Understanding, Preventing, And Managing COPD
Robert A. Wise, MD*
Chronic obstructive pulmonary disease (COPD) is one of the major leading causes of death in the United States, yet it is underappreciated by the medical community and virtually unknown among the general public. Approximately 80% to 90% of COPD cases are caused by cigarette smoking, an addictive habit inextricably linked to lung cancer but whose rates remain disappointingly high even with our current understanding of its pathological effects.1 If smokers are unable to stop smoking with the realization of the associated lung cancer, practitioners face an additional battle of making smokers aware of COPD and its effects on morbidity and mortality.
COPD has traditionally been considered a death sentence, perhaps self-inflicted. A sense of nihilism has long been assigned to this diagnosis, even among the pulmonary medicine community. The goal of this monograph, based on a slide set developed for a lecture series for primary care audiences, is to review the latest information on COPD, changing our attitudes from one of nihilism to a realistic understanding of what can be done to improve symptoms and quality of life in these patients.
Our interview with Dr Michael F. Busk illuminates the possibilities and benefits of collaboration between primary care practitioners (PCPs) and pulmonary specialists. This type of relationship benefits not only the patient but also the PCP, because a pulmonary specialist practice is designed to provide more educational resources and reinforcement of the PCP's messages to the patient. Dr Busk also addresses his thoughts on future directions in the consensus guidelines; as we are better able to target therapy, we can then focus on improving specific symptoms and thus quality of life. In that respect, therapeutic strategies may be individualized and enhanced by programs such as pulmonary rehabilitation.
The article by Dr Tina V. Hartert and Mary G. Gabb, MS puts COPD in perspective relative to the other major chronic diseases both in the United States and worldwide. Dr Hartert not only offers important information on the burden of disease compared with many other more well-known diseases, but also discusses the cost of COPD, both as monetary costs to the patient and health insurance industry as well as to primary care practitioners (PCPs) in terms of time and resource commitment. COPD and its associated comorbidities account for far more of a primary care patient load than is most likely realized, underscoring the need for more aggressive preventive interventions and earlier diagnosis to delay the debilitating decline in lung function later in life.
Our biggest gains in therapies for managing COPD arise from our greater understanding of the disease pathophysiology. COPD and asthma share many commonalities and indeed COPD is often misdiagnosed as asthma, but there are important differences in the inflammatory responses to both disorders, which impact treatment options. Dr Paul D. Scanlon discusses the risk factors for COPD, both internal and external, and the pathogenesis that leads to destruction of the lung parenchyma (ie, emphysema), mucus hypersecretion, and airway narrowing and fibrosis. He also relates these processes to various ways COPD can present, depending on the extent of disease progression.
Diagnosis remains the most significant challenge for PCPs, in part because COPD patients often do not present until their airflow limitation affects everyday activities until the disease is severe. COPD is diagnosed with spirometry in patients with a compatible history and physical examination. Advances in spirometry technology make earlier diagnosis much more possible, but only if the clinician knows and is comfortable with using the technology. Dr Frank C. Sciurba discusses the diagnosis of COPD, in accordance with both sets of recent guidelines published by the American Thoracic Society (in conjunction with the European Respiratory Society) and the Global Initiative for Obstructive Lung Disease (GOLD), and discusses practical strategies for incorporating these guidelines into clinical practice. Spirometry is absolutely appropriate and feasible in the primary care setting. We see recent descriptions of primary care practices that have incorporated spirometry into their patient services with earlier detection, improved patient care, and cost-effective resource use.2 We hope that this monograph will provide the information and confidence to physicians to offer this service more frequently.
Treatment options have also progressed. We now can address several aspects of the disease process in COPD and the published guidelines offer strategies for the best use of these medications. However, COPD patients often have comorbid chronic illnesses that affect treatment choices. In the end, COPD presenting symptoms and disease severity ultimately determine treatment options. Dr Barry J. Make reviews the different types of therapies available for COPD management, both acute and long term, in the context of the published guidelines and the realities of clinical practice. Advances in drug delivery and combination therapies offer more effective treatment, both in terms of pharmacology as well as improved patient compliance with what may appear to be complicated treatment regimens, especially in patients with comorbid conditions.
In addition to our current advances in COPD management, the future looks even brighter. Dr John J. Reilly reviews some of the current pharmacologic treatments under investigation, with the future goal of using "rational treatment" to match the appropriate drug(s) with the pathophysiological process(es). In this way, we hope to address not only symptoms but also survival. Of note, long-term oxygen therapy is the only treatment for COPD known to affect survival, although recent studies have suggested that inhaled corticosteroids may improve COPD survival.3,4 The Towards a Revolution in COPD Health (TORCH) study is now under way to assess the effect of inhaled corticosteroids and long-acting beta agonist(s) in COPD patients on mortality as well as exacerbation rate and health status.5 Similar studies are under way for long-acting anticholinergic bronchodilators. These types of studies may revolutionize our approaches to this often fatal disease.
With our more in-depth understanding of the causes of COPD and the development of targeted, multipronged treatment strategies, the healthcare practitionerÕs approach to a COPD patient should be one of hope and practical ideas for living with this chronic disease.
1. Centers for Disease Control and Prevention. COPD Fact Sheet. Available at: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35020. Accessed September 28, 2004.
2. Anderson S. Office spirometry. Don't just blow it off. Med Econ. 2004;81(13):63-65.
3. Sin DD, Tu JV. Inhaled corticosteroids and the risk of mortality and readmission in elderly patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164(4):580-584.
4. Soriano JB, Vestbo J, Pride NB, Kiri V, Maden C, Maier WC. Survival in COPD patients after use of salmeterol and/or fluticasone propionate in general practice. Eur Respir J. 2002;20(4):819-825.
5. Vestbo J; TORCH Study Group. The TORCH (Towards a Revolution in COPD Health) survival study protocol. Eur Respir J. 2004;24(2):206-210.
*Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Robert A. Wise, MD, Division of Pulmonary and Critical Care Medicine, Asthma and Allergy Center 4B74, 5501 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail: firstname.lastname@example.org.