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Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease – A Contemporary View
Lorenzo W Klein
1
and Paul D Scanlon
2
1. Fellow; 2. Professor of Medicine, Pulmonary and Critical Care Medicine, Mayo Clinic
Abstract
Chronic obstructive pulmonary disease (COPD) is a major health challenge worldwide. Recent advances in our understanding of this
condition accompanied by increased funding for research have led to improved and novel treatment approaches. The purpose of this
article is to familiarise practitioners with the current treatment guidelines for COPD, including supportive interventions such as pulmonary
rehabilitation. We point out common errors and misconceptions in the treatment of COPD, in particular underutilisation of long-acting
bronchodilators and overuse of inhaled corticosteroids. COPD is a chronic yet treatable disease, with important benefits for patients in
terms of quality and longevity of life when current treatment options are applied appropriately.
Keywords
Chronic obstructive pulmonary disease (COPD), pulmonary disease, chronic obstructive, bronchodilator agents, long-acting bronchodilators,
salmeterol, tiotropium, COPD exacerbation
Disclosure: Lorenzo W Klein has no conflicts of interest to declare. Paul D Scanlon receives salary support from clinical research studies sponsored by Boehringer Ingelheim,
Dey L.P. Pharmaceutical, GlaxoSmithKline, Novartis AG and Pfizer Inc. He has no related investments and receives no other income related to the subject of this manuscript.
Acknowledgement: Reprinted with permission from Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: Updated
2007 – Executive Summary. Global Initiative for Chronic Obstructive Lung Disease (GOLD)™, © 2006 Medical Communications Resources, Inc., www.goldcopd.com/
Guidelineitem.asp?l1=2&l2=1&intId=996
Received: 19 August 2008 Accepted: 8 July 2009
pscanlon@mayo.edu
Chronic obstructive pulmonary disease (COPD) is very common and is Treatment of Chronic Obstructive
increasing in prevalence, particularly in the developing world. In the Pulmonary Disease
US it is the fourth leading cause of death and was responsible for The management of COPD has been refined in recent years with
119,000 deaths in 2000 alone. It has a similar impact throughout the rapid evolution of the evidence base for therapy. Evidence- and
economically developed world. In developing countries, its adverse consensus-based guidelines have been developed. Two are widely
impact is growing rapidly. It is expected to be the fifth leading cause used, and are concordant in important details. They include the
of death worldwide by 2020.
1
Until recently, an inappropriate nihilistic Global Initiative for Chronic Obstructive Lung Disease (GOLD)
attitude has prevailed regarding COPD. It is often stated that COPD is guidelines (www.goldcopd.com/) and the Standards for the
not curable; however, this is true of many, perhaps most, diseases Diagnosis and Management of Patients with COPD by the American
encountered in internal medicine. It is not a cause for despair. COPD Thoracic Society (ATS) and the European Respiratory Society (ERS)
is a treatable and preventable disease. With appropriate treatment, (www.thoracic.org/sections/copd/index.html). The GOLD guidelines
symptoms, pulmonary function, exercise capacity and quality of life were updated in 2007,
3
and the ATS/ERS guidelines in 2004. There is
can be improved and the frequency of exacerbations reduced. Recent still a gap in understanding and compliance with these guidelines.
evidence even indicates improved survival with therapy for advanced
disease. The vast majority of persons with COPD have mild or COPD is commonly misdiagnosed. It is overdiagnosed in the elderly
moderate disease and need little or no medical intervention to and those with related symptoms and underdiagnosed in those with
stabilise their lung function. Persons with COPD, particularly those in early-stage disease. Other disorders are commonly mislabelled as
the early stages, are more likely to die of other diseases, particularly COPD; in fact, we sometimes observe that most respiratory disorders
lung cancer and cardiovascular disorders.
2
are “COPD until the correct diagnosis is made”.
4
Spirometry, the key to
correct diagnosis and staging, is underutilised in primary care
Until recently, research in COPD has been chronically underfunded. In practices. Currently, no guideline exists for the use of spirometry for
the past few years, the National Heart, Lung, and Blood Institute early diagnosis in asymptomatic smokers. The GOLD recommendation
(NHLBI) and other research funding agencies have increased funding to use a forced expiratory volume in one second (FEV
1
):forced vital
for research into COPD. The research community has responded by capacity (FVC) ratio of <0.70 to define obstruction is controversial.
improving its understanding of the disease and by beginning further There is good evidence that this recommendation will result
development in treatment. in overdiagnosis of obstruction in the elderly
5
and underdiagnosis in
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