Clinical Management of Chronic Obstructive Pulmonary Disease PDF

Preface

Since the publication of the first edition of Clinical Management of Chronic Obstructive Pulmonary Disease, the emerging awareness about chronic obstructive pulmonary disease as a public health issue that was ours then has become a major preoccupation. The burden of chronic obstructive pulmonary disease has continuously increased, in line with the predictions of the World Health Organization, and unfortunately this ominous trend is not waning. Indeed the enemy, tobacco smoking, although retreating on several fronts, has been winning enormous territories. In the often densely populated developing countries where health care resources are still focused on more basic issues, chronic obstructive pulmonary disease will undoubtedly become the main killer of the 2020s.

In parallel, our knowledge of the disease's determinants and correlates has progressed markedly; the results of several important large-scale therapeutic trials have become available; and international guidelines have been established, corrected, adapted, and rapidly evolving. The research on chronic obstructive pulmonary disease, long confined to pathophysiological studies and undervalued, is currently one of the most active in respiratory medicine. Therefore, updating Clinical Management of Chronic Obstructive Pulmonary Disease was mandatory to help clinicians to stay afloat in the maelstrom of new information that is bound to influence their everyday practice.

To begin with, many data have been published about the burden of chronic obstructive pulmonary disease. Gathering this information was difficult because of the requirement of mass-scale spirometry; most of the corresponding studies come from developed countries. They estimate a prevalence of chronic airflow obstruction of 4% to 10% among adults, and all agree on the marked under-diagnosis of the disease. Finally, they unmask the potential role of environmental risk factors in addition to the main one, tobacco smoking, including some occupational exposures. Although data from developing countries are still scarce, these areas of the world have become the main targets of the tobacco industry, and may well be particularly plagued by other risk factors such as the exposure to domestic fumes.

While epidemiologists provided us with increasingly reliable data on the prevalence of chronic obstructive pulmonary disease and environmental risk factors, the knowledge about chronic obstructive pulmonary disease's pathophysiology and possible genetic risk factors improved constantly. In parallel, the physiological mechanisms of chronic obstructive pulmonary disease-related dyspnea have been identified with more accuracy; the clinical and prognostic importance of systemic components of the disease has been better understood; and the role of exacerbations in the natural history of the disease has been thoroughly investigated. As a consequence, new tools have been proposed to help us assess patients with chronic obstructive pulmonary disease in their entirety rather than solely on the basis of lung function. Altogether, these progresses will allow us to define more accurately the various phenotypes of the disease, leading to more rational and effective choices of therapeutic strategies.

Last, but not least, new treatments and strategies have been made available and very new directions, targeting specific pathophysiological mechanisms, are being investigated. More efficient and practical bronchodilators are now widely used. The target population of inhaled corticosteroids is more precisely defined. Molecules targeting specific pathophysiological mechanisms are reaching the stage of human trials. The effectiveness of several non-pharmacological interventions included in respiratory rehabilitation, such as education or exercise training, has been demonstrated or confirmed, putting this approach on top of therapeutic options.

However, despite these tremendous advances in the knowledge about chronic obstructive pulmonary disease and in the management of patients suffering from this disease, several challenges remain. Large-scale long-term studies are being performed to assess the effect of treatments on the natural history of the disease, as reflected not only by the decline of lung function but also by exacerbations, exercise capacity, quality of life, and, of course, mortality. Together with economical analysis, the results of such trials should help us define the most effective strategies to decrease the disease's burden. To achieve this goal, strategies for early diagnosis also have to be investigated, especially from a cost-effectiveness point of view. Indeed, detecting chronic obstructive pulmonary disease is not a job for respiratory physicians only; general practitioners are concerned in the first place, together with all possible preventive structures. In addition, the general population has to be informed, since many studies show a very poor knowledge of the disease. All these points are now carefully addressed in recent international and local guidelines, but significant work remains to be done to implement them.

The purpose of this book is to provide clinicians with practical tools to understand the disease and integrate this understanding in clinical practice. Therefore, a first section has been added and is dedicated to an overview of epidemiological and pathophysiological considerations, addressing both respiratory and systemic aspects of the disease. The other sections deal with diagnostic and therapeutic issues, including specific problems such as smoking cessation, comorbidities, clinical implications of systemic manifestations, and palliative treatments. Following comments on the first edition, some chapters have been combined to make the book more practical for readers. Indeed, the target is not restricted to specialists: the variety of themes and approaches intends to cover all aspects of the disease (except exacerbations, which warrant a whole book by themselves), providing all health care professionals with useful and immediately applicable information.