In addition to recommendations for pharmacological treatment stratified for risk and phenotype, the new 2021 edition of the Spanish COPD Guidelines (GesEPOC 2021) proposes a personalized approach to treatable traits, defined as a characteristic (clinical, physiological, or biological) that can be identified by diagnostic tests or biomarkers, for which a specific treatment is available. Some treatable traits, such as malnutrition, sedentarism, emphysema or respiratory failure, can be treated with non-pharmacological therapies, and this was not covered in detail in the guidelines. This section of GesEPOC 2021 includes a narrative update with recommendations on dietary treatment, physical activity, respiratory rehabilitation, oxygen therapy, non-invasive ventilation, lung volume reduction, and lung transplantation. A PICO question with recommendations on the use of supplemental oxygen during exercise in COPD patients without severe hypoxemia is also included.
La nueva edición de 2021 de la Guía Española de la EPOC (GesEPOC 2021) propone, junto al tratamiento farmacológico ajustado por estratificación de riesgo y fenotipo, el abordaje personalizado de los rasgos tratables, definidos como una característica (clínica, fisiológica o biológica) que se puede identificar mediante pruebas diagnósticas o biomarcadores y que tiene un tratamiento específico. Existen algunos rasgos tratables que tienen un tratamiento no farmacológico y que no fueron contemplados en detalle en la guía, como puede ser la desnutrición, el sedentarismo, el enfisema o la insuficiencia respiratoria. En este capítulo de GesEPOC 2021 se presenta una actualización narrativa con recomendaciones sobre tratamiento dietético, actividad física, rehabilitación respiratoria, oxigenoterapia, ventilación no invasiva, reducción de volumen y trasplante pulmonar. Además, se incluye una pregunta PICO con recomendación sobre el uso de oxígeno suplementario durante el ejercicio en pacientes con EPOC sin hipoxemia grave.
Although the treatment of chronic obstructive pulmonary disease (COPD) relies mainly on medications, mostly inhaled, some other equally important aspects of disease management need to be fully explored in each patient. One of the recommendations of the recently updated GesEPOC pharmacological treatment guidelines1 is to evaluate a series of general measures in all patients diagnosed with COPD that include, along with other interventions, adequate nutrition and regular physical activity adapted to age and physical conditions. An innovative therapeutic approach described in the new guidelines is that of treatable traits, defined as characteristics (clinical, physiological, or biological) that can be identified by diagnostic tests or biomarkers for which a specific treatment is available. Some general characteristics, such as malnutrition or a sedentary lifestyle, can also be considered treatable traits, and these will be addressed as such in this article. Of particular interest in GesEPOC 2021 is the review of the guidelines on the specific approach to some treatable traits. Accordingly, the scientific evidence will be reviewed to develop dietary guidelines for patients with malnutrition, physical activity for sedentary patients, respiratory rehabilitation for the management of dyspnea, lung volume reduction for emphysema patients, lung transplantation for patients with advanced disease, and oxygen therapy and non-invasive mechanical ventilation for patients with respiratory failure.
This article also includes a PICO question and a clinical recommendation on the use of supplemental oxygen during exercise in COPD patients without severe hypoxemia. The main recommendations are listed in Table 1.
Guidelines and general observations on the medical approach to treatable traits in COPD.
| Approach to treatable trait | Guidelines |
|---|---|
| Malnutrition | Assessment of the nutritional status is critical in COPD patients. Avoiding low weight and malnutrition improves exercise capacity and survival. |
| Sedentary lifestyle | Avoiding a sedentary lifestyle and encouraging daily physical exercise is beneficial for the COPD patient and should be widely recommended. |
| Rehabilitation for the management of dyspnea | Pulmonary rehabilitation improves dyspnea, exercise capacity, and quality of life and should be recommended in all COPD patients. |
| Early initiation of pulmonary rehabilitation (<4 weeks) after hospitalization reduces the risk of hospital readmission and mortality. | |
| Respiratory failure | Chronic home oxygen therapy for at least 16h a day in patients with COPD and respiratory failure improves survival. In patients with hypoxemia and desaturation on exertion, there is no evidence that home oxygen therapy improves survival and exercise capacity, so an individualized approach should be taken in symptomatic patients, based on its effect on dyspnea. |
| Chronic hypercapnia | Long-term home mechanical ventilation in patients with stable hypercapnic COPD with a history of previous acidotic exacerbations should be recommended, given its benefit in patient prognosis. |
The methodology used to develop the recommendations included in this article is described in the latest update of GesEPOC 2021.1
Non-pharmacological treatment of treatable traitsNutritionLow weight and malnutrition constitute a common treatable trait in COPD patients (25%–35% of cases) and have a negative impact on the respiratory system, peripheral muscle function, and immune system.2 This leads to a greater loss of lung function expressed by forced expiratory volume in 1s (FEV1), greater deterioration of lung tissue with a higher rate of emphysema, decreased exercise capacity, and increased mortality.3,4
The GesEPOC task force believes that nutritional status should be assessed in all COPD patients. The patient's nutritional status will initially be assessed using the body mass index (BMI).5 Patients with malnutrition (defined by the World Health Organization as BMI<18.5kg/m2) and obese patients (BMI>30kg/m2) may require a more comprehensive assessment of their nutritional status with electrical bioimpedance for the estimation of their fat-free mass index and referral to nutrition units to optimize nutritional support.
The GesEPOC task force believes that malnourished patients should be offered nutritional support, although the intensity and duration of such treatments are not well established, reflecting the lack of knowledge about the etiopathogenic mechanisms that lead to this situation in COPD. Despite these limitations, dietary nutritional supplementation with high polyunsaturated fatty acid and antioxidant (vitamins C and E and selenium) content will improve weight and muscle strength, physical activity, exercise capacity, and quality of life in malnourished patients with COPD.6–8
The future challenge for clinical nutritionists involved in the management of malnutrition associated with COPD will be to identify and characterize the specific areas of nutritional deficit (energy imbalance, sarcopenia, cachexia, and frailty) that will respond best to targeted interventions.
Obesity is another possible detrimental factor in COPD patients, as it may limit exercise capacity, cause respiratory restriction, and aggravate dyspnea.9 However, it has less impact on disease prognosis than malnutrition. The objective of obesity management is to reduce the fat mass, so it is essential to offer dietary advice and promote physical activity.10
Finally, special consideration should be given to dietary supplementation with vitamin D. A recent meta-analysis of 4 controlled trials showed that oral administration of vitamin D reduces moderate-to-severe exacerbations in COPD patients, but only in cases with vitamin D levels <25nmol/L.11 On this basis, we propose the routine assessment of vitamin D levels in exacerbating phenotype COPD patients and the administration of replacement therapy to maintain levels >25nmol/L.11
Physical activityScientific evidence on the effects of physical activity on COPD consistently shows that reduced physical activity is associated with an increased risk of mortality, hospitalization, and readmission for disease exacerbation the following year.12 It is important to identify sedentary behavior in patients with COPD, since the evidence, while still limited, indicates that an extremely sedentary lifestyle is associated with an increased risk of mortality and cardiometabolic disease in people with COPD.13,14
It is well established that pulmonary rehabilitation (PR) improves exercise tolerance in patients with COPD.15,16 However, this improvement does not necessarily change or increase daily physical activity in these patients in the long term.17 Physical activity does not show a linear relationship with exercise capacity, and should therefore be considered independently when planning a PR program.16 We will, therefore, encounter patients who only need to increase their exercise capacity (e.g., with physical training within PR programs), patients who only need to increase their physical activity (e.g., with programs fostering physical activity), and patients who may need a more comprehensive intervention that includes both approaches.
According to current strategies, a combination of physical training and behavioral interventions can be considered at different time points during PR programs.18 Ideally, behavioral strategies should be implemented in the final phase of PR, when patients have greater exercise capacity and fewer symptoms because they have already undergone the physical training adaptation phase.
New PROactive Physical Activity Instruments in COPD have been published that combine questionnaires with accelerometer data to measure physical activity in terms of amount, difficulty, and patient experience.19 These instruments have been shown to be sensitive to change following pharmacological and non-pharmacological interventions. The feedback that the patient receives from their pedometer or activity monitor (including the latest mobile technology) is effective in encouraging them to increase their physical activity and optimizes physical activity counseling programs in patients with COPD.20
To address physical inactivity, long-term outcomes from studies that combine behavioral interventions (such as motivational interviews) with unsupervised walking and collection of pedometer data are effective in increasing physical activity (mean increase of 957 steps a day) after 12 months of follow-up.21 Nevertheless, most long-term studies (12 months) remain ineffective in maintaining physical activity behavior changes in patients with COPD.22–24
The GesEPOC task force believes that patients should perform moderate physical activity for a minimum of 30min a day, 5 days a week. However, strategies adapted to each patient's activities of daily living, backed up with specific quantifiable, feasible objectives set down in writing, must be designed and agreed on with the patient.
Pulmonary rehabilitationThe GesEPOC Pulmonary Rehabilitation (PR) guidelines are in line with the consensus reached between the American Thoracic Society (ATS) and the European Respiratory Society (ERS), which designated PR as a central part of comprehensive chronic patient care.15,25 The ATS and ERS have also developed guidelines to improve the implementation of PR, since access to programs and referral by professionals are still limited, despite current evidence supporting the inclusion of PR in the comprehensive treatment of COPD patients.26 In line with the definition of PR agreed by ERS and ATS,15 the latest evidence and recommendations also adopted in the GesEPOC guidelines are summarized below:
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All COPD patients should be included in a PR program as part of their treatment.27 However, the scientific evidence is more robust in patients with moderate-to-severe COPD,