Long-Term Intervention in Chronic Obstructive Pulmonary Disease PDF

PREFACE

Chronic Obstructive Pulmonary Disease (COPD) has been an ‘‘orphan disease'' for most of the twentieth century. In the last decade of that century and now into the twenty first, it became clear that COPD had to be recognized world-wide as a chronic disease that has a large impact on the lives of many patients, their families and care takers as well as on health care expenditure and world economics at large. COPD is the fourth leading cause of death and the most rapidly rising cause of death in those over age 65. This has led to the greater interest in the disease and its underlying pathophysiology as well as its management. This book aims to contribute to a better understanding of the epidemiology, pathology and pathophysiology, diagnosis, management and outcome of COPD.

COPD comprises a heterogeneous group of conditions, characterized by chronic airflow limitation and destruction of lung parenchyma with clinical manifestations of dyspnea, cough, sputum production and impaired exercise tolerance. In the US, COPD encompasses chronic bronchitis, chronic obstructive bronchitis, emphysema, or combinations of these conditions. The epidemiology of COPD shows that smoking is the main risk factor for its development. Breathing in other kinds of lung irritants, like pollution, dust, or chemicals over a long period of time may also cause or contribute to COPD. With increasing cumulative pack years of smoking, the risk of COPD increases. However, the risk is never 100% and only 10–20% of smokers develops COPD, providing evidence that a genetic component is present as well. Furthermore, cigarette smoking can only explain about 5% of the variation in level of FEV1. Finally, recent studies suggest that COPD development likely begins in early childhood perhaps even in utero. In such a scenario growth, maximally attained level of lung function and rate of decline all may be pertinent to disease risk.

Since COPD develops slowly, and it may be many years before an individual notices symptoms like feeling short of breath, most of the time COPD is diagnosed in middle-aged or older people. A medical history, physical examination and breathing tests are the most important tests to determine if one has COPD. Spirometry is the most sensitive and commonly used test of lung function. It can detect COPD long before significant symptoms exist. This book shows which physiologic alterations occur in COPD and how they relate to its pathology.

The clinical course of COPD is one of gradual progressive impairment, which may eventually lead to respiratory failure. With continued exposure to cigarette smoke, the disease progresses that can only be changed to some extent by smoking cessation, although even then the inflammatory process that underlies the disease seems to perpetuate. So far, no treatment can prevent the accelerated lung function loss in COPD. Therefore it is of great importance to better understand the pathology and pathophysiology of COPD, with the hope that this leads to new avenues for future treatments. Much attention is therefore paid in the current book towards the underlying mechanisms of COPD, i.e., inflammation, mechanisms of tissue degeneration like the imbalance in proteases and anti-proteases, oxidative stress and anti-oxidants, as well as defective tissue repair.

What can we do about COPD? International guidelines have put forward that the goals of treatment are to: 

• Relieve symptoms with no or minimal side effects of treatment 
• Slow the progress of the disease 
• Improve exercise tolerance 
• Prevent and treat complications and sudden onset of problems 
• Improve overall health.

Current national and international guidelines advocate the use of bronchodilators for the treatment of all degrees of severity of chronic obstructive pulmonary disease. While anticholinergics are preferred as initial therapy in some countries, the combination of beta-adrenoceptor agonists and anticholinergic drugs with a short or long duration of action are preferred and also more effective (GOLD update 2003) for moderate disease, sometimes supplemented with the use of theophylline. Bronchodilators are the mainstay of current therapy in COPD and while providing relatively little improvement in spirometric lung function compared to asthma, they may significantly reduce symptoms of dyspnea by reducing the increased lung volumes, and may also improve exercise tolerance. Bronchodilators are generally prescribed to symptomatic patients with COPD either for relief of their persistent or worsening symptoms on a p.r.n. basis, or regularly to prevent or to reduce the development of symptoms, especially dyspnea during exercise. In the past years, it has become apparent that further improvements by long-acting bronchodilators may include the reduction of mild exacerbations and the possible need for hospitalization and improvement of health status. This book addresses therefore the effects, benefits and side effects of all types of bronchodilators in COPD.

Given the inflammatory background of COPD, many studies have set out to assess the role of the anti-inflammatory inhaled steroids in COPD. Therefore this book devotes a chapter to the outcomes of the studies so far. Overall, it is clear that inhaled steroids do not reduce the accelerated lung function loss in COPD. However, there are benefits in more advanced disease with respect to quality of life, some symptoms and the frequency of exacerbations.

Pulmonary rehabilitation is a co-ordinated program of exercise, disease management training, and counselling that can help stay more active and carry out day-to-day activities. It may include exercise training, nutrition advice, education about your disease and how to manage it, and counseling. The different parts of the rehabilitation program are managed by different types of health care professionals (doctors, nurses, physical therapists, respiratory therapists, exercise specialists, and dieticians) who work together to develop an individually tailored program.

In summary, this book presents updated, and significant information concerning different aspects of COPD, pathology, pathophysiology, diagnosis, heterogeneity of the disease, management and future perspectives on new therapies. This book offers an overview for pulmonologists, medical students and provides non-specialist researchers in the pulmonary field up-to date information on virtually all aspects of COPD.

The meeting on which this book is based took place in Amsterdam, The Netherlands, and we are grateful to Astra Zeneca Pharmaceuticals, which graciously hosted the event. Finally, we would like to thank the editor of this series, Dr Claude Lenfant, the former director of the National Heart Lung and Blood Institute who has unfailingly supported our efforts.