Scanlon.qxp 11/8/09 2:40 pm Page 26
Chronic Obstructive Pulmonary Disease
Figure 1: Therapy at Each Stage of Chronic Obstuctive information and guidelines for counselling about smoking cessation
Pulmonary Disease
have been published elsewhere.
8
Infections are the most common cause of acute exacerbations and
I: Mild II: Moderate III: Severe IV: Very severe
can cause significant morbidity at every stage of the disease. Yearly
influenza vaccinations are highly effective in reducing respiratory
FEV
1
/FVC <0.70
FEV
hospitalisations and are recommended for every patient with COPD.
1
<30%
FEV predicted or FEV Pneumococcal polysaccharide vaccine is recommended at five-year
FEV /FVC <0.70
1
/FVC <0.70
1

FEV
1
30% ≤ FEV <50% predicted
1
/FVC <0.70
50%
1
intervals
9
for patients with COPD who are above 65 years of age, and≤ FEV
FEV
1
<50% predicted plus chronic
1
≥80%
<80% predicted
predicted
respiratory failure for those with an FEV
1
<40% predicted at any age.
Active reduction of risk factor(s); influenza vaccination; In mild COPD (stage I, FEV
1
≥80% predicted), the use of short-acting
add short-acting bronchodilator (when needed)
bronchodilator (SABD) therapy is recommended for the relief of
Add regular treatment with one or more long-acting
symptoms. Symptomatic benefit varies and is the primary motivator
bronchodilator (when needed); add rehabilitation
for therapy, since SABDs do not modify the course of disease. The
choice of medication and use of a single agent versus a combination
Add inhaled glucocorticosteroids
if repeated exacerbations
should also be based on the symptomatic benefit. It is important to
train patients in the proper inhaler technique and re-assess frequency
Add long-term of use and inhaler technique at regular intervals.
oxygen if chronic
respiratory failure;
consider surgical In our view, SABDs should also be offered to active smokers if they
treatments
experience symptomatic benefit. There is no evidence for the common
Post-bronchodilator forced expiratory volume in one second (FEV
concern that providing active smokers with a medication that relieves
1) is recommended for the
diagnosis and assessment of the severity of chronic obstructive pulmonary disease (COPD).
their symptoms will make them less likely to quit; in fact, there is
Source: Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease, Updated 2007: Executive Summary (www.goldcopd.com/).
evidence that the opposite may be true. Likewise, there is no evidence
Reproduced with permission.
that use of SABDs increases the adverse effects of continued smoking.
2
younger, middle-aged persons. We agree with those who recommend In moderate COPD (stage II, FEV
1
<80% predicted), the addition of one or
use of the lower limit of normal rather than an FEV1:FVC ratio <0.70. more long-acting bronchodilator (LABD) is recommended. There are two
classes of LABD available: anticholinergic (only tiotropium is currently
Once the correct diagnosis has been established by spirometry and approved in the US, although aclidinium and glycopyrrholate are being
common confounding co-morbidities such as congestive heart failure developed) and long-acting beta-agonists (LABAs, including salmeterol
(CHF) and asthma have been excluded, treatment should be based on and formoterol, with indacaterol and others in development). All
the disease stage as defined by the GOLD guidelines (based mainly on categories of LADB have been shown to improve symptoms, exercise
spirometry results), which are accepted by several major medical tolerance and pulmonary function in COPD, although the improvement
associations (see Figure 1). Treatment consists of monitoring, risk in pulmonary function does not always correlate well with other
reduction, managing stable disease and preventing and treating improvements. The use of more than one LABD (e.g. tiotropium plus a
exacerbations. Most patients have stage I and II disease and are LABA) may produce additional symptomatic relief or may produce
managed in the primary care setting. The GOLD guidelines divide additional improvements in lung function or both. The combination does
management into four components: not reduce the frequency of exacerbations more than a single LABD.
10
• assessment and monitoring of disease; Pulmonary rehabilitation – a structured programme of exercise, diet and
• reduction of risk factors; lifestyle modification – is recommended for stage II COPD or greater. It is
• management of stable COPD, i.e. long-term therapy; and associated with improved symptoms, quality of life, and exercise
• management of acute exacerbations. tolerance. Reimbursement by Medicare and some private insurers is
poor and programmes are not as widely available as they could be.
For all stages of disease, risk factor reduction, immunisation and
the use of short active bronchodilators are recommended. An acute exacerbation of COPD (AECOPD) is defined as a sustained
increase in symptoms of COPD beyond the usual day-to-day variation.
Cigarette smoking is by far the greatest risk factor for COPD in This usually requires an unscheduled medical visit or the addition of
economically developed countries. Smoking cessation reduces the risk either an antibiotic or a systemic corticosteroid to the treatment
of developing COPD and halts its progression. Significant advances regime. Inhaled corticosteroids (ICS) are recommended for the
have been made in developing smoking cessation strategies, including treatment of patients with frequent (more than once per year)
the careful evaluation of old and new pharmacological therapies. exacerbations of COPD. There is strong evidence that they reduce the
Inquiry into and documentation of smoking habits and the assessment frequency of exacerbations by 20–35%; however, it is not entirely clear
of intention to quit should be performed at every visit. Even short that this benefit persists in the presence of tiotropium. Furthermore,
periods of counseling to urge a smoker to quit can produce cessation ICS appeared to increase the risk of pneumonia in several large clinical
rates of up to 5–10%.
6,7
The treating physician should be familiar with trials.
11–13
The trend towards improved survival associated with
the available local support for patients who are willing to quit in order salmeterol plus fluticasone in the Toward a Revolution in COPD Health
to provide the most practical advice. Details on how to obtain this (TORCH) trial appears to be primarily due to salmeterol.
14
26 EUROPEAN RESPIRATORY DISEASE
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