PROPUESTAS PARA COMBATIR LA VIOLENCIA EN LAS ESCUELAS

In 1998, in an effort to bring more attention to COPD, its management and its prevention, the US National Heart, Lung and Blood Institute and the World Health Organisation formed the Global Initiative for Chronic Obstructive Lung Disease (GOLD).360 The GOLD Expert Panel consisted of health professionals from around the world with expertise in respiratory medicine, epidemiology, socioeconomics, public health and health education.445 The model for this initiative was the Global Initiative for Asthma, an international strategy for developing comprehensive evidence-based guidelines on asthma control and management using a committee of experts.16 The central objectives of GOLD are to:

• Increase awareness of COPD amongst governments, public health officials, healthcare workers and the general public;

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• Improve prevention and management of the disease;

• Decrease COPD morbidity and mortality; and

• Encourage new research into the disease.360

In 2001, GOLD published a consensus report outlaying recommendations for the diagnosis, management and prevention of COPD. Importantly, the report includes grades for the weight of scientific evidence supporting each recommendation. The GOLD strategy presents a COPD management plan divided into four components:

• Assessment and monitoring of disease;

• Reduction of risk factors;

• Management of stable COPD; and

• Management of exacerbations.

Information and recommendations presented in the GOLD report are based on “the best- validated current concepts of COPD pathogenesis and the available evidence on the most appropriate management and prevention strategies.”360 The report is updated annually to reflect changing evidence in best practice.

In recognition of the significant burden that COPD places on the Australian community, the Australian Lung Foundation and Thoracic Society of Australia and New Zealand developed clinical practice guidelines to improve the diagnosis and management of COPD, called COPD-X (Table 53).446 The guidelines, based upon the GOLD strategy for COPD diagnosis, management and prevention, aim to affect 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.446

Table 53. Summary of the COPD-X guidelines443

C: Confirm diagnosis and assess severity Evidence*

Smoking is the most important risk factor for COPD Level I Consider COPD in patients with other smoking-related diseases Level I Consider COPD in all smokers and ex-smokers older than 35 years Level II The diagnosis of COPD rests on the demonstration of airflow limitation which is

not fully reversible Level II

O: Optimise function Evidence*

Inhaled bronchodilators provide symptom relief in patients with COPD and may

increase exercise capacity Level I

Long-acting bronchodilators provide sustained relief of symptoms in moderate-to-

severe COPD Level I

Long-term use of oral corticosteroids is not recommended Level I Inhaled corticosteroids should be considered in patients with a documented

response or those who have severe COPD with frequent exacerbations Level II Pulmonary rehabilitation reduces dyspnoea, anxiety and depression, improves

exercise capacity and quality of life and may reduce hospitalisation Level I

P: Prevent deterioration Evidence*

Smoking cessation reduces the rate of decline of lung function Level I General practitioners and pharmacists can help smokers quit Level I Treatment of nicotine dependence is effective and should be offered to smokers Level I Pharmacotherapies double the success of quit attempts; behavioural techniques

further increase the quit rate by up to 50% Level I Influenza vaccination reduces the risk of exacerbations, hospitalisation and death Level I Inhaled corticosteroids are indicated for patients with a documented response or

who have severe COPD with frequent exacerbations Level II Mucolytics may reduce the frequency and duration of exacerbations Level I

D: Develop a support network and self-management plan Evidence*

Pulmonary rehabilitation increases patient/carer knowledge base, reduces carer

strain and develops positive attitudes towards self-management and exercise Level I COPD imposes handicaps which affect both patients and carers Level II Multidisciplinary care plans and individual self-management plans may help to

prevent or manage crises Level II

X: Manage eXacerbations Evidence*

Inhaled bronchodilators are effective treatments for acute exacerbations Level I Oral corticosteroids reduce the severity of and shorten recovery from acute

exacerbations Level I

Exacerbations with clinical signs of infection (increased volume and change in

colour of sputum and/or fever, leukocytosis) benefit from antibiotic therapy Level II Multidisciplinary care may assist home management Level II *Level I evidence = systematic review of RCTs, level II evidence = one or more RCTs.

Despite widely distributed evidence-based management guidelines, knowledge of and adherence to the guidelines amongst doctors remains suboptimal.4,447-451 Multiple studies demonstrate that doctors are often slow to adopt best clinical practices into their daily patterns of care,78 and patients do not have the resources to recognise the gaps between available care and the care they receive.452 Existing COPD guidelines have depended largely on diffusion and dissemination of their recommendations.453 However, only the GOLD guidelines designed an implementation strategy concurrently with the guidelines.454

Disseminating guidelines requires an appreciation of the issues that prevent translation of guideline definitions of best practice into improved patient care.454 Few data exist regarding attitudes towards existing COPD guidelines amongst doctors. In the Netherlands, Jans et al. began a guideline implementation project that first assessed barriers to acceptance of COPD and asthma guideline recommendations among GPs.455,456 They then designed an implementation strategy to overcome these barriers and promote guideline adherence in a randomised, controlled trial. One year after the project started, they found greater adherence to guideline recommendations and improved patient outcomes, as measured by lung function and symptom scores.

Although some COPD is managed satisfactorily in the community, there is still room for substantial improvement.4 Clearly, there needs to be further research into effective ways of educating patients, doctors and the general community about COPD.