The intravenous route of administration, the high cost of treatment and the differences in natural course and prognosis among patients, force us to be as precise as possible in recommending leave a message augmentation. This supports the idea of a personalised approach to treatment in reference centres with experts who can take into account all the characteristics of each individual with the deficiency and evaluate the future risks and eventually make the decision to initiate augmentation therapy based on a personalised evaluation of risks, benefits and costs. The adequacy of treatment can be represented by a continuous line from one end in which augmentation therapy would not be recommended, to the opposite end where all patients fulfilling those characteristics would be recommended to start augmentation therapy (summarised in proposed quartiles in Table Table2).

2). Each individual patient should be placed at a given point between these two opposite ends, which would indicate the strength of the recommendation for therapy (Figure 3). The threshold for recommendation of augmentation therapy could be established at a given point between both ends, always recommended or never recommended, based on the existing evidence of benefits of therapy, baseline presenting demographics, future known or projected prognosis and evaluation of costs [65]. At present decision making is largely instigated on a cross sectional basis. Ideally decision making should be with a clear understanding of the future predicted progression and that requires a period of observation once smoking cessation has been confirmed, all other known factors avoided and optimal COPD therapy instigated.

Slow and fast decline based on expected changes with age can be used to place the subjects between the 2 ends of the treatment spectrum. Continued observation may enable the patient to be moved within the spectrum and this depends on a clearer understanding of the natural history both before and after diagnosis. Clearly urgent research is needed to clarify this approach in the few remaining cohorts where therapy has not been instigated or made available. It may be possible to develop a more objective scoring system based on a weighted score of the key factors of age, current severity and preceding rate of decline coupled with health economic data and examination of such an approach is urgently required to obtain international agreement and the development of firm guidelines. Figure 3 Recommendation for augmentation therapy. A new scale. Cilengitide Indications for augmentation therapy can vary from not to definitely indicated. Several factors will influence where the patient is placed on the scale including age, baseline lung function (FEV1 and/or …