Despite the numerous strategic plans for the prevention and management of chronic obstructive pulmonary disease (COPD) that have been implemented to date, high prevalence, underdiagnosis, and burden of care all remain a challenge in clinical practice1–4. Some of the main difficulties in COPD management include the prioritization and degree of control of treatable traits, and problems with inhaled therapy, such as device selection and patient adherence to prescribed maintenance treatment3,5–8. Moreover, new care strategies and, above all, new therapeutic strategies are scene-changers in the clinical management of COPD. The aim of this study was to reach a consensus among COPD experts on controversial issues in the evaluation and treatment of the disease, using Delphi methodology9.

A scientific committee of 17 COPD experts participated in the project. The project coordinators selected a committee of SEPAR members whose profile demonstrated a consolidated background in COPD supported by publications, while ensuring that the whole of Spain was represented by regions. The committee analyzed the scientific evidence in four areas: therapeutic adherence, COPD control, COPD treatable traits, and inhalation devices. This evidence was then examined in 15 discussion sessions, to which 5 attending pulmonologists from each area were invited, selected by the expert committee. Using the information obtained at these meetings, a questionnaire of 43 statements (Table 1) was developed and sent to a panel of 95 experienced COPD pulmonologists who were asked to grade them on a Likert scale of 1–9. Statements that were scored 1–3 (disagreement, median ≤3) or 7–9 (agreement, median ≥7) by more than two-thirds of the panelists, were considered to have achieved consensus. When more than two-thirds scored a statement in the range of 4–6, it was considered inconclusive. After two consecutive rounds, consensus was reached on 37 statements: 36 in agreement (83.7%) and one in disagreement (2.3%). Only six statements (14%) failed to achieve consensus. Table 1 shows the scores and the degree of agreement for each statement.

Seven of the nine statements on therapeutic adherence reached a consensus of agreement. The panelists believed that trust between the physician and the patient was important but noted that the information provided by the latter is not always reliable. Although there was no consensus on whether adherence to 12- and 24-h regimens differed significantly, panelists agreed (68.82%) that the 12-h regimen is preferable in patients with more symptomatic COPD. It was agreed that in order to increase adherence, the number of inhalers should be reduced and the patient’s preferences must be taken into account.

Consensus agreement was achieved in 12 of the 14 statements on COPD control. A high percentage (>72%) agreed that control targets should be established on the basis of severity, symptoms, exacerbations, lung function, and smoking habit. Only 36.57% considered that disease impact and stability were sufficient to assess COPD control. However, there was broad agreement (93.76%) that a patient with controlled COPD shows few symptoms and no exacerbations and remains stable over time. This suggests that, in the participants’ view, a patient with a persistent absence of symptoms or exacerbations over time would probably be well controlled, but it is unclear whether, as a general rule, control can be established solely on the basis of these 2 variables. This becomes clear in statement 18, in which panelists value the importance of lung function in disease control. According to the agreement reached (69.8%), a low-risk patient must be clinically stable for 1 year to be considered controlled. However, in high-risk patients, agreement was not reached (27.96%) on the statement that stability should be maintained for 3 months for a patient to be considered controlled. Most panelists (>92%) indicated their agreement with the following criteria for adjusting treatment: adherence, physical activity, comorbidities, and patient preferences.

All statements on COPD treatable traits achieved consensus agreement. Those with the greatest degree of agreement (>91%) were those that stated that these traits should be prioritized because of their impact on prognosis, symptoms and exacerbations. It was also agreed (>75%) that the definition of treatable traits should include individual, quantifiable, and prognostic traits.

Finally, of the 14 statements on inhalation devices, 11 achieved consensus agreement and 1 consensus disagreement. Nearly 74% of panelists agreed that if the inhaler is being used properly in stable COPD, treatment outcomes depend on the lung deposition achieved by the device. However, there was consensus disagreement that if the inhalation device is used properly, there are no differences in clinical outcomes, regardless of the type of device used. Nonetheless, panelists agreed that outcomes depend on the type of inhaler, lung deposition, and the characteristics of the drug. The criterion that achieved the highest degree of consensus regarding inhaler choice was inspiratory flow (92.70%). There was no consensus with the statement that there are no differences in the outcomes obtained with nebulizers or inhalers with spacers in the management of exacerbations, regardless of their severity. It was argued that there was insufficient evidence to claim that both devices are the same in this clinical context. In fact, 67.74% agreed that nebulizers are preferable in severe exacerbations. In the absence of therapeutic response, and before escalating treatment, the main consensus (98.96%) was to check the correct use of the device. No consensus was reached for the statement that the physician should be responsible for educating patients in inhaler use. Panelists considered that the nursing staff would be more appropriate for this task.

This Delphi study highlights the concerns of panelists surrounding the challenges faced by clinicians in the care of the COPD patient. Although controversial issues still persist, the high degree of agreement reached by the panelists identifies some key messages that should be taken into account in recommendations on the management of these patients. These include the importance of therapeutic adherence, the need to define COPD control, a more personalized approach based on treatable traits, verification of proper use of inhalers before escalating treatment, and consideration of inspiratory flow as a significant criterion in the choice of inhalation device.