Chronic obstructive pulmonary disease (COPD) is preventable, common and treatable, and yet is a leading cause of morbidity and mortality worldwide. In fact, projections show it could be the third leading cause of death by 2020. Healthcare provider familiarity with COPD prevention, treatment and effective management is important so that they may help educate patients on disease prevention or to help improve health status and reduce mortality if the disease emerges.
COPD typically presents with symptoms of chronic bronchitis and emphysema, which include breathlessness, cough with colorless sputum that is usually worse in the morning, acute chest illness and wheezing. There are multiple risk factors for the disease, but exposure to tobacco smoke is the primary cause, accounting for approximately 90% of COPD risk. Other factors include airway hyperresponsiveness, intravenous drug use, and immunodeficiency syndromes. In order to confirm a COPD diagnosis, persistent airflow limitation needs to be established, by way of assessment of symptoms, risk factors, and spirometry (post-bronchodilator FEV1/FVC <0.7).
The assumed pathogenic mechanism involves increased numbers of activated polymorphonuclear leukocytes and macrophages releasing elastase. Free radicals in cigarette smoke cause increased oxidative stress which leads to cellular apoptosis or necrosis, resulting in lung destruction. Smoking cessation is a necessary part of treatment. It is also important for those with the disease to maintain influenza and pneumococcal vaccinations, to help themselves avoid having to contend with severe respiratory illness.
Stable COPD can be treated through pharmacological means. Common therapies include:
- Short-acting beta2-agonist bronchodilators (e.g., albuterol, levalbuterol)
- Long-acting beta2-agonist bronchodilators (e.g., salmeterol, formoterol)
- Antimuscarinic antagonists (formerly referred to as anticholinergics), both short-acting (e.g., ipratropium) and long-acting (e.g., tiotropium)
- Inhaled corticosteroids (e.g., fluticasone, budesonide)
The Global Initiative for Chronic Lung Disease (GOLD) program has produced recommendations for COPD management since 2001. Its 2018 report is a minor revision of its 2017 report, which conveyed several updated guidelines. The first of these covered the newer determination to separate symptom evaluation from spirometric assessment in diagnosing COPD and the placement of patients into ABCD groups that guide therapy; the assessment types are both still vital, but the refinement allows for more precise treatment recommendations. Next is the addition of escalation and de-escalation treatment strategies; earlier GOLD reports only covered initial therapy recommendations. Emphasis was also made to the nonpharmacologic therapies available, which reach from education to treatment of hypercapnia to surgery. Lastly, the report expounded the importance of management of comorbidities, pointing out that there should be attention paid to ensure simplicity of treatment and minimize polypharmacy.
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2018 Global Strategy for Prevention, Diagnosis and Management of COPD. Global Initiative for Chronic Obstructive Lung Disease website.
http://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. Updated November 20, 2017. Accessed February 6, 2018.
Managing Chronic Obstructive Pulmonary Disease. Laura Blackler, Christine Jones, Caroline Mooney. John Wiley & Sons, Sep 27, 2007.
Pathogenesis of Chronic Obstructive Pulmonary Disease. William MacNee. Proc Am Thorac Soc. 2005 Nov; 2(4): 258–266.