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iDiS PEARLs:
Prompt Evidence Assessment and Review of the Literature
 

Breathless ... Current concepts in managing chronic obstructive pulmonary disease

 

COPD is one of the most common problems in primary care, and a major cause of disability and death. These evidence-based recommendations can help optimize functional status.

The root of most evil:

       Smoking is by far the most common cause of COPD.1  About 80% of smokers develop COPD, and 20% do so rapidly.2  A small percentage of COPD cases are caused by occupational dust and fumes.3  The amount of tobacco smoked generally predicts the rate of pulmonary damage.  Quitting can slow the loss of respiratory function, even in long-time smokers.

Diagnosis

       COPD should be considered in any patient with dyspnea, chronic cough, or chronic sputum production and/or a history of exposure to COPD risk factors (especially tobacco).1, 3, 5

        Spirometry is used to diagnose COPD by measuring Forced Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC).  An FEV1/FVC less than 0.7 combined with a post-bronchodilator FEV1 less than 80% of the predicted value confirm the presence of airflow limitation that is not fully reversible.3, 6, 7  Follow-up spirometry can also be useful as a means of assessing treatment response.  However, spirometry results don’t always correlate exactly with changes in the patient’s functional status; there’s still a role for a careful history.

 

Managing stable disease

        Aggressive treatment can alter the natural history of the disease, and non-drug approaches are a vital foundation of therapy.8, 9 

 Smoking Cessation

        Stopping tobacco use is the most effective single intervention to delay the development of COPD, slow the rate of decline in lung function, reduce the risk of exacerbations, and delay the onset of disability and mortality.10, 11  It should be the cornerstone of management in smokers.12  

        Even a brief intervention by a clinician can be effective for many patients.  The key steps for brief intervention are the “5 As”:
  • Ask: Identify tobacco users at every visit.
  • Advise: Strongly urge all smokers to quit, using a clear, personalized message.
  • Assess: Determine willingness to make a quit attempt.
  • Assist: Help the patient develop a quit plan, including counseling, social supports, pharmacotherapy, and supplementary materials.
  • Arrange: Schedule follow-up contact, in person or by telephone.

        Pharmacological options to assist with smoking cessation include nicotine replacement therapy (gum, lozenges, patches, inhaled), bupropion (generic, Zyban, Budeprion, Buproban), and varenicline (Chantix).  Smoking cessation is more likely to succeed when drug therapy is combined with other interventions such as education and behavior modification.

       A clinical guideline, "Treating Tobacco Use and Dependence: 2008 Update", sponsored by the Department of Health and Human Services, describes treatments for tobacco dependence and provides information on quitting. It includes materials for clinicians and patients, and is available at

http://www.surgeongeneral.gov/tobacco/default.htm.

 Pulmonary Rehabilitation

       Pulmonary rehabilitation programs can increase exercise capacity, reduce dyspnea, improve health-related quality of life, help control anxiety and depression, prevent exacerbations and hospitalization, and possibly reduce mortality.1, 3, 13, 14

 Drug therapy

       Inhaled bronchodilators form the cornerstone of pharmacotherapy in stable COPD, supplemented when necessary with inhaled corticosteroids (ICS).  Drug therapy can significantly improve symptoms, quality of life, lung function, and exercise performance, and reduce the frequency of exacerbations.

       Inhaled bronchodilators (β-agonists and anticholinergics) are available as short- and long-acting agents.  Combining bronchodilators of different pharmacologic classes may be more effective than increasing the dose of a single agent.    

The benefit of therapy is best assessed by asking the patient:1 

·         Is your treatment helping you?

·         Is your breathing easier in any way?

·         Can you do some things now that you couldn’t do before or do the same things faster?

·         Do you get less breathless when you are doing the things you did before?

·         Has your sleep improved?

Always ensure the patient knows how to use the inhaler device effectively and understands its purpose.

 

Management at various stages of disease

       COPD is progressive, characterized by a steady decline in lung function and functional status that can be accelerated by acute exacerbations.

Managing exacerbations

       The downward progression in respiratory status for most COPD patients is often punctuated by acute decompensations requiring additional treatment.  These should be addressed promptly and aggressively.17-19

 

References:

  1.  

    1. American Thoracic Society, European Respiratory Society. Standards for the diagnosis and management of patients with COPD. Available at:

    http://www.thoracic.org/sections/copd/index.html. 2004.  2. Doherty DE, Briggs DD, Jr. Chronic obstructive pulmonary disease: epidemiology, pathogenesis, disease course, and prognosis. Clin Cornerstone. 2004;Suppl 2:S5-16.  3. Global Initiative for Chronic Obstructive Lung Disease (GOLD), Global Strategy for Diagnosis, Management, and Prevention of COPD: Guidelines. Available at: http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003. 2008.  4. Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. Jun 25 1977;1(6077):1645-1648.  5. National Institute for Clinical Excellence. Clinical Guidelines for COPD.  Available at:

    http://www.nice.org.uk/page.aspx?o=104441

     

    . 2004.  6. Pauwels RA, Rabe KF. Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet. Aug 14 2004;364(9434):613-620.  7. Weiss ST, DeMeo DL, Postma DS. COPD: problems in diagnosis and measurement. Eur Respir J Suppl. Jun 2003;41:4s-12s.  8. Briggs DD, Brixner DI, Cannon HE, George DL. Overview of chronic obstructive pulmonary disease: new approaches to patient management in managed care systems. J Manag Care Pharm. 2004;10(4 Supplement A):S1-S25.  9. van der Valk P, Monninkhof E, van ver Palen J, Zielhuis G, van Herwaarden C. Management of stable COPD. Patient Educ Couns. Mar 2004;52(3):225-229.  10. Reilly JJ. COPD and declining FEV1--time to divide and conquer? NEJM. Oct 9 2008;359(15):1616-1618.  11. Au DH, Bryson CL, Chien JW, et al. The effects of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations. J Gen Intern Med. Apr 2009;24(4):457-463.  12. Celli BR, Thomas NE, Anderson JA, et al. Effect of pharmacotherapy on rate of decline of lung function in chronic obstructive pulmonary disease: results from the TORCH study. Am J Respir Crit Care Med. Aug 15 2008;178(4):332-338.  13. Doherty DE, Briggs DD, Jr. Long-term nonpharmacologic management of patients with chronic obstructive pulmonary disease. Clin Cornerstone. 2004;Suppl 2:S29-34.  14. Casaburi R, ZuWallack R. Pulmonary rehabilitation for management of chronic obstructive pulmonary disease. NEJM. Mar 26 2009;360(13):1329-1335.  15. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. Sep 24 2008;300(12):1439-1450.  16. Nannini L, Cates CJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta-agonist in one inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007(4):CD003794.  17. Blanchard AR. Treatment of acute exacerbations of COPD. Clin Cornerstone. 2003;5(1):28-36. 18. Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. Eur Respir J Suppl. Jun 2003;41:46s-53s.  19. Hurst JR, Wedzicha JA. Chronic obstructive pulmonary disease: the clinical management of an acute exacerbation. Postgrad Med J. Sep 2004;80(947):497-505.

 

Additional references documenting these recommendations are provided in the evidence document accompanying this material.

This material was produced by Leslie Jackowski, B.Sc.(Hon).,MBBS, Research Fellow, Harvard University; Niteesh K. Choudhry, M.D., Ph.D., Assistant Professor of Medicine, Harvard Medical School; Michael A. Fischer, M.D., M.S., Assistant Professor of Medicine, Harvard Medical School and William H. Shrank, M.D., M.S.H.S., Assistant Professor of Medicine, Harvard Medical School. Series editor: Jerry Avorn, M.D., Professor of Medicine, Harvard Medical School. Drs Avorn, Choudhry, Fischer, and Shrank are all physicians at the Brigham and Women’s Hospital in Boston. None of the authors receives any personal compensation from any drug company.

The Independent Drug Information Service (iDiS) is supported by the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania, the Massachusetts Department of Public Health, and the Washington, D.C. Department of Health .

This material is provided by the nonprofit Alosa Foundation, which is not affiliated in any way with any pharmaceutical company.

These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient’s clinical condition.