Recommendations for research
The guideline committee has made the following recommendations for research. As part of the 2018 update, the guideline committee made additional research recommendations on prognostic indices, inhaled therapies, prophylactic antibiotics, pulmonary hypertension and the diagnosis of chronic obstructive pulmonary disease (COPD) through incidental CT scans.
In people with COPD, does pulmonary rehabilitation during hospital admission for exacerbation and/or in the early recovery period (within 1 month of an exacerbation) improve quality of life and reduce hospitalisations and exacerbations compared with a later (defined as after 1 month) pulmonary rehabilitation programme, and in which groups is it most clinically and cost effective?
The greatest reconditioning and potential benefit from rehabilitation may occur in the early post-exacerbation phase. If inpatient pulmonary rehabilitation is demonstrated to be effective, this may potentially impact on service delivery (for example, early discharge schemes). The cost effectiveness of early versus later pulmonary rehabilitation programmes should also be evaluated. Studies should be cluster randomised, be of sufficiently long duration and be adequately powered.
How can the individual factors associated with COPD prognosis (collected from a range of sources including primary care, imaging and pulmonary rehabilitation results) be combined into a multidimensional analysis that provides accurate and useful information on prognosis?
People with COPD can experience anxiety concerning their disease prognosis. Suitable prognostic tools could help alleviate this stress and allow people to make plans for the future. Existing multidimensional indices are:
unable to classify people reliably into high- and low-risk groups better than FEV1 alone or
no better at predicting outcomes than FEV1 alone or
time-consuming and consisting of components that would not be routinely available in primary care.
However, many individual factors are known to provide information, and the development of an index/indices combining these factors could help with prognosis. These indices should be validated in a general UK COPD population, and in primary care, in a wider range of outcomes than mortality alone.
What is the clinical and cost effectiveness of inhaled therapies (bronchodilators and/or inhaled corticosteroids) in people with both stable COPD and asthma?
There are a large number of trials that look at the effectiveness of bronchodilators and/or steroids in people with COPD, but the majority of them specifically excluded people with comorbid asthma. As a result, there is a lack of evidence concerning the most clinically and cost-effective treatments for this subgroup of people with COPD. Trials that recruit people with asthma and COPD could provide this evidence and ensure that these people receive the most effective maintenance treatments for their COPD and asthma.
What features predict inhaled corticosteroid responsiveness most accurately in people with COPD?
Bronchodilators and/or steroids are the main pharmacological treatments used to manage COPD. People with asthma or asthmatic features that may make them steroid responsive may need a different combination of drugs to other groups of people with COPD for the most effective treatment of their symptoms. Identifying these people would help ensure that they receive appropriate treatment.
Which subgroups of people with stable COPD who are at high risk of exacerbations are most likely to benefit from prophylactic antibiotics?
People with COPD commonly experience exacerbations, which have a negative impact on their quality of life and are linked to worse disease prognosis. Certain groups of people with COPD are at higher risk of exacerbations, and reducing the number of exacerbations they experience should improve quality of life for them and their families. However, subgroups of these people may benefit particularly from this treatment.
Identifying and targeting prophylactic antibiotics for these people should help improve their quality of life. It may also identify people who would not benefit from prophylactic antibiotics, and so reduce the risk of antibiotic resistance by reducing the overall number of people taking prophylactic antibiotics for COPD. Randomised trials that include subgroup analysis of participants based on factors such as biomarkers, clinical features, bacterial patterns and comorbidities could provide useful information on this topic.
What are the characteristics of people diagnosed with COPD as a result of an incidental finding of emphysema on a CT scan, compared with those diagnosed with symptoms?
What is the long-term clinical and cost effectiveness of prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?
What is the comparative effectiveness of different antibiotics, doses and regimens of prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?
What is the comparative effectiveness of seasonal versus continuous prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?
What are the most clinical and cost-effective treatments for pulmonary hypertension in people with COPD?