Appendix

Table 6. COPD Symptoms and Risk Factors

Symptoms of COPD	COPD Risk Factors
Dyspnea that is progressive, worse with exercise, or persistent Chronic cough that may be intermittent and may be unproductive Recurrent wheezing Chronic sputum production Recurrent lower respiratory tract infections	Tobacco smoke Smoke from home cooking and heating fuels Occupational dusts and chemicals Congenital or genetic predisposing factors Family history of COPD or childhood predisposing factors
Adapted from: GOLD guidelines. URL: http://www.goldcopd.org/. Updated: 2020. Accessed: November 13, 2019. Abbreviations: COPD = Chronic Obstructive Pulmonary Disease

Table 7. American College of Physicians’ Guideline Grading System

Level of Evidence	Methodological Quality of Supporting Evidence	Interpretation
Strong recommendation; high-quality evidence	RCTs without important limitations or overwhelming evidence from observational studies	Strong recommendation; can apply to most patients in most circumstances without reservation
Strong recommendation; moderate-quality evidence	RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies	Strong recommendation; can apply to most patients in most circumstances without reservation
Strong recommendation; low-quality evidence	Observational studies or case series	Strong recommendation, but may change when higher-quality evidence becomes available
Weak recommendation; high-quality evidence	RCTs without important limitations or overwhelming evidence from observational studies	Weak recommendation; best action may differ depending on circumstances or patients’ or societal values
Weak recommendation; moderate-quality evidence	RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies	Weak recommendation; best action may differ depending on circumstances or patients’ or societal values
Weak recommendation; low-quality evidence	Observational studies or case series	Very weak recommendations; other alternatives may be equally reasonable
Insufficient	Evidence is conflicting, poor quality, or lacking	Insufficient evidence to recommend for or against routinely providing the service
Adapted from: Qaseem A, et al. Ann Intern Med. 2011;155:179-191. Abbreviations: RCT = randomized controlled trial

Table 8. GOLD Description of Levels of Evidence

Evidence Category	Source of Evidence	Definition
A	RCTs with rich body of data	Evidence is from well-designed RCTs that provide a consistent findings in the population for which the recommendation is made without important limitations.
B	RCTs with important limitations	Evidence is from RCTs that include only a limited number of patients, post-hoc or subgroup analyses of RCTs, or meta-analysis of RCTs. This category also pertains when few randomized trials exist or there are significant limitations (e.g., small sample sizes, short duration, population that differs from the target population, or results are inconsistent).
C	Non-randomized trials and observational studies	Evidence is from uncontrolled or non-randomized trials or from observational studies.
D	Panel consensus	Provision of guidance is deemed valuable, but the clinical literature addressing the subject is insufficient. The panel consensus is based on clinical experience or knowledge that does not meet the above criteria.
Adapted from: GOLD guidelines. URL: http://www.goldcopd.org/. Updated: 2020. Accessed: November 13, 2019. Abbreviations: RCT = randomized controlled trial