Chest

Chest

Volume 133, Issue 6, June 2008, Pages 1451-1462
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Recent Advances in Chest Medicine
Update on the Management of COPD

https://doi.org/10.1378/chest.07-2061Get rights and content

COPD is highly prevalent and will continue to be an increasing cause of morbidity and mortality worldwide. COPD is now viewed under a new paradigm as preventable and treatable. In addition, it has become accepted that COPD is not solely a pulmonary disease but also one with important measurable systemic consequences. Patients with COPD have to be comprehensively evaluated to determine the extent of disease so that therapy can be adequately individualized. We now know that smoking cessation, oxygen for hypoxemic patients, lung reduction surgery for selected patients with emphysema, and noninvasive ventilation during severe exacerbations have an impact on mortality. The completion of well-planned pharmacologic trials have shown the importance of decreasing resting and dynamic hyperinflation on patient-centered outcomes and the possible impact on mortality and rate of decline of lung function. In addition, therapy with pulmonary rehabilitation and lung transplantation improve patient-centered outcomes such as health-related quality of life, dyspnea, and exercise capacity. Rational use of single or multiple therapeutic modalities in combination have an impact on exacerbations and hospitalizations. This monograph presents an integrated approach to patients with COPD and updates their management incorporating the recent advances in the field. The future for patients with COPD is bright as primary and secondary prevention of smoking becomes more effective and air quality improves. In addition, current research will unravel the pathogenesis, clinical, and phenotypic manifestations of COPD, thus providing exciting therapeutic targets. Ultimately, the advent of newer and more effective therapies will lead to a decline in the contribution of this disease to poor world health.

Section snippets

COPD Is Highly Prevalent, Underdiagnosed, Undertreated, and Underperceived

COPD affects millions of individuals, limits the functional capacity of many, and has become an important cause of death worldwide. Although preventable, COPD has a long subclinical phase. The previously accepted thought that COPD develops in only 15% of smokers is an underestimation of the actual number that is now known to be much larger. Once dyspnea develops, it occurs at ever lower levels of exercise. With disease progression, gas exchange becomes compromised and patients may have

COPD, a Multicomponent Disease

The airflow obstruction of COPD, as expressed by FEV1, is by definition only partially reversible.1, 2 In a paradoxical way, this defining physiology has been used as the outcome to determine the effectiveness of interventions. It is no surprise that the lack of large response in FEV1 to different therapies17, 18, 19, 20, 21, 22, 23, 24, 25, 26 has resulted in an undeserved nihilism. There is increasing evidence that independent of the degree of airflow obstruction, lung volumes are important

COPD, a Treatable Disease

Current evidence suggests that smoking cessation,6 long-term oxygen therapy in hypoxemic patients,42, 43 noninvasive mechanical ventilation in some patients with acute-on-chronic respiratory failure,44, 45, 46 and LVRS for patients with upper-lobe emphysema and poor exercise capacity47 improve survival. The TORCH (Towards a Revolution in COPD Health) study48 of >6,000 patients showed that the combination of salmeterol and fluticasone not only improved lung function and health status, but that

Therapy Is Effective for the Respiratory Manifestations of COPD

Once COPD is diagnosed, the patient should be encouraged to actively participate in disease management. This concept of “collaborative management” may improve self-reliance and esteem. All patients should be encouraged to lead a healthy lifestyle and exercise regularly. Preventive care is extremely important at this time, and all patients should receive immunizations including pneumococcal vaccine and yearly influenza vaccinations.1, 3 This comprehensive approach is summarized as a proposal in

Smoking Cessation and Decreased Exposure to Biomass Fuel Combustion Fumes

As smoking is the major cause of COPD, smoking cessation is the most important component of therapy for patients who still smoke.1, 3 Because secondhand smoking is known to damage lung function, limitation of exposure to involuntary smoke, particularly in children, should be encouraged. The factors that cause patients to smoke include the addictive potential of nicotine; conditional responses to stimuli surrounding smoking; psychosocial problems such as depression, poor education, and low

Pharmacologic Therapy of Airflow Obstruction

Many patients with COPD require pharmacologic therapy. This should be organized according to the severity of symptoms (dyspnea and functional capacity), the degree of lung dysfunction, and the tolerance to specific drugs.1, 3 A step-wise approach similar in concept to that developed for systemic hypertension may be helpful because medications alleviate symptoms, improve exercise tolerance and quality of life, and may decrease mortality. Table 1, Table 2 provide a summary of the evidence

Therapies That Are Effective for the Nonrespiratory Manifestations of COPD

The most exciting changes in the way we conceptualize COPD is the recognition of the extrapulmonary manifestations of COPD.5, 111, 112 Some of the most important advances in the therapy of COPD center on our capacity to impact on the disease without having to necessarily alter lung function. Two of the proven forms of therapy for COPD fall within this category: pulmonary rehabilitation and oxygen therapy. If we add mechanical ventilation during exacerbations, the field is wide open to explore

Pulmonary Rehabilitation

Pulmonary rehabilitation is an essential component of the comprehensive management of patients with symptomatic COPD.1, 2, 113, 114, 115, 116, 117, 118, 119, 120 Patients with moderate-to-moderately severe disease are the best candidates for treatment, for whom the disabling effects of end-stage respiratory failure can be prevented. The rehabilitation program should have resources available to teach and supervise respiratory therapy techniques such as oxygen, use of inhalers and nebulizers,

Supplemental Oxygen Therapy

The results of the Nocturnal Oxygen Therapy Trial42 and Medical Research Council study43 showed that supplemental oxygen improves survival in patients with hypoxemic COPD. Other beneficial effects of long-term oxygen include reductions in polycythemia, pulmonary artery pressures, dyspnea, hypoxemia during sleep, and reduced nocturnal arrhythmias. Importantly, oxygen can also improve neuropsychiatric testing124, 125 and exercise tolerance.126, 127, 128 Oxygen supplementation to patients who

Exacerbations

An exacerbation is an event in the natural course of the COPD characterized by a change in the patient's baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in management.1, 3, 129, 130 Care must be taken to rule out heart failure, myocardial infarction, arrhythmias, and pulmonary embolism, all of which may present with clinical signs and symptoms similar to exacerbation of COPD. An algorithm describing a rational approach to exacerbations is

Conclusion

Over the years, our knowledge about COPD and the capacity to treat it have increased significantly. We now know that COPD is not just a disease affecting the lungs,140 but that it has important systemic consequences.141 Smoking cessation campaigns have resulted in a decrease in smoking prevalence in the United States. Similar efforts in the rest of the world should have the same impact. The widespread application of long-term oxygen therapy for hypoxemic patients has resulted in increased

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