diagnostics

Article
COPD Guidelines in the Asia-Pacific Regions: Similarities
and Differences
Shih-Lung Cheng 1,2, * and Ching-Hsiung Lin 3,4,5

1 Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei 22060, Taiwan
2 Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli District,
Taoyuan 320315, Taiwan
3 Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital,
Changhua 50006, Taiwan; teddy@cch.org.tw
4 Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan
5 Department of Recreation and Holistic Wellness, MingDao University, Changhua 50006, Taiwan
* Correspondence: shihlungcheng@gmail.com; Tel.: +886-2-8966-7000 (ext. 2160); Fax: +886-2-7738-0708

Abstract: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease
that is associated with significant morbidity and mortality, giving rise to an enormous social and
economic burden. The Global Strategy for the Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease (GOLD) report is one of the most frequently used documents for
managing COPD patients worldwide. A survey was conducted across country-level members of Asia-
Pacific Society of Respiratory (APSR) for collecting an updated version of local COPD guidelines,
which were implemented in each country. This is the first report to summarize the similarities
and differences among the COPD guidelines across the Asia-Pacific region. The degree of airflow
limitation, assessment of COPD severity, management, and pharmacologic therapy of stable COPD
will be reviewed in this report.






Keywords: COPD guideline; Asia
Citation: Cheng, S.-L.; Lin, C.-H.
COPD Guidelines in the Asia-Pacific
Regions: Similarities and Differences.
Diagnostics 2021, 11, 1153. https://
1. Introduction
doi.org/10.3390/diagnostics11071153
Although chronic obstructive pulmonary disease (COPD) is a preventable and treat-
Academic Editor: Koichi Nishimura able disease, it is associated with significant morbidity and mortality, giving rise to an
enormous social and economic burden. The results from the Epidemiology and Impact of
Received: 1 June 2021 COPD (EPIC) Asia population-based survey suggest a high prevalence of COPD in the
Accepted: 21 June 2021 participating Asia-Pacific territories [1] and indicate a substantial socioeconomic burden of
Published: 24 June 2021 the disease in this region. Individuals with the disease reported substantial limitations in
their daily activities and loss in work productivity. To address this situation and influence
Publisher’s Note: MDPI stays neutral the behavior of healthcare providers and health policy makers and payers, numerous
with regard to jurisdictional claims in organizations have developed clinical practice guidelines (CPG) to assist in the diagnosis
published maps and institutional affil- and treatment of COPD. In such an environment, CPG development often relies upon
iations. expert opinion. Conflicting interpretations of the literature regarding COPD management
may result in disparities across guidelines. Local factors, such as the availability of certain
health care services or the cost impact of an intervention, may also influence how local
experts view and apply the published literature during guideline development.
Copyright: © 2021 by the authors. The Global Strategy for the Diagnosis, Management and Prevention of Chronic Ob-
Licensee MDPI, Basel, Switzerland. structive Pulmonary Disease (GOLD) report is one of the most frequently used documents
This article is an open access article for managing COPD patients worldwide [2,3]. It was developed by using an evidence-
distributed under the terms and based methodology and expert opinion consensus and is considered the most up-to-date,
conditions of the Creative Commons comprehensive reference for COPD diagnosis and management. However, a major gap
Attribution (CC BY) license (https:// is that its focus is only in the application of the recommended GOLD strategies for phar-
creativecommons.org/licenses/by/
macological treatment of COPD based on the A, B, C, and D groups. Here, our focus of
4.0/).

Diagnostics 2021, 11, 1153. https://doi.org/10.3390/diagnostics11071153 https://www.mdpi.com/journal/diagnostics

Diagnostics 2021, 11, 1153 2 of 11

this survey is to determine the degree of consensus in the Asian Pacific region’s practice
guidelines for COPD regarding the diagnosis and management of COPD.

Estimated Prevalence
The prevalence of COPD in the Asia-Pacific countries is estimated at 14.5% in Aus-
tralia [4], 4.4% to 16.7% in China [5–7], and 5.6% in Indonesia [1]; the prevalence of Air
Flow Limitation (FEV1/FVC < 70%) was reported at 10.9% and COPD (after excluding
asthmatics) was 8.6% in Japan [8], 13.4% in Korea [9], 4.7% in Malaysia [1], 5.4% to 6.1% in
Taiwan [1,10], 3.7% to 6.8% in Thailand [11], 3.5% to 20.8% in Philippines [1,12], and 6.7%
in Vietnam [1], respectively (Table 1).

Table 1. Publication year of current and last version of Asia Pacific (APAC) guidelines, and COPD prevalence in the
reviewed APAC countries.

Australia/New Zealand * China Indonesia Japan Korea Malaysia Taiwan Thailand Philippines Vietnam
Current version 2020 2017 2011 2018 2018 2009 2020 2010 2009 2009
Last version 2013 2007 NA 2009 2014 1998 2011 NA 2003 2009
Planned next version NA NA NA NA NA NA 2023 2016 NA 2018
COPD prevalence 14.5% 4.4–16.7% 5.6% 8.6–10.9% 13.4% 4.7% 5.4–6.1% 3.7–6.8% 3.5–20.8% 6.7%

* Stepwise management table of COPD was published in 2017; Concise Guide for Primary Care (COPD-X plan) was published in 2017.

2. Method
A survey was conducted across country-level members of the Asia-Pacific Society of
Respiratory (APSR) for collecting an updated version of COPD guidelines which were im-
plemented in each country. The APSR sent a questionnaire to members, who were asked to
provide the current local guideline and comparative review of the collected guidelines. Ten
guidelines were reviewed, including those of Australia/New Zealand, China, Indonesia,
Japan, Korea, Malaysia, Taiwan, Thailand, Philippines, and Vietnam, in either English or
national language. The key disease management graphs, flowcharts, and algorithms were
translated into English language for review. Detailed information was completely collected,
including the definition, the approach to diagnosis, severity classification of staging, phar-
macotherapy for stable COPD, and other recommendations. In the Asia-Pacific available
COPD guidelines, Australia, Japan, Korea, Taiwan, and China have revised and updated
guidelines during the period of 2013 to 2020 (Table 1). Guidelines in the other countries
were not revised in the recent three years. We compared the similarities and differences
between these guidelines.
The different methods used to estimate disease prevalence including expert opinion,
patient-reported diagnosis, and symptom-based or spirometry-based methods may affect
the results. In the People’s Republic of China, COPD is one of the most common chronic
diseases in the population older than 40 years of age, with a prevalence of 8.2% in 2007
and increased to 13.6% in 2015 using spirometry-based survey. [5,7] Comparatively higher
prevalence with 13.7% to 13.4% was noted in Korea using spirometry-based survey [9,13].
Another study in the Asia-Pacific region, EPIC Asia population-based survey [1] based
on face-to-face or fixed-line telephone interviews, revealed that the prevalence of COPD
is between 6.2% and 19.1%. Regarding the estimated prevalence rate of COPD in each
country, there is no appropriate method to do this in current status.

3. Results
COPD diagnosis, classification, and treatment recommendation from Taiwan and
China were similar to the GOLD guidelines. The degree of airflow limitation, assessment
of COPD severity, management, and pharmacologic therapy of stable COPD were based
on the GOLD principles. Australia, Japan, and Korea guidelines display some differ-
ences regarding classification and management strategy of stable COPD compared with
the GOLD (Table 2). Besides, Taiwan guidelines have been written based on GRADE
(Grading of Recommendations, Assessment, Development and Evaluations)’s recommen-
Diagnostics 2021, 11, 1153 3 of 11

dation, which is the most widely adopted tool for grading the quality of evidence and for
making recommendations.

Table 2. Comparison of GOLD 2015 and APAC guidelines with current version updated after 2011.

Disease Classification and Management Major Difference in COPD Major Difference in COPD
Recommendation Same as GOLD Diagnosis Classification Treatment Recommendation

(1) Typical symptoms and lung

function assessed in parallel for
COPD severity classification
(1) Stepwise management of
(2) FEV1 40%, 60% and 80%
stable COPD; therapeutic
Australia No predicted as the cut points of
choices appropriately fully
COPD severity
aligned with disease severity.
(3) No specified cut points of
mMRC and CAT for
symptom evaluation

China Yes
(1) Typical symptoms and lung
function assessed in parallel for (1) Stepwise management of
COPD severity classification stable COPD; therapeutic
Japan No (2) No specified cut points of choices not fully aligned
mMRC and CAT for with disease severity.
symptom evaluation

(1) Specified criteria, the

occurrence of exacerbation
(1) FEV1 60% predicted as the cut or mMRC ≥2 despite of
point of high- and low-risk class. current treatment, for add
Korea No (2) Combined GOLD C and GOLD up treatment from first
D into one group (Korean therapeutic choice.
group ‘da’) (2) Mixed treatment
recommendation of GOLD
C and D for group ‘da.’

Taiwan Yes

3.1. Combined COPD Assessment

The Korean COPD guideline categorizes severity into three groups, Group ga (GOLD
Group A), Group na (GOLD Group B), and Group da (GOLD Group C and D) [13]
(Figure 1). The spirometric cutoff point of FEV1 is 60% predicted to distinct Group ga,
na from Group da. They further divide Group da into two groups with FEV1 < 60%
predicted, but >=50% predicted, or FEV1 < 50% predicted. [14]. Assessment of symptoms
and exacerbation is similar as described in GOLD. In Australia, COPD-X concise guide [15]
for primary care categorizes the severity of COPD into mild (FEV1: 60–80% of predicted),
moderate (FEV1: 40–59% of predicted), and severe (FEV1: <40% of predicted) accompanied
with typical symptoms of varying degree of dyspnea, cough, and limitation of daily activity
(Figure 2) [16]. The rationale was that regular treatment with inhaled corticosteroid (ICS)
can improve symptoms, lung function, quality of life, and reduce the frequency of exac-
erbation for patients with FEV1 < 50% predicted and a history of frequent exacerbations,
observed in several clinical studies [16–18].
Diagnostics Diagnostics
Diagnostics2021,
2021, 11,1153
11, 2021,
x FOR PEER11, REVIEW
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of11
11 4o

FigureFigure
1. Korean COPD
Figure
1. Korean classification
1. Korean
COPD COPD systemsystem
and GOLD
classification
classification systemclassification
and GOLD
and GOLD system.
classification
classification system.system.

Figure 2.
Figure 2. Stepwise
Stepwise management
management ofof stable
stable COPD
COPD guidelines
guidelines in
in Australia
Australia and
and New
New Zealand.
Zealand.
Figure 2. Stepwise management of stable COPD guidelines in Australia and New Zealand.

3.2. Pharmacologic Management of Stable Disease

3.2. Pharmacologic Management of Stable Disease
Diagnostics 2021, 11, 1153 5 of 11

3.2. Pharmacologic Management of Stable Disease

In the GOLD guideline, the initial pharmacological management of COPD is accord-
ing to patient group which has different recommended treatments. In the guidelines of
Australia, Japan, and Korea (Figure 2 [15], Figure 3 [19], and Figure 4 [14]), a stepwise
approach of optimized pharmacotherapy for stable COPD is used which recommends a
gradual increase of bronchodilators, inhaled corticosteroids, or other drugs based on a
comprehensive evaluation of symptoms, airflow obstruction, and exacerbation. In Japan’s
Diagnostics 2021, 11, x FOR PEER REVIEW 5 of 11
2018 guideline, ICS positioning for COPD treatment had been revised from the previous
criteria of FEV1 < 50% of predicted, frequent exacerbation, and concomitant asthma to only
the concomitant asthma (ACO) criterion.
In the GOLD guideline, the initial pharmacological management of COPD is accord-
ing to patient group which
3.3. Non-Pharmacologic has different recommended treatments. In the guidelines of
Management
Australia, Japan, andhad
Most guidelines Korea (Figure 2 the
emphasized [15],importance
Figure 3 [19], and Figurerehabilitation,
of pulmonary 4 [14]), a stepwise
long-
approach
term oxygenof optimized
therapy, andpharmacotherapy
self-management forplan
stable COPD is
including used which
smoking recommends
cessation and vacci-a
gradualParticularly,
nation. increase of Japan’s
bronchodilators,
guideline inhaled corticosteroids,
(fifth edition) discussed or
theother drugs
nutrition based on a
management
comprehensive evaluation of symptoms, airflow obstruction, and exacerbation.
including nutritional impairment, evaluation, therapy, and diet education [19]. In Japan’s
COPD
2018 guideline,
patients whose BMIICSispositioning
less than 90%forare
COPD treatment
suspected hada been
to have revised
nutrition fromand
disorder the nutrition
previous
criteria of
therapy mayFEV1 < 50% of predicted,
be indicated. frequent
Nutritionists, exacerbation,
physician, and should
and nurses concomitant
form asthma
a team to to
only thenutritional
provide concomitant asthma (ACO) criterion.
guidance.

Figure 3.
Figure 3. Stepwise
Stepwise approach
approach recommended
recommended by
by the
the fifth
fifth edition
edition of
of Japanese
JapaneseRespiratory
RespiratorySociety
SocietyCOPD
COPDguidelines.
guidelines.
Diagnostics 2021, 11, x FOR PEER REVIEW 6 of 11
Diagnostics 2021, 11, 1153 6 of 11

Figure
Figure 4. Algorithm
4. Algorithm of pharmacologic
of pharmacologic treatment
treatment in patients
in patients withwith stable
stable COPDCOPD in Korea.
in Korea.
3.4. Coexisting Asthma and COPD
3.3. Non-Pharmacologic Management
Coexisting asthma and COPD are only defined and described in Australia and Japan
Most guidelines
guidelines. had emphasized
This Australia therecommends
guideline importance ofthat
pulmonary
an FEV1 rehabilitation,
increase over long-
12% and
term200oxygen therapy, and self-management plan including smoking cessation
mL constitutes a positive bronchodilator response. An FEV1 increase >400and vac-
mL strongly
cination. Particularly, Japan’s guideline (fifth edition) discussed the nutrition
suggests underlying asthma or coexisting asthma and COPD diagnosis. Besides, the manage-
ment including
diagnosis nutritional impairment,
of asthma–COPD evaluation,
overlap (ACO) therapy,
has both and diet
characteristics of education
COPD and[19].
asthma
COPD patients
(Figure 5). whose BMI is less than 90% are suspected to have a nutrition disorder and
nutrition therapy may be indicated. Nutritionists, physician, and nurses should form a
team3.5.
to End-of-Life
provide nutritional
ISSUES guidance.
GOLD 2013, for the first time, proposed that palliative care may be applied in advanced
3.4. severe
Coexisting
COPDAsthma and COPD
patients. Among these guidelines in the Asia-Pacific region, Taiwan, Japan,
Coexisting
China [20], asthma and COPD
and Australia [15]are
mayonly defined
already andtheir
have described in Australia
policies and Japancare.
about end-of-life
guidelines. This Australia guideline recommends that an FEV1 increase over 12% and
Improving quality of life, optimizing function, helping with decision- making 200end-
about
mL of-life
constitutes a positive
care, and bronchodilator
providing emotional andresponse. Ansupport
spiritual FEV1 increase > 400
to patients mL
and strongly
family are the
suggests
main underlying asthmathe
goals. In Taiwan, or National
coexistingHealth
asthma and COPD
Insurance diagnosis. Besides,
Administration theof
Ministry diag-
Health
nosis of Welfare
and asthma–COPD overlap (ACO)
had programmed has bothplans
hospice-care characteristics of provided
in 2011 and COPD and asthma (Fig-
in-hospital critical
ure care
5). facilities for patients with advanced diseases and poor response to regular treatments
instead of home or hospice ward care.
Diagnostics 2021, 11, 1153 7 of 11
Diagnostics 2021, 11, x FOR PEER REVIEW 7 of 11

Figure5.5.Diagnostic
Figure Diagnosticcriteria
criteriaofofasthma–COPD
asthma–COPDoverlap
overlapininJapanese
JapaneseACO
ACOguideline
guideline2018.
2018.

4.3.5.
Discussion
End-of-Life ISSUES
There
GOLD are2013,
several
for studies
the firstevaluating and validating
time, proposed the newcare
that palliative GOLD may assessment
be applied system;
in ad-
however, uneven distribution of COPD patients and limited data on the clinical outcomes
vanced severe COPD patients. Among these guidelines in the Asia-Pacific region, Taiwan,
are noticed under these combined assessments. [21–24] The degree of the COPD Assess-
Japan, China [20], and Australia [15] may already have their policies about end-of-life
ment Test (CAT) score of ≥10 might not be equivalent to that of the mMRC score of ≥2 for
care. Improving quality of life, optimizing function, helping with decision- making about
categorizing patients’ symptoms. [25–28] Neither the 2007 GOLD nor the 2011 classification
end-of-life care, and providing emotional and spiritual support to patients and family are
scheme has sufficient discriminatory power to be used clinically for risk classification
the main goals. In Taiwan, the National Health Insurance Administration Ministry of
to predict total mortality at the individual level. [29] Accordingly, some countries have
Health and Welfare had programmed hospice-care plans in 2011 and provided in-hospital
developed COPD guidelines to build up appropriate strategies for diagnosis, assessment,
critical care facilities for patients with advanced diseases and poor response to regular
pharmacotherapy, and prediction of acute exacerbation and mortality based on evidence
treatments instead of home or hospice ward care.
and real-world clinical practice.
The Korean and Australia guidelines stratified the lung function severity and exac-
4. Discussion
erbation risk with FEV1 < 60% or ≥ 60% of predicted value. From the validation study
There
in Korea, it are
wasseveral
found studies
that there evaluating
were many and patients
validating the new
(15.3% GOLD
to 16%) whoassessment
experienced sys-
tem; however, uneven distribution of COPD patients and limited
exacerbation with FEV1 between 50% and 60% of predicted value. [14] The cutoff point of data on the clinical out-
comes
an FEV1are
50% noticed under
predicted doesthese combined
not address theassessments.
heterogeneity[21–24] The degree
in the GOLD Stage of the COPD
II (50%–80%
predicted). Patients with limited airflow around FEV1 50% to 60% predicted had ascore
Assessment Test (CAT) score of ≥10 might not be equivalent to that of the mMRC moreof
≥2 fordecline
rapid categorizing
in lungpatients’
functionsymptoms.
than patients[25–28]
with Neither
FEV1 < 50%the 2007
in the GOLD
TORCH norstudy
the 2011 clas-
[30,31].
Asification scheme
recent study has sufficient
showed discriminatory
that parameters relatedpower to be diffusing
to volume, used clinically for risk
capacity, andclassi-
reac-
fication
tance to predict
showed total mortality
break-points around at 65%
the individual
of FEV1 which level.may
[29] Accordingly,
have an impact some countries
on patients’
have developed
management plan.COPD guidelines to build up appropriate strategies for diagnosis, assess-
ment, pharmacotherapy,
The strategy for stableand COPDprediction of acute
management was exacerbation
based on lung andfunction
mortality basedbefore
severity on ev-
idence2011.
GOLD and real-world
A refinement clinical
of thepractice.
ABCD assessment tool had been separated from spiromet-
The from
ric grade Korean and Australia
“ABCD” groups in guidelines
GOLD 2020. stratified the lung
A stepwise functionpolicy
approach severity and exac-
is currently
erbation risk
presented in thewith FEV1
Japan and<Australia
60% or ≥60% of predicted
guidelines. value. Fromstrategy
The management the validation
is similar study
in thein
Korea,and
Korea it was
GOLD found that there
guidelines were many
including patients (15.3%
for symptoms severityto 16%) who experienced
and exacerbation exac-
frequency.
erbation with
Moreover, FEV1 between 50%
a phenotype-guided and 60%
treatment of predicted
policy has been value.
shown [14] The
in the cutoff and
Spanish point of an
Czech
FEV1 50% predicted does not address the heterogeneity in the GOLD Stage II (50%–80%
guidelines. [32,33] Which strategies are optimal in clinical practice guidelines for COPD
predicted). Patients
management? Therewithwerelimited
severalairflow around
strategies FEV1 50%
including lungtofunction-guided,
60% predicted had a more
stepwise
rapid decline in lung
approach-guided, GOLDfunction than patients
A–D-guided, andwith FEV1 < 50% in the
phenotype-guided TORCH The
strategies. study [30,31].
optimal
treatment of COPD patients requires an individualized, multidisciplinary approach to the
Diagnostics 2021, 11, 1153 8 of 11

lung function severity, patient’s symptoms, clinical phenotypes, biomarkers, comorbidity

evaluation, and needs.
The treatment of patients with COPD in a more personalized way must address
diverse aspects not only related with the disease, but also with its comorbidities, and
current schemes do not offer such personalized medical treatment. Comorbidity evaluation
and management were all mentioned in each Asia country CPG. In the JRS guideline l19],
the comorbidities included systemic inflammation, osteoporosis, musculoskeletal defect,
cardiovascular disorders, gastro-intestinal dysfunction, depression, metabolic disorders,
and obstructive sleep apnea. Additionally, the variability of the clinical presentation
interacts with comorbidities to form a complex clinical scenario for clinicians. Different
comorbidities have different evaluation and management policies. Consequently, the CPG
or consensus should be reached over a practical approach for combining comorbidities and
disease presentation markers in the therapeutic algorithm, in order to improve the quality
of clinical care.
In a previous study, the increased total health expenditure was shown as share
GDP ≥ 7% in Korea, Japan, and Australia in 2007. [34] In Japan, major reforms are needed
to reduce waste and enhance cost-effectiveness. Moreover, a national system to accredit
training programs, including for general practice, has been introduced. [35] The challenges
of the healthcare system in Korea include over-consumption and excessively high frequency
of specialist consultation, which are major problems for the medical system. The govern-
ment and the primary care group seek to strengthen primary care, but this is opposed by the
medical society governed by the specialist group. [35] In Australia, some provider payment
methods were performed such as case payment, diagnostic-related groups, etc. [34]. We
think that guideline differences are driven by the disparities in diagnosis modalities or by
the treatment variations in different healthcare systems and the socioeconomic burden in
each country.
Additionally, diagnosis tools and management of COPD were among the lower
guideline-recommended levels in most of the regions investigated among primary care
physicians or general practitioners (GPs). [36] The survey demonstrated that the GPs’ un-
derstanding of COPD was variable and large numbers of GPs have very limited knowledge
of COPD and its management in Asia countries. The percentage for COPD management by
guideline is as follows: Australia 64%, Japan 74%, Korea 54%, and Taiwan 70%. In China,
only 50% of patients with COPD have ever had spirometry tests in tertiary hospitals, and
only 18% had in primary or secondary hospitals. [37] Therefore, from the education system,
clinical practice, and medical impact, there appears to be an optimal strategy developed to
simplify the guidelines for daily practice in each country.
Research evidence has raised concerns that hospital death may be preceded by poten-
tially burdensome and inappropriate hospital admission and aggressive treatments shortly
before death, which could be a threat to better end-of-life care and death. [38–41] On the
other hand, enabling people to have end-of-life care at home compared with end-of-life
care in hospital may incur a potential cost saving. [42,43] The concepts of palliative and
hospice care should be established gradually in regards to diseases with an advanced stage.

APSR Recommendations for COPD Diagnosis and Treatment

1. COPD is characterized by persistent respiratory symptoms and airflow limitation.
Spirometry is required to make the diagnosis.
2. The severity of COPD should be comprehensively assessed on the basis of the
degree of obstruction severity (FEV1, GOLD stage), impairment of exercise toler-
ance/physical activity, intensity of dyspnea, and frequency/ severity of exacerbation.
3. The goal of pharmacological treatment should be to treat the symptoms (e.g., breath-
lessness) or to prevent deterioration (either by decreasing exacerbations or by reducing
the decline in lung function and quality of life) or both. A stepwise approach is rec-
ommended, irrespective of disease severity, until adequate control has been achieved.
Diagnostics 2021, 11, 1153 9 of 11

4. Management of non-pharmacological strategies for stable COPD should center around

supporting smoking patients to quit. Encouraging physical activity and maintenance
of a normal weight range are also important. Pulmonary rehabilitation is recom-
mended in all symptomatic patients.
5. Stepwise management of optimized pharmacotherapy for stable COPD which recom-
mends gradual increase of bronchodilators, inhaled corticosteroids, or other drugs
based on clinical symptoms, airflow obstruction severity, and exacerbation history.
6. ICS should be used in cases with concomitant asthmatic conditions and/or 2 or more
exacerbations in the previous 12 months. LABA/ICS combinations are also allowed.
7. In the end-of-life care, improving quality of life and providing emotional and spiritual
support to COPD patients and their family are the main goals.

5. Conclusions
This is the first report to summarize the similarities and differences among the COPD
guidelines across the Asia-Pacific region. The guideline developed in each country would
be based on clinical evidence, experts’ consensus, healthcare insurance, reality of clinical
practice, and the best interests of patients. We hope, through collaboration of research, that
the guidelines will evolve positively and that differences or gaps will diminish with time.

Author Contributions: S.-L.C. and C.-H.L.; methodology, validation, and formal analysis; S.-L.C.;
writing—original draft preparation, S.-L.C.; writing—review and editing, C.-H.L. Both authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: Thanks to the professors for finishing this work including: Kazuto Matsunaga
(Japan); Chin Kook Rhee (Korea); Diahn-Warng Perng (Taiwan).
Conflicts of Interest: The authors declare no conflict of interest.

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