Guidelines for the management of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by progressive decline in lung function. It imposes a considerable burden on patients, healthcare services and society that is likely to increase in the future. It is, therefore, important to ensure that this disease is managed as effectively as possible. In many therapeutic areas, management guidelines have been developed in an attempt to ensure that physicians are aware of optimal disease management and cost-effective use of healthcare resources. Such guidelines are usually prepared by consensus among clinical experts or following a systematic review of the evidence. However, there are a number of barriers to the implementation of treatment guidelines, including the sheer weight of guidelines in all therapeutic areas, a focus on scientific knowledge rather than on clinical practice, lack of trust in the recommendations, practical considerations (e.g. time, resources, budget) and failure to include the perspective of patients. The management guidelines most likely to be implemented are those that are quick and easy to use, relevant to the user's practice and from a credible source. In COPD, over 40 guidelines have been developed, mainly by local respiratory societies as a result of local expert consensus. The guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) are evidence-based and have the backing of international experts. Local implementation plans have been developed to help ensure that GOLD recommendations are implemented in practice. In all COPD guidelines, however, lung function measures feature prominently with limited reference to outcome measures of interest to patients and healthcare payers (e.g. frequency of exacerbations requiring hospitalization). Low expectations among physicians and patients may also impair implementation. In conclusion, guidelines may improve the management of COPD, but the main challenge is to ensure implementation.