Advances in Prevention and Treatment of Chronic Obstructive Pulmonary Disease

Donald P. Tashkin, MD

Chronic obstructive pulmonary disease (COPD), a leading cause of death and disability worldwide, is both preventable and treatable.[1] Remarkable strides have already been made in both prevention (largely through smoking cessation) and treatment (through pharmacologic and nonpharmacologic measures). However, further advances are eagerly anticipated through the identification of phenotypes (defined by clinical features that distinguish between individuals) and endotypes (subtypes defined by distinct physiological mechanisms) and a greater understanding of the biologic basis for the heterogeneity of COPD that hopefully will lead to a more personalized approach to therapy.[2]

In this issue of Seminars in Respiratory and Critical Care Medicine, leading authorities in COPD review the most current information concerning the disease state as well as new approaches to pharmacotherapy, nonpharmacologic treatment, and comprehensive self-management. The article by Rosenberg et al reviews the most recent trends in COPD prevalence, hospitalizations, and mortality. Strange and Belko discuss the different clinical phenotypes associated with severe α-1-antitrypsin deficiency (AATD), patient outcomes of AAT augmentation therapy and lung transplantation, and some theoretical approaches to gene therapy. The article by Dr. Rennard discusses the potential of three large recent/ongoing observational cohort studies involving the collection of a wide range of clinical, physiologic, radiographic, biomarker, and genetic data for identifying distinct phenotypes and endotypes of COPD through sophisticated statistical analyses that might provide clues as to the optimal treatment of the individual patient. In the article by Dr. Tashkin, data from the limited number of clinical trials of pharmacologic aids to smoking cessation combined with behavioral therapy are reviewed, along with novel approaches to the treatment of tobacco dependence. Dr. Barnes provides a comprehensive review of molecular targets for novel therapies that are currently in various phases of development. Calverley and Blies review the most recent clinical trials data concerning the efficacy of the newer long-acting inhaled β-agonist and muscarinic antagonist bronchodilators alone and in combination with one another and with inhaled corticosteroids, as well as the efficacy of agents designed specifically to prevent exacerbations of COPD and attempts to identify patient characteristics that might predict a preferential response to a specific treatment regimen. The choice of inhaled medications for COPD must take into account the device used to deliver the aerosolized medication, of which there are now several varieties. The article by Singh et al comprehensively reviews recent advances in these aerosol delivery devices. Barjarkarevic and Cooper provide a thorough review of the physiologic effects of supplemental oxygen, the limited evidence concerning the long-term clinical benefits of oxygen therapy, the potential hazards of oxygen therapy, the evolution of newer methods of home oxygen delivery, and guidelines for prescribing supplemental oxygen. ZuWallack and Nici review the important components of a pulmonary rehabilitation program, criteria for referral of both stable and postexacerbation COPD patients for pulmonary rehabilitation in both traditional and nontraditional settings, the concept of collaborative self-management and methods of sustaining effectiveness of pulmonary rehabilitation, in addition to reimbursement issues. The vast majority of COPD patients have one or more comorbid conditions that have a significant impact on outcomes. Putcha et al summarize what is known concerning the prevalence of specific comorbidities in COPD and strategies for their treatment. Marchetti and Criner provide an in-depth examination of the benefits and risks of lung volume reduction surgery (LVRS) for advanced emphysema, including the results of long-term follow-up, as well as the indications for and outcomes of bullectomy and lung transplantation. To avoid the perioperative morbidity and mortality of LVRS, strenuous efforts have been directed toward developing various nonsurgical, endoscopic approaches to lung volume reduction in patients with advanced emphysema. These are comprehensively reviewed in the article by Gompelmann et al. Noninvasive ventilation (NIV) has become the primary approach to managing COPD patients hospitalized with hypercapnic ventilatory failure, obviating the complications of intubation for mechanical ventilation. The article by Dr. Soo Hoo reviews the technical aspects of NIV, its role in managing COPD patients hospitalized for a severe acute exacerbation or severe pneumonia or with overlapping obstructive sleep apnea and COPD, as well as its potential outpatient use in COPD patients with chronic respiratory failure. Finally, Bourbeau et al provide a detailed review of publications related to self-management interventions for patients with COPD and a perspective concerning the extrapolation of the published results to real-life situations.

In summary, this issue of Seminars will hopefully illustrate not only recent advances in the prevention and management of COPD but also the challenges that lie ahead for improving preventive strategies (particularly smoking cessation interventions) and both pharmacologic and nonpharmacologic approaches to therapy.

• References

• 1 From the Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD). 2014 Update. Available at: http://www.goldcopd.org/
• 2 Woodruff PG, Agusti A, Roche N, Singh D, Martinez FJ. Current concepts in targeting chronic obstructive pulmonary disease pharmacotherapy: making progress towards personalised management. Lancet 2015; 385 (9979) 1789-1798