Elsevier

The Lancet

Volume 364, Issue 9436, 28 August–3 September 2004, Pages 791-802
The Lancet

Seminar
Treatment of stable chronic obstructive pulmonary disease

https://doi.org/10.1016/S0140-6736(04)16941-9Get rights and content

Summary

Chronic obstructive pulmonary disease (COPD) is a readily diagnosable disorder that responds to treatment. Smoking cessation can reduce symptoms and prevent progression of disease. Bronchodilator therapy is key in improvement of lung function. Three classes of bronchodilators— β agonists, anticholinergics, and theophylline—are available and can be used individually or in combination. Inhaled glucocorticoids can also improve airflow and can be combined with bronchodilators. Inhaled glucocorticoids, in addition, might reduce exacerbation frequency and severity as might some bronchodilators. Effective use of pharmacotherapy in COPD needs integration with a rehabilitation programme and successful treatment of co-morbidities, including depression and anxiety. Treatment for stable COPD can improve the function and quality of life of many patients, could reduce admissions to hospital, and has been suggested to improve survival.

Introduction

Two major problems facing the clinician treating the stable COPD patient are diagnosis and attitude. First, COPD is underdiagnosed.1, 2 Even when diagnosed, the clinical importance of the disease is often underestimated.3 This underestimation might reflect, in part, an inappropriate inclination of many clinicians toward therapeutic nihilism for COPD patients. This attitude might be based on the historical approach toward such patients as stated by Williams in Middle and Old Age (Oxford Medical Publications), quoted by Fletcher and colleagues4: “Chronic bronchitis with it accompanying emphysema is a disease on which a good deal of wholly unmerited sympathy is frequently wasted. It is a disease of the gluttonous, bibulous, otiose, and obese and represents a well-deserved nemesis for these unlovely indulgences … the majority of cases are undoubtedly due to surfeit and self-indulgence.” This attitude toward COPD patients is inappropriate not only for its lack of compassion, but, at the present time, because therapeutic interventions for stable patients can result in substantial clinical benefit. This Seminar will highlight current approaches to the management of stable COPD patients. Issues relating to clinical features of COPD, its pathophysiology, and management of its severe form, including surgical treatments and ventilatory support, and future therapies are addressed elsewhere in this Series.

Several sets of guidelines by various societies provide definitions, classifications, and management strategies for COPD. The widely cited documents prepared by the American Thoracic Society,5 the European Respiratory Society,6 and the GOLD Guidelines organised by a collaboration of the National Heart, Lung and Blood Institute and WHO7 have been updated.8, 9 A stepwise approach to therapy based on the five stages of disease severity has been suggested in the recent revision of the GOLD Guidelines (Figure 1).8 This guidance provides an excellent basis for the clinician to begin therapy, although COPD patients are heterogeneous, and therapy should be individualised. Although ongoing research promises to help understand this heterogeneity and might help the clinician predict individual therapeutic responses, every COPD patient treated could be regarded as an individual clinical trial.

Section snippets

Smoking cessation

Cigarette smoking is the single most important risk factor for the development of the disease. In the USA, about 80% of patients with COPD are current or former smokers,1 and smoking accounts for about 80% of the mortality attributable to COPD.10 Smoking cessation substantially improves the rate at which lung function is lost in patients with mild COPD.11, 12, 13 Smoking cessation can also reduce symptoms of cough and sputum production,14 and can reduce airways reactivity.15 Smoking cessation,

Behavioural support

Many studies have shown that behavioural support can increase quit rates in smokers.16, 27 The more behavioural support provided, both in terms of number of sessions and duration of sessions, the greater the quit rates. The most intensive programmes generally report cessation rates of about 20% with behavioural support alone, although it is likely that those who participate in such programmes are more highly motivated than those who don't.31 Whereas intensive behavioural interventions are

Pharmacological support

Pharmacological support should be provided for all smokers for whom it is not contraindicated and who are willing to use medications.16 There are two first-line categories of pharmacological support and two second-line.

Treatment of symptomatic COPD

Most patients with COPD lose lung function slowly and gradually over a period of decades. As lung function is slowly compromised, physical limitations occur insidiously.4 Since patients with the disease typically develop dyspnoea with exertion, individuals will often compromise their level of activity and thus avoid specific complaints. As a result, patients often present with symptoms of dyspnoea only after lung function is severely compromised. The astute clinician, however, might be able to

Inhaled glucocorticoids

Inhaled glucocorticoids have been assessed in four large clinical trials87, 88, 89, 90 to look for an effect in altering the natural history of COPD. None of these showed a significant effect in reducing the rate at which lung function declines. Although a meta-analysis91 suggested that, a 5 mL per year beneficial effect in the rate of FEV1 decline was seen, this finding was not significant. Inhaled glucocorticoids, therefore, are not currently recommended for routine use in COPD patients to

Influenza

Viral infections are a major cause of COPD exacerbations and are associated with increased mortality.108 Influenza vaccination has been reported to reduce serious illness and death in COPD patients by 50%.109 Since many patients with the disease are elderly, as with other elderly patients, vaccines containing killed or live inactivated virus are recommended.8, 110 The strain of virus should be appropriate for the year, and the vaccination should be given either once in the autumn or twice in

Conclusion

COPD is a highly prevalent disorder associated with both recognised and unrecognised morbidity. Currently available treatments can be highly effective in managing patients' symptoms and in improving several key clinical outcomes. The successful implementation of these therapies, however, needs a comprehensive management plan individualised for each patient. COPD, therefore, should not engender therapeutic nihilism, but should be approached aggressively with the recognition that optimal patient

Search strategy and selection criteria

References for this review were collected by several criteria. First, therapeutic recommendations indicated by major guidelines were collected and, where appropriate, compared with earlier versions of the same guidelines. These included the GOLD guidelines (www.goldcopd.com) and the updated guidelines of the American Thoracic Society and European Respiratory Society (www.thoracic.org) on COPD; the US DHHS practice guideline on smoking cessation;16 and the pulmonary rehabiliation guideline.115

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