Elsevier

The Lancet

Volume 362, Issue 9389, 27 September 2003, Pages 1053-1061
The Lancet

Seminar
Chronic obstructive pulmonary disease

https://doi.org/10.1016/S0140-6736(03)14416-9Get rights and content

Summary

Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide. Recognition that the burden of this disorder will continue to increase over the next 20 years despite medical intervention has stimulated new research into the underlying mechanisms, leading to a rational basis for evaluation of existing therapies, and has suggested novel treatment approaches. Tobacco exposure remains the main but not exclusive cause of COPD. Whether the lung is injured by changes in the balance of proteases and antiproteases, tissue damage by oxidative stress, or a combination of the two is still not known. The genetic basis of susceptibility to COPD is now being studied as is the role of computed tomography in the identification of structural damage in individuals with less symptomatic disease. Clinical diagnosis still relies heavily on an appropriate history confirmed by abnormal spirometry. Smoking cessation is possible in a substantial proportion of individuals with symptoms but is most effective if withdrawal is supported by pharmacological treatment. Treatment with long-acting inhaled bronchodilators and, in more severe disease, inhaled corticosteroids reduces symptoms and exacerbation frequency and improves health status. Rehabilitation can be even more effective, at least for a year after the treatment. Recent guidelines have made practical suggestions about how to optimise these treatments and when to consider addition of oxygen, surgery, and non-invasive ventilation. Regular review of this guidance is important if future management advances are to be implemented effectively.

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

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

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