We searched PubMed with the search terms “COPD”, “phenotype”, “exacerbations”, “inhaled corticosteroids”, “inhaled bronchodilators”, “co-morbidity”, and “long-term antibiotics” for papers published up to 2011. There were no language restrictions. We also searched reference lists identified in articles that were found in the searches. Clinical practice guidelines were also included.
SeriesControversies in treatment of chronic obstructive pulmonary disease
Introduction
Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory disorder that affects millions of people worldwide. It has a major societal effect due to the high morbidity and mortality rates.1, 2 The main risk factors for the disease include cigarette smoke in most developed countries, but indoor air pollution, biomass fuel, and occupational exposures are increasingly recognised as major risk factors. Notably, knowledge about the immunological and pathological processes implicated in COPD are almost exclusively based on disease caused by cigarette smoke.3 Therefore, effective treatments are needed for non-smoking patients with COPD because these individuals are regularly excluded from clinical trials.
Patients with COPD frequently have comorbidities because smoking is a general risk factor for a range of other chronic illnesses such as cardiovascular disease and lung cancer, also peaking in prevalence in the fifth to sixth decades. Not only is COPD a heterogeneous disease with varying disease activity, but other comorbid illnesses might be major determinants of disease severity. The current focus on lung function impairment as the main or sole determinant of disease classification is no longer feasible for estimation of risk and prognosis. New treatment algorithms will need to be developed on the basis of our current understanding of COPD as a complex disorder that not only affects the lungs.4
Globally, the management of chronic non-communicable diseases, including COPD, is likely to become more complex in the rapidly ageing population. Health-care systems are increasingly challenged to offer affordable, humane care models, based on best current evidence. Treatment recommendations and guidelines rely on reported evidence. However, the systematic exclusion of patients from large clinical trials of COPD on the basis of complex comorbidities and age is one of the main obstacles in the generation of universally acceptable guidance for treatment. The participation of a broad range of medical specialties, and patient organisations, is needed to address the controversial issues before treatment guidelines can be drawn up. Here, we discuss the controversies in the treatment of COPD.
Section snippets
What defines disease severity?
The conceptual view of COPD has changed from a rather simplistic view of a cigarette-smoke-induced illness involving chronic bronchitis and varying degrees of lung emphysema to a complex disorder affecting patients’ lives on several levels. Previous attempts to classify the severity of the disease by spirometric methods such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification were logical, but the different classes of severity were chosen on the basis of expert
Should treatment be started early?
Data from the observational ECLIPSE study11 showed that 22% of patients with GOLD stage 2 (FEV1 50–79% predicted) moderate COPD already had frequent exacerbations (figure 1) and were thus at risk of rapid decline in FEV1, poor health status, hospital admission, and increased mortality rate.12, 13, 14 Severe disease was targeted in most interventional studies of symptomatic (bronchodilators) or anti-inflammatory treatments; therefore, little evidence exists for the benefit of therapy in early
When should inhaled corticosteroids be prescribed?
Inhaled corticosteroids are the main anti-inflammatory treatment for patients with asthma. They alone or in combination with longacting bronchodilator drugs are also used extensively in COPD, yet the airway inflammatory response is different in the two disorders, with a preponderance of CD8 lymphocytes and neutrophils in the airways of patients with COPD that are related to disease severity.30 Anti-inflammatory effects of inhaled corticosteroids in COPD and asthma were compared in only a few
Should treatment focus on cardiac comorbidities?
Because of the frequency of chronic comorbidities in patients with COPD54 and their effect on patient outcomes, including acute exacerbations,55, 56 a more comprehensive approach to COPD treatment might focus on these targets to modify the natural course of the disease.57, 58 This focus is particularly relevant for common comorbid disorders that seem more preventable and treatable than is COPD, such as cardiovascular and metabolic disorders. The available evidence seems to be increasingly in
What is the role of long-term antibiotics?
Although healthy people with normal lung function and without a history of smoking were thought to have a sterile lower respiratory tract, data suggest that the lungs have a bacterial microbiome that is diverse but different from that in the oral cavity and nasopharynx (figure 2).72, 73 In patients with COPD, there is evidence of the presence of airway bacteria in the lower airway in up to 50% of patients in the stable state by use of traditional bacterial culture techniques.74, 75, 76 Lower
How effective is management of acute exacerbations?
COPD exacerbations have an important effect on health status, disease progression, and mortality rate.85 An important goal of treatment of the acute exacerbation is to prevent hospital admission and reduce health-care costs. Patients often present late in the time course of the exacerbation and some evidence suggests that delayed treatment of exacerbation leads to longer exacerbations and hospital admission.86 Thus, a key objective of COPD management programmes must be early recognition of
Phenotypes of COPD and therapeutic consequences
The usefulness of conventional methods for the diagnosis, assessment, and management of COPD are debatable.101 The disease is defined by the presence of airflow limitation that is not fully reversible, and treatment is mostly guided by the severity of this limitation.45 COPD, however, is a complex disease, with a range of pulmonary and extrapulmonary components, and significant heterogeneity with respect to clinical presentation, physiology, imaging, response to treatment, decline in lung
Search strategy and selection criteria
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Understanding COPD: A vision on phenotypes, comorbidities and treatment approach
2016, Revista Portuguesa de Pneumologia (English Edition)COPD: A stepwise or a hit hard approach?
2016, Revista Portuguesa de Pneumologia (English Edition)Citation Excerpt :Current guidelines differ slightly on the recommendations for treatment of Chronic Obstructive Pulmonary Disease (COPD) patients, mainly because patient stratification is not consensual across guidelines.1–5 Although there are some undisputed recommendations, such as smoking cessation, physical activity programs, and influenza and pneumococcal vaccination, there is still debate regarding the management of COPD.6–12 The therapeutic approach proposed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and based solely on the GOLD classification of COPD,2 is not entirely satisfactory, given the variability within GOLD groups, namely regarding hospitalizations and mortality.13
Optimal treatment sequence in COPD: Can a consensus be found?
2016, Revista Portuguesa de Pneumologia (English Edition)Citation Excerpt :Table 2 and Fig. 1 summarize our proposals, suggestions and recommendations on COPD treatment sequence. Difficulties in early interventions (GOLD stage 1 and 2) are mainly due to low compliance, with increased mortality rate regardless of the type of therapy.12 A patient with dyspnea and fatigue will be more likely to comply with treatment whereas a less symptomatic patient will tend to be non-compliant.
New drug therapies for COPD
2014, Clinics in Chest MedicineThe Diagnosis and Treatment of COPD and Its Comorbidities
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