Introduction

Jump to section

• Forward
• The origins of the COPD-X Guidelines
• COPD-X Methodology
• Acknowledgement of Country

Foreword

Chronic Obstructive Pulmonary Disease (COPD) places an enormous burden on people living with this lung condition and on the Australian healthcare system. COPD was the 5^th leading cause of death in Australia in 2017 (AIHW 2021). In 2015–16, COPD cost the Australian health system an estimated $977 million (AIHW 2020). The Australian Institute of Health and Welfare estimates that COPD is the foremost cause of preventable hospitalisations amongst chronic health conditions (AIHW 2019). Furthermore, COPD was the third leading specific cause of total disease burden in Australia in 2015 (AIHW & NIAA 2020).

There is a great deal of work to be done to better understand the prevalence and outcomes of COPD in First Nations Australians. The prevalence of COPD among First Nations people is estimated to be 2.3 times as high as in the non-First Nations population (AIHW 2020). The mortality rate of COPD among First Nations Australians was 2.7 times as high as the non-First Nations rate (AIHW 2020). However, our current approach to COPD diagnosis, treatment and management is based on recommendations largely drawn from non-First Nations populations. As applicability cannot be assumed, further evidence on the management and diagnosis of COPD is needed for First Nations people. The aim of these guidelines is to improve health outcomes for all Australians with COPD by translating the latest evidence-based recommendations into everyday clinical practice.

In 2001 a multidisciplinary steering committee was convened by the Thoracic Society of Australia and New Zealand (TSANZ) and Lung Foundation Australia (LFA) to write guidelines for the management of COPD, specific for the Australasian context. The guidelines were launched as ‘COPD-X’ and first published as a supplement to The Medical Journal of Australia in 2003. The guidelines strive to provide clear recommendations relevant for Australian healthcare workers, accompanied by a discussion of the evidence.

COPD-X provides guidance for Case finding and confirming diagnosis, Optimising function, Prevention of deterioration, Development of care plans and management of eXacerbations. COPD-X highlights the critical role of reducing risk factors (particularly through smoking avoidance and cessation), optimising function with multidisciplinary care, improving treatment of comorbidities and referring symptomatic patients to pulmonary rehabilitation. The guidelines promote the concept of ‘stepwise management’, beginning with one pharmacological intervention and evaluating response before adding another agent. The guidelines also emphasise the importance of non-pharmacological therapy for COPD. The recommendations made in the guidelines are applicable across multiple care settings. The guidelines recognise that a patient-centred approach involving a team of healthcare workers is required for optimal outcomes.

The COPD-X Guidelines Committee is a multidisciplinary group of clinicians convened by LFA, that meets quarterly to review the current COPD literature and update the guidelines. With such frequent updates and literature reviews, COPD-X should be seen as an early example of ‘Living Guidelines’. This approach allows the guidelines to constantly evolve to meet the needs of people with COPD.

All changes and updates to the guidelines are made by consensus and quarterly digital updates are published online. TSANZ endorses the updates on a yearly basis, and the Guidelines have received endorsement from The Royal Australian College of General Practitioners. Across the entire spectrum of COPD care, the Guidelines aim to provide a detailed discussion of the evidence followed by a summary of recommendations. The Guidelines are freely accessible via the LFA website in an easily searchable web-based format and offered as a pdf.

To accompany the comprehensive Guidelines, LFA has launched a complementary suite of resources to assist Australian health care practitioners caring for individuals with COPD. In 2014, the ‘COPD-X Concise Guide for Primary Care’ was published with the aim of providing a practical point-of-care guide for primary care physicians. This was relaunched in 2020 as the ‘Concise Guide’ in 2020, and again in 2024 as the ‘COPD‑X Handbook’, to help provide a wide range of clinicians with succinct, evidence-based recommendations. ‘Stepwise Management of COPD’ is a graphical, single page summary of the pharmacological and non-pharmacological therapies across the severity continuum of COPD that encapsulates the management principles outlined in COPD-X.

Our greatest challenge lies in guideline implementation. Our key goal is to translate the evidence-based recommendations in COPD-X into everyday practice across Australia. For this knowledge translation to occur, a multi-faceted approach across platforms will be required. Strategies will need to include digital integration, such as software for clinical decision support systems and prompts in electronic health records that aid with management decisions accompanied by professional education delivered by traditional and innovative techniques. Dimensions of impact of uptake of the guidelines should be measured, to enhance reach and impact of key recommendations, and maintenance of knowledge translation.

It is our hope that these Guidelines will advance clinical practice and standardise COPD care. The ultimate aim of these Guidelines is to improve health outcomes and optimise quality of life for people with COPD.

Professor Ian Yang and Associate Professor Eli Dabscheck

Co-Chairs, COPD Guidelines Committee

June 2024

The origins of the COPD-X guidelines

These guidelines are the outcome of a joint project of the Thoracic Society of Australia and New Zealand and Lung Foundation Australia. The guidelines aim to:

• effect changes in clinical practice based on sound evidence; and
• shift the emphasis from a predominant reliance on pharmacological treatment of COPD to a range of interventions which include patient education, self-management of exacerbations and pulmonary rehabilitation.

These guidelines deal mainly with the management of established disease and exacerbations. However, this is only one element of the COPD Strategy of Lung Foundation Australia, which has the long-term goals of:

• primary prevention of smoking;
• improving rates of smoking cessation;
• early detection of airflow limitation in smokers before disablement; and
• improved management of stable disease and prevention of exacerbations.

In May 2001 a multidisciplinary steering committee was convened by the Thoracic Society of Australia and New Zealand (TSANZ) and The Australian Lung Foundation in accordance with the National Health and Medical Research Council recommendations for guideline development (National Health and Medical Research Council 1998). The Committee agreed to use the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Report (NHLBI/WHO Workshop Report April 2001) as the prime evidence base, together with systematic reviews and meta-analyses from the Cochrane Database. The GOLD Report, released in April 2001, was produced by an international panel of experts in collaboration with the United States National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). The levels of evidence in the current guidelines were assigned according to the system developed by the NHLBI (Box 1). Any changes to the guidelines have been based on subsequent versions of the GOLD report and on the results of systematic reviews or consistent evidence from well conducted randomised controlled trials.

The Guidelines Steering Committee supervised the development of specific items such as the COPDX Plan and a management handbook for primary care clinicians. Drafts of these documents were widely circulated to key stakeholder groups and professional organisations. In addition, the draft guidelines were published on the Internet http://www.lungnet.com.au (now http://www.lungfoundation.com.au) and access to them was advertised in a national newspaper. The draft guidelines were circulated to all members of the TSANZ and Australian Divisions of General Practice. All comments received were reviewed by the Steering Committee. The Guidelines were then published as a supplement to The Medical Journal of Australia in March 2003.

The Steering Committee then resolved to establish a COPD Guidelines Implementation Committee and a Guidelines Evaluation Committee. The terms of reference of the Evaluation Committee included scientific assessment of the impact of the guidelines on clinical practice and rigorous examination of the relevant medical literature to ensure the guidelines remain up to date. Any suggested modifications were circulated to members of the COPD Coordinating Committee and other key stakeholders prior to ratification. Following this, the guidelines were submitted to the COPD Special Interest Group of the Thoracic Society of Australia and New Zealand for endorsement.

Associate Professor David K McKenzie and Professor Peter Frith.

Principal authors and members of the COPD Implementation Committee.

July 2005

COPD-X Methodology

COPD-X is produced by Lung Foundation Australia’s COPD Guidelines Committee, which meets to evaluate the current literature and undertake quarterly updates of the Guidelines. The Committee is comprised of a multidisciplinary group of national COPD opinion leaders with expertise in evidence-based medicine, as well as Lung Foundation Australia staff who represent consumer priorities and lived experience perspectives in relevant discussions as the national peak consumer organisation.

A PubMed systematic literature search is performed quarterly by the Guidelines Coordinator for new papers in COPD, emphysema and chronic bronchitis, encompassing systematic reviews, clinical trials, and cohort and case-control studies. Guidelines committee members also propose studies for inclusion in the screening and subsequent review process, noting their awareness of key evidence being published in their respective areas of expertise. The Guidelines co-chairs screen all abstracts for inclusion. Relevant papers are critically appraised by a committee member with expertise in that area.

At the full Committee meeting, a decision about whether to cite a paper is made by consensus, and wording for incorporation is discussed. When making changes to Guideline recommendations, the Committee preferences randomised controlled trials and meta-analyses. The healthcare setting and patient population are also considered for relevance. Study methodology, bias, consistency of results, applicability to local practice and magnitude of benefit are all considered. Potential harms and side effects are also discussed and reported. The Committee discusses all potential Guideline changes and always reaches a group consensus. Guideline updates are focused on changes that are likely to modify or influence practice. Any disagreement is resolved with discussion.

All recommendations are linked to the key evidence used in making the recommendation and this evidence is routinely reviewed and updated. Evidence summaries and tables are provided in the Guidelines. Economic evaluation and funding implications are beyond the scope of the Guidelines in their current format. Although current resources do not allow routine audit and analysis with respect to the impact of and adherence to the Guidelines, independent researchers frequently use the Guidelines to audit local practice.

The Guidelines are endorsed by the Thoracic Society of Australia New Zealand (TSANZ). The TSANZ Clinical Care and Resources Sub-committee provides annual external review and considers key findings and updates, and the strength of recommendations. The reviewers provide written feedback that is addressed by the co-Chairs and expert members as applicable. Furthermore, within the Lung Foundation Australia, key stakeholders such as general practitioners are also invited to provide regular feedback. Following the external approval process, the updated Guidelines including a summary of changes are uploaded quarterly to the COPD-X website (https://copdx.org.au/).

Ongoing administrative, technical, logistical and financial support for the development of the COPD-X Guidelines is provided by Lung Foundation Australia as part of its national COPD program. This program receives sponsorship funding from a number of industry partners. Industry partners of Lung Foundation Australia have no direct or indirect influence over the content of the COPD-X Guidelines. Lung Foundation Australia has complete editorial and design control over the content of the COPD-X Guidelines as well as all other resources, promotions and educational programs. All members of the Guidelines committee serve as volunteers. No funding body has any influence on content or recommendations. Where applicable, Lung Foundation Australia funds members’ travel and accommodation for in-person Guidelines meetings. Committee members’ conflicts of interest are declared on an annual basis and can be viewed at: https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/conflicts-of-interest/. Any relevant potential conflict is addressed during the quarterly meetings.

Acknowledgement of Country

We acknowledge the Traditional Custodians of the many lands on which each iteration of the COPD-X Plan and all related resources have been developed. As the many beautiful landscapes including Rivers, Mountains, Seas, and winds that blow over their ancestral lands which were never ceded and remains in their continual custodianship, we extend our thanks to the Traditional Custodians of the lands for all future versions of COPD-X, and any supporting materials that it may inspire. We would also like to pay our respects to the Elders Past and Present for their courage and bravery in laying a firm foundation and for their wisdom and guidance that supports us in the work we undertake, and to future generations of Aboriginal and Torres Strait Islander Leaders and to our Aboriginal and Torres Strait Islander and non-Indigenous peoples.

Karl Briscoe,

Chief Executive Officer at National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners (NAATSIHWP)

Recognising COPD-X Plan is a resource that is used binationally, we also acknowledge and respect Māori as tangata whenua and Te Tiriti o Waitangi partners in Aotearoa New Zealand.