The American Journal of Medicine
Volume 120, Issue 8, Supplement 1 , Pages S1-S3, August 2007

Introduction

  • Robert A. Wise, MD

      Affiliations

    • Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • Corresponding Author InformationRequests for reprints should be addressed to Robert A. Wise, MD, Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine at the JHU Asthma and Allergy Center, 5501 Hopkins Bay View Circle, Room 4B.74, Baltimore, MD 21224.
    • ,
  • Donald P. Tashkin, MD

      Affiliations

    • Division of Pulmonary, Critical Care Medicine, and Hospitalists, David Geffen School of Medicine at UCLA, University of California–Los Angeles, Los Angeles, California

Article Outline

 

Chronic obstructive pulmonary disease (COPD) is a major health problem in the United States and worldwide.1 It is important to note that mortality rates for COPD are rising, while rates for other chronic diseases, such as heart disease, cancer, and stroke, are declining.1, 2 Because increased incidences of COPD-related mortality and morbidity have a negative impact on public health and the economy,1 there is an urgent need to control the growing epidemic of COPD.

Management of COPD poses a variety of challenges resulting from patients’ misconceptions about their disease and the negative attitude of healthcare professionals regarding the treatment and prognosis of these patients.3 Despite scientific advances leading to our understanding of the pathophysiology of COPD, clinical evidence based on pivotal trials, and the development of new therapies, much remains to be accomplished in preventing COPD and providing optimal patient care. COPD is a multifaceted problem requiring education in evidence-based medicine, practice management, and patient–provider communications to achieve meaningful improvements in patient care.

This supplement to The American Journal of Medicine is based on the proceedings of a CME-accredited regional dinner conference entitled “Creating Optimism in Managing Pulmonary Disease,” which was presented by the Johns Hopkins University School of Medicine, on October 10, 2006, in Brooklyn, New York. The articles in this supplement examine COPD prevalence, diagnosis, clinical evidence, appropriate application of treatment guidelines, and best practices for disease management and patient outcomes.

In the first article, we focus on the prevention of COPD and discuss various risk factors, diagnostic challenges, integration of spirometry into diagnosis, and the importance of smoking-cessation efforts. COPD is defined by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) as a disease state that is preventable and treatable.4 The identification of risk factors for COPD is important in developing strategies for its prevention and treatment. According to a US Surgeon General’s report, the leading cause of COPD is cigarette smoking: 80% to 90% of patients diagnosed with COPD have a history of smoking.5 The identification of cigarette smoking as a major risk factor has led to the development of smoking-cessation programs. Other risk factors for COPD include genetic components and occupational or environmental exposure.6, 7, 8

Educating patients about the avoidance of risk factors and motivating them to stop smoking cigarettes are central components in the management of COPD. It is also important to change the perception of patients and healthcare providers about COPD from one of nihilism to one of optimism that it is a preventable and treatable disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines state that smoking cessation is the single most clinically effective and cost-effective intervention to both reduce the risk for developing COPD and limit its progression.8 Clinical studies have demonstrated that smoking cessation slows the progression of COPD and decreases the associated risk for mortality.8, 9, 10, 11 Other treatment options, such as office-based behavioral intervention,12 “5 As strategy” (ask, advise, assess, assist, and arrange),8 telephone quitlines,13 and pharmacologic treatments,14, 15, 16, 17 have also been shown to help smokers—including patients with COPD—quit smoking.

COPD most often refers to patients with chronic bronchitis and/or emphysema with airflow obstruction.4, 18 Although a considerable symptomatic overlap exists between COPD and asthma, these 2 conditions are different. Patients with asthma can usually be distinguished because, unlike those with COPD, their airflow obstruction is usually completely reversible with treatment.4

The ATS/ERS and GOLD guidelines state that spirometry is essential for diagnosing COPD.4, 19 Spirometry not only helps diagnosis but it can also be useful for monitoring therapy and predicting prognosis over time. However, barriers and misperceptions have prevented its widespread use in office practice.20

Underdiagnosis of COPD by physicians is also a significant problem. The National Health and Nutrition Examination Survey (NHANES) III study (1988 to 1994) found that 24 million subjects had spirometric evidence of COPD, but only 10.5 million reported physician-diagnosed COPD.21

In our second article, we review both pharmacologic and nonpharmacologic treatment strategies for optimal management of COPD. The GOLD guidelines recommend step-care therapy at each stage of the disease, based on the need for symptom control.19 For patients with normal spirometry and chronic symptoms, and those with COPD stages I, II, III, and IV, avoidance of risk factors and vaccination against influenza are recommended. For those with few or intermittent symptoms and mild disease (stage I), short-acting inhaled bronchodilators alone can be used as needed to control dyspnea and coughing spasms. For patients with stage II (moderate), stage III (severe), or stage IV (very severe) COPD, in whom symptoms are not adequately controlled with as-needed use of short-acting bronchodilators, the GOLD guidelines recommend adding regular treatment with ≥1 long-acting inhaled bronchodilator. A number of short- and long-acting β2-agonists and short- and long-acting antimuscarinic agents are available for the management of symptoms.19 Whether a β2-agonist or an antimuscarinic agent is prescribed depends on availability of the drug and the symptom relief and adverse effects experienced by the patient.19

Several combination products containing a short-acting β2-agonist with a short-acting antimuscarinic agent or a long-acting β2-agonist with an inhaled corticosteroid are available for the relief of symptoms.19 Combination products may provide greater efficacy and cause fewer side effects than an individual agent used alone.19 Recently, a preliminary report of a study called Towards a Revolution in COPD Health (TORCH) demonstrated that combination therapy with a long-acting β2-agonist and a corticosteroid improved survival in patients with COPD.22 In addition, the study showed improvements in quality of life and lung function, as well as reductions in exacerbations.22 TORCH indicates that combination therapy yields better clinical outcomes and may have implications for future treatment strategies. In patients with acute exacerbations of COPD, treatment with antibiotics has been shown to provide significant clinical benefit,23, 24 as does a short course of oral corticosteroids.25, 26, 27 Various nonpharmacologic treatments—e.g., pulmonary rehabilitation, oxygen therapy, and lung volume reduction surgery—have also been shown to help some patients with COPD.19, 28, 29, 30

The third article, by Dr. Pamela L. Moore, which focuses on practice management in primary care of COPD, details simple operational changes to facilitate better disease management, patient care, and outcomes. Recognizing that clinical medicine is directly affected by business practices, Dr. Moore highlights strategies and tools for implementing operational improvements for physicians and their staff. These include a model defining the role of the care manager, integrating spirometry, smoking-cessation dialogues, providing written pulmonary action plans, and other strategies. The clinician should find these useful approaches to strengthen practice operations and thus improve patient care.

In the final article, Meaghan Nelson and Dr. Heidi Hamilton report findings from an in-office linguistic study examining communication between patients with COPD and physicians. The study reveals that, although several significant gaps exist in current communication, there is an opportunity to improve COPD-related communication in community-based practices. To create engagement surrounding COPD and its treatment, the dialogue should focus more specifically on educating patients about the disease and its management. However, within the confines of a busy practice, successful physician–patient communication must be streamlined, allowing both physicians and patients to accomplish their goals efficiently during each office visit. This article gives community-based physicians a menu of communication techniques to use with patients who have COPD that will foster improved dialogue without increasing time spent with patients. These real-world solutions can help clinicians to more effectively connect with their patients, with the goals of enhancing the interpersonal relationship and improving treatment outcomes.

On behalf of the “Creating Optimism in Manging Pulmonary Disease” editorial board, we hope that readers will find this supplement interesting, informative, and beneficial to your COPD practice.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30

Back to Article Outline

References 

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PII: S0002-9343(07)00402-0

doi:10.1016/j.amjmed.2007.04.006

The American Journal of Medicine
Volume 120, Issue 8, Supplement 1 , Pages S1-S3, August 2007

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