMH])
Pulmonologis s, GPs, in e nal
medicine and specialis s
[55]
Abb e ia ions:GP gene al p ac i ione , GRADE g ading o ecommenda ions assessmen , de elopmen and e alua ion
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 4 o 9
(GPs), o he heal hca e p o essionals, pa ien s, payo s
and policy-make s a e he p ima y audiences o COPD
guidelines.
Al hough no di ec ly in ol ed in he deli e y o pa-
ien ca e, heal hca e payo s, policy-make s and egu-
la o y agencies also comp ise he eade ship o CPGs.
Recommenda ions ha elie e he bu den o disease
(e.g. educe he equency o se e i y o cos ly exace -
ba ions) o s a egies o encou age ea ly diagnosis in
COPD pa ien s can be o conside able bene i o
payo s. Payo s ely on CPGs and obus e icacy e i-
dence in o de o make in o med decisions on und-
ing and eimbu semen policies o speci ic he apies
[27, 28]. Policy-make s also need CPGs o de elop ad-
equa e p e en ion s a egies and o build pa hways o
ca e [29]. Guidelines a e hea ily ega ded by egula-
o y au ho i ies, which may impac he design o
clinical ials. This is o signi ican impo ance when
egula o y au ho i ies adop he de ini ion o diagnos-
ic c i e ia used by a pa icula guideline when de in-
ing he equi emen s o no el d ugs, he eby (and
pe haps inad e en ly) in luencing he design o
clinical ials [30].
Who is in ol ed in he de elopmen o CPGs?
Guidelines ha a e in ended o widesp ead use in clin-
ical p ac ice should include ele an s akeholde s a a i-
ous and app op ia e s ages o he de elopmen p ocess,
which may encou age imp o ed implemen a ion and ad-
he ence o he ecommenda ions h ough an inc eased
sense o owne ship [31, 32]. Al hough i may no be ap-
p op ia e o all s akeholde s o ake an ac i e ole in he
de elopmen p ocess om he beginning, ce ain g oups
may pa icipa e in he d a ing o ecommenda ions o
a he e iew s ages.
Academic o clinical expe in ol emen in guideline
p epa a ion should include GPs, pulmonologis s, nu ses
and physio he apis s whe e app op ia e [31]. As he ma-
jo i y o COPD ca e is adminis e ed by GPs, hei in-
ol emen in guideline de elopmen may d i e inc eased
p ima y ca e physician-specialis communica ion and in-
eg a ion, which is c ucial in he managemen o COPD,
pa icula ly when pa ien e e al is necessa y. Inpu
om nu ses, ca diologis s, physio he apis s and die i-
cians may also add alue and clinical expe ise o guide-
lines in he pa hways o ca e [26].
Impo an ly, guidelines should in ol e all “end-use s”,
including pa ien s, non-expe p ac i ione s and payo s
o ensu e ha he guidelines add ess he igh ques ions
om a amily o socie y pe spec i e. C i ically, his may
also help o inco po a e pa ien p e e ences in o he
guidelines. Inc eased in ol emen may encou age pa-
ien s o play a mo e ac i e ole in hei heal hca e
managemen [33].
A s anda dised pan-Eu opean guideline; is his ealis ic?
Duplica e e o s a e made ac oss Eu ope, wi h indi id-
ual coun ies in es ing signi ican esou ces in o he de-
elopmen o CPGs [34]. Ins i u ional collabo a ion and
consolida ion o e o s may signi ican ly educe he
cumbe some na u e o guideline de elopmen and
equen upda es [35]. Fu he mo e, a ia ions in
indi idual se s o guidelines will ine i ably con inue
unless collabo a ion is encou aged and op imised be-
ween coun ies. These a ia ions, howe e mino ,
ha e he po en ial o mislead o con use p ac icing
heal hca e p o essionals [10].
Mos na ional guidelines in Eu ope ha e been in lu-
enced o a ying ex en s by GOLD. Mo eo e , GOLD
2017 [36] will likely impac u u e e isions o Eu opean
na ional guidelines in a mo e owa ds mo e pe sonalised
ea men o COPD. The GOLD s a egy also ca ies a
majo posi i e ad an age in ha he documen is
upda ed annually wi h he mos ecen and ele an li -
e a u e and s udies; howe e , no o mal e alua ion o
e idence (i.e. GRADE o simila ) is pe o med. In
addi ion, since by i s de ini ion, GOLD aims o p o ide a
global s a egy documen , some ecommenda ions may
no be di ec ly (i.e. wi hou any adap a ion) applicable in
some a eas o con ex s. As mos coun ies do no ha e
he esou ces o acili a e an annual upda e o hei na-
ional guidelines, each coun y has he oppo uni y o
adop speci ic sec ions o GOLD ha a e locally ele an .
Such p ocesses could be acili a ed by igh e collabo -
a ion be ween GOLD commi ees and egional, na ional
o local ini ia i es.
Owing o he impo ance o na ional guidelines, coupled
wi h he in e na ional a ailabili y o he GOLD 2017 docu-
men , he e may be po en ial o he de elopmen o an
in e media y documen be ween he wo. This could com-
p ise a single de ailed “umb ella”e idence base suppo ing
common p inciples bu wi h an adap a ion o ecommen-
da ions o e lec local p ac ices. Indi idual sensi i i ies
could he e o e be acili a ed wi hin his common adap -
able empla e. Na ional eimbu semen policies, a ailabil-
i y o esou ces and/o egula o y legisla ion may cause
guideline ecommenda ion and p esc ip ion de ia ions
be ween coun ies. In b ie , i s -line ea men ecom-
menda ions (a he class le el) and seconda y ecommen-
da ions could be included wi hin he common guideline,
wi h local al e na i e sugges ions added a a local le el in
line wi h local policy and scien i ic socie ies.
To suppo he in oduc ion and implemen a ion o
a common, adap able Eu opean guideline, a pan-
Eu opean guideline de elopmen esou ce eposi o y
could be compiled as a suppo ool. Mo eo e , di e -
en sec ions o a guideline dedica ed o a speci ic
heal hca e p ac i ione ole may boos implemen a ion
ac oss clinical p ac ice.
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 5 o 9

The e is po en ial o signi ican alle ia ion o ime
and budge cons ain s h ough a conce ed, collabo a-
i e e o be ween Eu opean coun ies. Who should ake
he lead du ing such a collabo a ion emains o be
discussed, bu i is likely ha he Eu opean Respi a o y
Socie y (ERS) is in he bes posi ion o lead such a p o-
jec . The ERS is commi ed o he de elopmen o high
quali y CPGs [37], and ei he alone o in conce wi h
sis e socie ies such as he Ame ican Tho acic Socie y
(ATS), has also deli e ed e idence-based CPGs o he
managemen o COPD [38, 39]. De eloping a Eu opean
collabo a ion would be bes achie ed h ough he ERS
and na ional socie ies, ag eeing on a common me hod-
ology. Tigh links wi h he GOLD g oup could also be
use ul o sha e e ie ed e idence and inc ease eac i i y,
allowing a con inuous upda e and adap a ion p ocess.
Can COPD guidelines be simpli ied?
The e is an appa en con adic ion be ween he expo-
nen ial inc ease in he scien i ic knowledge o COPD
complexi y (pheno ypes, endo ypes, como bidi ies e c.)
and he need o simpli ied ea men pa hways. Com-
plex aw da a needs o be agg ega ed and ansla ed in o
meaning ul, use ul in o ma ion o suppo ecommenda-
ions o new ea men s [29]. Algo i hms may be help ul
o guide COPD he apy in a simple, s epwise and coo di-
na ed manne [40]. Such algo i hms need o be lexible
and con inuously e ol ing in o de o emain up- o-da e
and clinically ele an . Impo an ly, he a ailabili y o al-
go i hms does no nega e he need o scien i ic p inci-
ples, and he ole o clinical judgemen should always be
acknowledged.
Conside a ions o e ec i e guideline dissemina ion
Once inalised, he CPGs should be sha ed in many ways
o ensu e op imal dissemina ion. F eely accessible online
publishing o he guidelines is impo an . A way o wa d
could be o amalgama e CPGs on all diseases in o one
single po al ha is accessible by all physicians, o he
heal hca e p o essionals and he gene al public ee o
cha ge. This has been done in Finland by he gene al
Medical Socie y Duodecim Cu en Ca e Guideline
sys em whe e guidelines on mo e han 100 diseases a e
colla ed on a single online po al and used by mos
heal hca e p o essionals [41]. Also, p esen ing he guide-
lines a local, na ional and in e na ional cong esses may
inc ease awa eness amongs a my iad o heal hca e p ac-
i ione s. Fu he mo e, inno a i e me hods o in o m
ele an end-use s o CPGs could be conside ed e.g. e-
mail blas s o social media communica ions. Plain
language summa ies may also p o e help ul o guide pa-
ien s and hei ela i es on a ailable ea men s. A sho
pocke e sion should be made a ailable o all physicians
o acili a e quick and easy access du ing pa ien
consul a ions. Use ul ea men algo i hms should be
a ailable on an easily-na igable websi e. Using sma
echnology may also imp o e he implemen a ion o
guidelines. Such applica ions may also ha e a place
wi hin al eady-exis ing clinical in eg a ed managemen
sys ems such as GP p ac ice compu e so wa e.
The inal p esen a ion o he ecommenda ions should
also be ca e ully conside ed. Succinc and concise ec-
ommenda ions p esen ed in an easily-diges ible o ma
such as ables o cha s should be conside ed o busy
heal hca e p ac i ione s [10].
Conclusions
E idence-based CPGs a e igo ous by hei e y na u e,
bu a e di icul o implemen in eal-li e clinical p ac ice
[11]. Some sugges ions o imp o emen in he de elop-
men and implemen a ion o COPD CPGs a e p esen ed
in Table 2. The au ho s sugges ha an ideal COPD
guideline documen should comp ise a ai balance be-
ween e idence-based and expe opinion-based ecom-
menda ions whe e de ini i e e idence is una ailable. Fo
anspa ency, each ecommenda ion should clea ly s a e
whe he i is suppo ed by e idence o based on expe
opinion and clinical judgemen .
The key a ge medical audience o COPD guidelines
include pulmonologis s and GPs, wi h pa ien s, payo s
and policy-make s also comp ising he in ended audi-
ence. All end-use s should be in ol ed in he de elop-
men o guidelines. Fo mally assessing wha hey expec
om he guidelines and which ba ie s may impede hei
implemen a ion could help o e come cu en insu i-
ciencies in ou ine ca e o COPD pa ien s.
Some guideline de elope s s uggle o p o ide he ne-
cessa y esou ces o suppo he de elopmen and/o
Table 2 Sugges ions o imp o emen in he de elopmen and
implemen a ion o COPD guidelines
De elopmen o CPG mus be based on a alida e me hod o
e alua ion and g ading o e idence (GRADE o simila )
In a eas in which GRADE may no be applied, consensus o
opinion-based ecommenda ions should be inco po a ed
A clea iden i ica ion o e idence-based and consensus-based
ecommenda ions is manda o y o anspa ency
Clea and simple algo i hms a e necessa y o in e p e a ion and
implemen a ion
All s akeholde s mus pa icipa e in CPGs de elopmen
A common Eu opean guideline could be used as a e e ence and
can be adap ed o local heal h sys ems
The Eu opean Respi a o y Socie y could be he pla o m o
gene a e and discuss na ional Eu opean CPGs
Dissemina ion and adhe ence is c ucial and new echnologies may
help o his objec i e
New s udies a e equi ed o e alua e he impac o CPGs on clinical
and economic ou comes in COPD
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 6 o 9
egula upda e o hei guidelines. Fu he mo e, i is pos-
sible ha no all aspec s o in e na ional guidelines will
be di ec ly ele an o all local pa ien s. In his ega d,
imp o ed collabo a ion be ween Eu opean coun ies and
he ERS may be bene icial, whe e a single in e media y
s a egy documen o he managemen o COPD should
be conside ed. This documen could encompass some
o e a ching high-le el common p inciples, wi h he im-
po an oppo uni y o local adap a ion. This may sig-
ni ican ly educe he cos s and esou ces associa ed wi h
guideline de elopmen o many coun ies.
Al hough he majo i y o COPD managemen is con-
duc ed by GPs, amilia i y o guidelines amongs gene al
p ac i ione s is subop imal. App oxima ely 24% o gen-
e al p ac i ione s ha e epo ed ha hey a e no amilia
wi h he GOLD s a egy o COPD [42].
Quick and easy access o guidelines on a websi e o
sma phone is impo an o maximise guideline imple-
men a ion. A quickly- and easily-unde s andable ea -
men algo i hm may help o simpli y COPD guidelines.
The algo i hm mus be lexible and con inually e ol ing
in acco dance wi h new esea ch and e idence.
The e is s ill a pauci y o knowledge on he e ec o
adequa e COPD guideline implemen a ion on disease
managemen and pa ien ou comes. Fu he s udies a e
wa an ed o add ess his gap in he li e a u e.
Abb e ia ions
ATS: Ame ican Tho acic Socie y; COPD: Ch onic obs uc i e pulmona y
disease; CPG: Clinical p ac ice guidelines; ERS: Eu opean Respi a o y Socie y;
GOLD: Global Ini ia i e o Ch onic Obs uc i e Lung Disease; GP: Gene al
p ac i ione ; GRADE: G ading o Recommenda ions Assessmen ,
De elopmen and E alua ion; PICO: Popula ion/in e en ion/compa a o /
ou come ques ion; RCT: Randomised con olled ial
Acknowledgmen s
The au ho s hank Gillian La elle, PhD, o No a is P oduc Li ecycle Se ices
(Dublin, I eland), o p o iding medical w i ing suppo o his a icle, which
was unded by No a is Pha ma AG, Basel, Swi ze land in acco dance wi h
Good Publica ion P ac ice (GPP3) guidelines (h p://www.ismpp.o g/gpp3).
The au ho s also hank P o esso Ba olome Celli (Bos on, US) o b inging
he de ini ion o a guideline by he US Depa men o Ve e ans A ai s o
hei a en ion.
Funding
None o he au ho s ecei ed paymen o compensa ion o he de elopmen
o his a icle. Medical w i ing suppo was unded by No a is Pha ma AG,
Basel, Swi ze land.
A ailabili y o da a and ma e ials
No applicable
Au ho s’con ibu ions
All au ho s made subs an ial con ibu ions o he d a ing and c i ical e iew o
all s ages o his a icle. All au ho s ha e gi en inal app o al o he e sion o
be published and ag ee o be accoun able o all aspec s o his wo k.
E hics app o al and consen o pa icipa e
No applicable
Consen o publica ion
No applicable
Compe ing in e es s
Ma c Mi a i lles has ecei ed speake ees om Boeh inge Ingelheim,
Chiesi, Cipla, Mena ini, G i ols and No a is, and consul ing ees om
Boeh inge Ingelheim, GlaxoSmi hKline, Geb o Pha ma, CLS Beh ing,
No a is and G i ols.
Nicolas Roche epo s g an s om Boeh inge Ingelheim, P ize and No a is,
and pe sonal ees om Boeh inge Ingelheim, No a is, Te a, GSK,
As aZeneca, Chiesi, Mundipha ma, Cipla, P ize , Sano i, Sandoz, 3 M,
Zambon.
João Ca doso epo s pe sonal ees om No a is, and has ecei ed
hono a ia o scien i ic ad ice and/o lec u e ees om As aZeneca,
Boeh inge Ingelheim, GSK, Mundipha ma and No a is.
Da id Halpin epo s pe sonal ees om No a is.
Zau bek Aisano and Michael Tamm ha e no con lic s o in e es o
decla e.
Hannu Kankaan an a epo s pe sonal ees om Almi all, As aZeneca,
Chiesi, GSK, Boeh inge Ingelheim, Lei as-Takeda, MSD, No a is,
Mundipha ma, Medi h, ResMed Finland, Roche and O ion Pha ma. He also
epo s non- inancial suppo om Almi all, As aZeneca and In e mune,
and g an s om As aZeneca.
Vladimi Kobližek epo s pe sonal ees om As aZeneca, Angelini,
Boeh inge Ingelheim, GSK, No a is, Pulmonx, Sandoz and Mundipha ma. He
also epo s g an s om As aZeneca, GSK and No a is.
PawełŚliwiński epo s pe sonal ees om Boeh inge Ingelheim, Chiesi,
G i ols, No a is, Roche and Te a, and non- inancial suppo om Boeh inge
Ingelheim and Chiesi.
Lei Bje me epo s ha he has ecei ed hono a ia o a ending ad iso y
boa ds o gi ing lec u es om As aZeneca, Boeh inge Ingelheim, Chiesi,
GSK, No a is and Te a.
F ancesco Blasi epo s pe sonal ees and g an s om As aZeneca, Baye ,
Chiesi, Mena ini, G i ols, P ize and Zambon, and pe sonal ees om GSK,
Guido i and No a is.
Claus F. Vogelmeie epo s pe sonal ees and g an s om As aZeneca,
Boeh inge Ingelheim, Chiesi, GlaxoSmi hKline, G i ols, Mundipha ma,
No a is and Takeda. He also epo s pe sonal ees om Almi all, Cipla,
Be lin Chemie/Mena ini, CSL Beh ing and Te a, and g an s om he
Ge man Fede al Minis y o Educa ion and Resea ch (BMBF) Compe ence
Ne wo k As hma and COPD (ASCONET), Baye Sche ing Pha ma AG, MSD
and P ize .
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Au ho de ails
1
Pneumology Depa men , Uni e si y Hospi al Vall d’Heb on, Cibe de
En e medades Respi a o ias (CIBERES), Ba celona, Spain.
2
Se ice de
Pneumologie e Soins In ensi s Respi a oi es, Hôpi al Cochin (AP-HP),
Uni e si y Pa is Desca es (EA2511), Pa is, F ance.
3
Hospi al de San a Ma a,
Cen o Hospi ala de Lisboa Cen al, Uni e sidade No a de Lisboa, Lisbon,
Po ugal.
4
Royal De on and Exe e Hospi al, Exe e , UK.
5
Pulmonology
Depa men , Pulmonology Resea ch Ins i u e, Russian Na ional Medical
Uni e si y, Moscow, Russia.
6
Depa men o Respi a o y Medicine, Seinäjoki
Cen al Hospi al, Seinäjoki, Finland.
7
Facul y o Medicine and Li e Sciences,
Uni e si y o Tampe e, Tampe e, Finland.
8
Depa men o Pneumology,
Uni e si y Hospi al H adec K alo e, Facul y o Medicine in H adec K alo e,
Cha les Uni e si y in P ague, H adec K alo e, Czech Republic.
9
2nd
Depa men o Respi a o y Medicine, Ins i u e o Tube culosis and Lung
Diseases, Wa saw, Poland.
10
Depa men o Respi a o y Medicine &
Alle gology, Skåne Uni e si y Hospi al, Lund, Sweden.
11
Clinic o Pulmona y
Medicine and Respi a o y Cell Resea ch, Uni e si y Hospi al, Basel,
Swi ze land.
12
Depa men o Pa hophysiology and T ansplan a ion,
Uni e si y o Milan, and Depa men o In e nal Medicine, Respi a o y Uni
and Adul Cys ic Fib osis Cen e , Fondazione IRCCS Cà G anda Ospedale
Maggio e Policlinico, Milan, I aly.
13
Depa men o Medicine, Pulmona y and
C i ical Ca e Medicine, Uni e si y Medical Cen e Giessen and Ma bu g,
Philipps-Uni e si y Ma bu g, Membe o he Ge man Cen e o Lung
Resea ch (DZL), Ma bu g, Ge many.
Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 7 o 9
Recei ed: 13 Decembe 2017 Accep ed: 5 Janua y 2018
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