Management of Chronic Obstructive Pulmonary Disease (COPD)
By Merlin Goldman, Ph.D., M.B.A.
Chronic obstructive pulmonary disease (COPD) is comprised primarily of two related diseases: chronic bronchitis and emphysema. In COPD, the lung is damaged and airways are partly obstructed, making it difficult to breathe. Cigarette smoking is the most common cause of COPD--most people with COPD are smokers or former smokers. Breathing in other kinds of lung irritants, like pollution, dust, or chemicals over a long period of time may also cause or contribute to COPD. The disease develops slowly, and it may be many years before symptoms such as shortness of breath are noticed. Most of the time, COPD is diagnosed in middle-aged or older people.

COPD is the 4th leading cause of death in the U.S. and the world--12.1 million adults aged 25 and older reported being diagnosed with COPD in 2001. However, about 24 million adults have evidence of impaired lung function, indicating that COPD is underdiagnosed. The total estimated cost of COPD in 2002 was $32.1 billion.

Several organizations exist that seek to provide guidance on COPD. For instance, guidelines have been published by the Global Initiative in Obstructive Lung Disease (GOLD) and the National Institute for Clinical Excellence (NICE), and new guidelines have come from the European Respiratory Society and the American Thoracic Society. This has triggered an increasing recognition of the burden of COPD. Previously considered to be an area of healthcare with few therapeutic options, COPD is now considered treatable, with findings from numerous studies in recent years supporting both a pharmacological and non-pharmacological approach to treatment.

The GOLD program was initiated in 1997 to increase awareness of COPD and to decrease morbidity and mortality from this chronic lung disorder. In 2003 updated recommendations made in their Workshop Report (Global Strategy for the Diagnosis, Management, and Prevention of COPD) published in 2001 were given to healthcare workers, healthcare authorities, and the general public. These included:

• Long-acting bronchodilators are more convenient than short-acting bronchodilators for moderate-to-severe COPD.
• Use of inhaled glucocorticosteroids is only suitable for patients with severe COPD and frequent exacerbations.
• Duration of >=2 months for rehabilitation programs.
• Nurse-administered homecare represents an effective and practical alternative to hospitalization in selected patients with exacerbations of COPD without acidotic respiratory failure.

NICE, part of the NHS, is the independent organization responsible for providing national guidance on treatments and care for those using the NHS in England and Wales. In collaboration with the National Collaborating Center for Chronic Conditions, they issued their own guidelines on the management of COPD in 2004. An estimated 900,000 people in the U.K. have diagnosed COPD, and there may be as many who remain undiagnosed. COPD accounts for approximately 30,000 deaths each year. Their guidelines included:

• A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter 'bronchitis' or wheeze.
• Use of spirometry to confirm the presence of airflow obstruction. All health professionals managing patients with COPD should have access to spirometry and be competent in the interpretation of the results.
• Encouraging patients with COPD to stop smoking.
• Use of long-acting inhaled bronchodilators to control symptoms and improve exercise capacity in patients who continue to experience problems despite the use of short-acting drugs.
• The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations.

In 1995, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) agreed to work together to develop a document entitled "Standards for the diagnosis and treatment of patients with chronic obstructive pulmonary disease." They recently updated the document in response to the prevalence and overall importance of COPD as a health problem, recent medical advances, as well as a response to GOLD's recommendations (www.thoracic.org/COPD). The majority of these proposals are updated in the European Respiratory Society's most recent publication (Eur. Respir. J., 2004;23:932-946). In summary, they state:

• The diagnosis of COPD should be considered in any patient who has the following: symptoms of cough, sputum production, or dyspnoea, or history of exposure to risk factors for the disease. Patients presenting with airflow limitation at a relatively early age (4th or 5th decade) and particularly those with a family history of COPD should be tested for _1-antitrypsin deficiency.
• Examination should aim at eliciting the presence of respiratory and systemic effects of COPD. All patients should have their respiratory rate, weight and height, and BMI measured.
• Treating tobacco use and dependence should be regarded as a primary and specific intervention. Smoking should be routinely evaluated whenever a patient presents to a healthcare facility, and all smokers should be offered the best chance to treat this disorder.
• Effective medications for COPD are available, and all patients who are symptomatic merit a trial of drug treatment.
• Pulmonary rehabilitation should be considered for patients who have dyspnoea or other respiratory symptoms, reduced exercise tolerance, a restriction in activities because of their disease, or impaired health status.
• Bullectomy, lung volume reduction surgery, and lung transplantation may result in improved spirometry, lung volumes, exercise capacity, dyspnoea, health-related quality of life, and possibly survival in highly selected patients.
• Management of sleep problems in COPD should particularly focus on minimizing sleep disturbance by measures to limit cough and dyspnoea, and nocturnal oxygen therapy may be indicated for nocturnal hypoxemia.

According to Scrip Reports, the world market for COPD drugs is worth an estimated $3.2 billion and rapidly expanding. Driven primarily by the aging population and new product launches, the COPD market could more than double by 2010. Although there is no cure for COPD, new therapies combined with this recent collection of guidelines should provide an improved outlook for an increasingly prevalent range of diseases.

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Updated guidelines on the management of COPD are reviewed by Merlin Goldman, Ph.D., M.B.A. He may be contacted via e-mail at mhgoldmanuk@yahoo.com .

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