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Strategies in Preserving Lung Health and Preventing COPD and Associated Diseases: The National Lung Health Education Program (NLHEP)
Section snippets
Background
This special supplement represents the resource document for a new national health-care initiative that is aimed at preventing or forestalling premature morbidity and mortality from COPD and related disorders. COPD is now the fourth most common cause of death in the United States and will account for >105,000 deaths in 1997. COPD is the only major disease that is rising in prevalence and mortality; all other major causes of death are declining. An abnormal spirometry result is a marker for not
Definitions
COPD is an all-inclusive and nonspecific term that refers to a defined set of breathing-related symptoms:10, 11 chronic cough, expectoration, varying degrees of exertional dyspnea, and a significant and progressive reduction in expiratory airflow. Most patients with COPD are smokers. This airflow abnormality does not show major reversibility in response to pharmacologic agents. Hyperinflation and a reduced diffusing capacity may be present. Inflammatory damage to both airways (asthmatic and
Pathophysiology
Limitation of airflow can result from several pathophysiologic mechanisms.12, 13, 14, 15 Contraction of airway smooth muscle can narrow airways and obstruct airflow. This mechanism likely plays an important role in asthma and may also contribute to airflow obstruction in other forms of COPD. Narrowing of airways can also be affected by inflammation, edema, and peribronchiolar fibrosis that can both distort and narrow the airways.15 Mechanisms that cause these inflammatory changes may be
Magnitude of the Problem and Socioeconomic Differences
In the United States, COPD is the fourth leading cause of death after heart disease, cancer, and stroke.40 These diseases are present in nearly 16 million persons, and in 1993, there were >500,000 hospitalizations, 14 million physician office visits, and nearly 96,000 deaths from COPD, excluding asthma (Tables 1 and 2). Prevalence and mortality have been increasing appreciably and in contrast to many leading chronic diseases.41 As life expectancy increases, greater prevalence and mortality from
Early Airflow Decline as a Predictor of COPD
The natural history of COPD is characterized by slowly progressive limitation of expiratory airflow. This can be well assessed by simple spirometry and only two parameters, the FEV1 and the FVC, need to be measured to obtain almost all the useful information available.48 Variations in natural history are probably related to differences in the dose and influence of various risk factors. Beyond question and by common consensus, the most important risk factor is cigarette smoking. Fortunately, it
Signs and Symptoms
Significant overlaps exist in signs and symptoms among the three major diseases of airflow obstruction: asthmatic bronchitis, chronic bronchitis, and emphysema. The large overlap has been long noted and well illustrated in Venn diagram fashion (Fig 4).11 Nevertheless, signs and symptoms of COPD have been well characterized and can be identified through appropriate history and physical examination. While acute, episodic, or even perennial but reversible asthma does not strictly fall under the
Prevention
Prevention is the goal of all of medicine. This includes both primary and secondary prevention. Of course, it would be ideal to prevent COPD. The factors that impact on prevention are basically three.
The first is smoking, which is by far the greatest risk factor in the causation of COPD. Right now we are not making much progress in preventing teenagers from starting to smoke. This is because of the advertising success of the tobacco industry that daily seduces 3,000 teenagers into the high risk
Education
Healthy living practices provide the most effective method of preventing COPD. Avoidance of smoking is probably the single most important behavior to protect the lungs throughout life. This concept should be instilled as early in life as possible, through family, school, and the media, as well as the primary care practitioner at the time of an individual's routine health examination. The partnership of each person with his or her educators and health-care providers is important in maintaining
Clinical Management
Many management options are available for the clinician to relieve symptoms and improve quality of life in patients with all stages of symptomatic COPD. Only oxygen has been the subject of randomized controlled clinical trials, which showed it to increase survival and improve quality of life. In addition to oxygen, there are other strategies, including vaccines and other pharmacologic measures, recognized by clinicians to be valuable management tools for COPD. The benefits and limits of each of
NLHEP and the Primary Health Provider
Following a planning meeting and a major workshop, a new national strategy aimed at the early identification of and intervention in COPD and related disorders became formalized.155, 156 The NLHEP is conducted through an Executive Committee with membership from the ACCP, ATS, American College of Physicians, American Association for Respiratory Care, the American Association for Cardiovascular and Pulmonary Rehabilitation, the Society for General Internal Medicine, the National Heart, Lung, and
Indications for Consultation with a Pulmonologist
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Severe disease, including:
- a.
persistent dyspnea with activities of daily living despite adequate therapy, or
- b.
frequent recurrent exacerbations of COPD.
Consultation on these patients may address:
- a.
the evaluation of other etiologies of dyspnea
- b.
review of the therapeutic regimen and recommendations for revisions or additional therapy,
- c.
consideration of additional therapy for intractable dyspnea, including possible use of narcotics (to partially blunt excessive respiratory drives, especially
- a.
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Copies of this supplement can be ordered from the American College of Chest Physicians (1-800-343-2227; 1-847-498-1400).
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William C. Bailey, MD, FCCP; Gary T. Ferguson, MD, FCCP; Millicent Higgins, MD, FCCP; Leonard D. Hudson, MD, FCCP; R. Drew Miller, MD; Ray Masferrer, RRT; Sreedhar Nair, MD, FCCP; Stephen I. Rennard, MD, FCCP; Thomas L. Petty, MD, Master FCCP (Chair); Deborah Shure, MD, FCCP; Michele Hindi-Alexander, PhD; Gail Weinmann, MD; and Suzanne S. Hurd, PhD.