This seminar is based on a comprehensive review of work published between 1966 and 2002 (Medline, Cochrane Library databases) with the keywords “chronic obstructive pulmonary disease” and the terms “chronic bronchitis”, “emphysema but not bronchitis unspecified”. The information reviewed inevitably reflects a personal perspective, but the studies selected are those we believe contribute most to the epidemiology, pathobiology, and management of the disease. In the case of treatment
SeminarChronic obstructive pulmonary disease
Section snippets
Definition
Patients with COPD have been poorly served by clinicians' inability to agree on a simple formulation of their illness that captures both its biology and its effect on their lives. Early attempts relied on epidemiological definitions of chronic cough and sputum production lasting for 3 months over a period of at least 2 years (chronic bronchitis) or on the presence of emphysema in pathological specimens. In practice, neither approach was of much help in clinical management. A major step forward
Pathophysiology
Airflow obstruction in COPD arises as a result of variable degrees of narrowing, smooth-muscle hypertrophy, and fibrosis in the respiratory bronchioles25, 26 and loss of elastic recoil pressure due to pulmonary emphysema.27, 28 The physiological abnormalities that accompany these changes are shown in figure 2. The reduction in FEV1 that defines COPD is due mainly to an increase in resistance in the peripheral airways with a contribution from loss of elastic recoil. Attempts to define consistent
Physiological consequences
Advances in the biology of COPD have been accompanied by improved understanding of the factors leading to the disabling symptoms, particularly exercise-induced breathlessness. The development of simpler methods that reliably detect expiratory flow limitation during breathing at rest50 and measure inspiratory capacity and hence end-expiratory lung volume during exercise51 has enabled a convincing explanation of the origin of dyspnoea, at least in severe disease. Figure 4 shows that in patients
Clinical assessment
The diagnosis of COPD is based on a typical history of persistent progressive symptoms, an appropriate risk factor (eg, cigarette smoking), and a confirmatory spirometric test. Despite much discussion and a clear difference between North America and Europe in its definition,15, 17, 18 bronchodilator reversibility testing plays only a small part in the assessment of the COPD patient. A useful feature for confirmation of the diagnosis is that the patient's lung function does not return to normal
Treatment approaches
These fall into three broad areas: prevention of disease progression, management of stable disease, and management of exacerbations. There is now a much firmer evidence base for many of the management suggestions incorporated in the various guidelines.15, 16, 17, 18, 19
Prevention of disease progression
Smoking cessation early in the natural history of COPD not only returns the subsequent rate of declining function towards normal but also reduces future mortality,20 as confirmed by the 11-year follow-up of the original Lung Health Study population62 (figure 5). Whether this is true in more advanced disease is still unclear, but ex-smokers have better health status than current smokers with a similar degree of lung-function impairment.63 Although patients with COPD are not easily persuaded to
Management of stable disease
Management should involve several different treatment approaches and should be directed at control of symptoms, improvement in exercise capacity, and prevention of exacerbations (figure 6).
Since airflow obstruction is a constant feature of COPD, a reasonable approach is to try to maintain effective bronchodilation continuously. This aim is now possible with negligible side-effects by use of long-acting inhaled β agonist or anticholinergic drugs.69, 70, 71, 72, 73, 74 The greater side-effect
Management of exacerbations
The most recent definition for these events is given in panel 2.106 Exacerbations become progressively more troublesome as baseline lung function declines and patients who have frequent exacerbations have worse health status107 and may show more rapid deterioration in lung function than those who seldom have exacerbations.108 Previous viral infection accounts for about 30% of exacerbations,109 with bacterial infection present in 30–50% of cases, depending on the severity of the episode.110, 111
Future progress
The next 5 years should see improvements in our understanding of many areas relevant to COPD. A selection of some of the more promising areas is given in panel 3.
The epidemiology of the disease will continue to change with a steady rise in the number of cases identified among women. A more comprehensive description of the physiological abnormalities accompanying expiratory flow limitation at rest is likely, as well as the development of simpler ways to detect this feature. The use of CT to
Search strategy
References (128)
- et al.
Mortality by cause for eight regions of the world: Global Burden of Disease Study
Lancet
(1997) - et al.
Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study
Lancet
(1997) - et al.
Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study
Lancet
(1997) - et al.
Collagenase expression in the lungs of transgenic mice causes pulmonary emphysema
Cell
(1992) Expiratory flow limitation: Roger S Mitchell Lecture
Chest
(2000)- et al.
Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD
Chest
(2002) - et al.
Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial
Lancet
(2001) - et al.
Efficacy of salmeterol xinafoate in the treatment of COPD
Chest
(1999) - et al.
A 6 month placebo controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol
Chest
(2002) - et al.
Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
(1999)
Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
Randomised controlled trial of respiratory rehabilitation
Lancet
Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial
Lancet
The Global Burden of Disease 2000 Project: global programme on evidence for health policy discussion, paper number 36
NHLBI Morbidity and Mortality Chartbook, 2002. Bethseda: US Department of Health and Human Services, Public Health Service, 2002
Recent trends in physician diagnosed COPD in women and men in the UK
Thorax
A self-complete measure of health status for chronic airflow limitation: the St George's respiratory questionnaire
Am Rev Respir Dis
Life quality of patients with chronic obstructive pulmonary disease
Arch Intern Med
Determinants of health-related quality of life in patients with chronic obstructive pulmonary disease
Thorax
Comparison of discriminative properties among disease-specific questionnaires for measuring health-related quality of life in patients with chronic obstructive pulmonary disease
Am J Respir Crit Care Med
Living with COPD: results of the British Lung Foundation survey
The impact of COPD in North America and Europe in 2000: the patients perspective of the Confronting COPD International Survey
Eur Respir J
Standards for the diagnosis of patients with chronic obstructive pulmonary disease (COPD) and asthma
AmRev Respir Dis
Guidelines for the assessment and management of chronic obstructive pulmonary disease
Can Med Assoc J
Optimal assessment and management of chronic obstructive pulmonary disease
Eur Respir J
BTS guidelines for the management of chronic obstructive pulmonary disease
Thorax
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary
Am J Respir Crit Care Med
The natural history of chronic airflow obstruction
BMJ
The relevance in adults of air-flow obstruction, but not of mucus hypersecretion, to mortality from chronic lung disease: results from 20 years of prospective observation
Am Rev Respir Dis
Domestic smoke pollution and respiratory function in rural Nepal
Tokai J Exp Clin Med
Prevalence of chronic bronchitis in a rural community of the hill region of Nepal
Thorax
Exposure to biomass smoke and chronic airway disease in Mexican women: a case-control study
Am J Respir Crit Care Med
The relations between structural changes in small airways and pulmonary function tests
N Engl J Med
Chronic airflow obstruction
The progress of chronic airway obstruction in relation to measurements of airway resistance and lung elastic recoil
Am Rev Respir Dis
Pulmonary conductance and elastic recoil relationships in asthma and emphysema
J Appl Physiol
Differences in interleukin-8 and tumor necrosis factor-alpha in induced sputum from patients with chronic obstructive pulmonary disease or asthma
JRespir Crit Care Med
Inflammatory cells and mediators in bronchial lavage of patients with chronic obstructive pulmonary disease
Eur Respir J
Airway inflammation in severe chronic obstructive pulmonary disease: relationship with lung function and radiologic emphysema
Am J Respir Crit Care Med
CD8+ve cells in the lungs of smokers with chronic obstructive pulmonary disease
Am J Respir Crit Care Med
Inflammation in bronchial biopsies of subjects with chronic bronchitis: inverse relationship of CD8+ T-lymphocytes with FEV1
Am J Respir Crit Care Med
Amplification of inflammation in emphysema and its association with latent adenoviral infection
Am J Respir Crit Care Med
Differences in airway inflmmation in patients with fixed airflow obstruction due to asthma or chronic obstructive pulmonary disease
Am J Respir Crit Care Med
Alpha 1 antitrypsin polymerisation and the serpinopathies: pathobiology and prospects for treatment
J Clin Invest
Increased nitrosothiols in exhaled breath condensate in inflammatory airway diseases
Am J Respir Crit Care Med
Exhaled 8-isoprostane as an in vivo biomarker of lung oxidative stress in patients with COPD and healthy smokers
Am J Respir Crit Care Med
Superoxide mediates cigarette smoke-induced infiltration of neutrophils into the airways through nuclear factor-kappa B activation and IL-8 mRNA expression in guinea pigs in vivo
Am J Respir Cell Mol Biol
Requirement for macrophage elastase for cigarette smoke-induced emphysema in mice
Science
Cited by (239)
Expanding role of deoxyribonucleic acid-sensing mechanism in the development of lifestyle-related diseases
2022, Frontiers in Cardiovascular MedicineRehabilitation
2022, Pathy's Principles and Practice of Geriatric Medicine