This site is intended for health professionals only

Early identification of chronic obstructive pulmonary disease

Steve Dawber
BSc(Hons) MCIJ
Freelance Medical Writer and Journalist

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease. It is characterised by airflow limitation that is not fully reversible. This airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.(1) Other common COPD symptoms include cough, wheezing, sputum production and dyspnoea.(2,3)
COPD is a disease of loss - loss of physical vitality; loss of social interaction; loss of self-worth and all too often, loss of hope. Daily activities are often affected by COPD, and there are vast repercussions on emotional, social and behavioural wellbeing. COPD can also have a negative impact on social, recreational, and sexual activities, which can consequently strain the patient's ability to maintain a sense of self-worth. Moreover, respiratory deterioration and the impact of frequent co-existing illness make COPD patients fearful of not being able to maintain their independence, and often create anxiety for both themselves and their families.
There is currently no cure for COPD, and apart from smoking cessation, no intervention can halt the relentless and progressive deterioration in lung function. There is, however, much that can be done to improve the symptoms and quality-of-life for COPD patients and their families, especially if patients are diagnosed and treated early in the disease continuum. Timely recognition of high-risk individuals can lead to earlier and more vigorous prevention strategies (largely smoking cessation), and allows clinicians to adopt an individual, tailored approach.

An extremely widespread and burdensome chronic disease
COPD is the fourth most common cause of death after cancer, ischaemic heart disease and cerebrovascular disease. However, of these conditions, only COPD is associated with increasing mortality, and by 2020, COPD is expected to become the third most common cause of death worldwide (see Figure 1).(4)

[[nip33_fig1_28]]

Cigarette smoking is the predominant cause of COPD, accounting for 80-90% of cases.(5) Pollution, including indoor pollution from use of wood and coal-burning stoves and heaters, and occupational exposure to a variety of pollutants, also greatly increases risk.(1)
Unsurprisingly, COPD places a considerable burden on economic resources, with direct and indirect costs being comparable to those associated with breast cancer, stroke and peptic ulcer disease.(6-9)
Like many chronic illnesses, COPD has both physiological and psychological elements, which combine to result in an overall deterioration in patient quality-of-life. Indeed, COPD is now considered to be a lung disease with significant repercussions on the body as a whole. COPD-associated comorbid characteristics include muscle wasting, reduced exercise tolerance and profound emotional effects. As the disease evolves, its impact on the patient and the patient's family becomes part of the disease process itself. Thus, when managing COPD, it is important to consider not only the physical symptoms of the disease, but also its social impact on patients, carers and families.

Effective COPD diagnosis and management
GOLD (the Global Initiative for Chronic Obstructive Lung Disease), which is endorsed by the World Health Organization (WHO) and the United States National Heart, Lung, and Blood Institute (US NHLBI) has identified four distinct stages of COPD:1

Stage one: mild COPD
Characterised by mild airflow limitation (FEV1/FVC

[[nip33_box1_30]]

Stage two: moderate COPD
Characterised by worsening airflow limitation (FEV1/FVC

Stage three: severe COPD
Characterised by further worsening of airflow limitation (FEV1/FVC

Stage four: very severe COPD
Characterised by severe airflow limitation (FEV1/FVC 6.7kPa (50mmHg) while breathing air at sea level. Respiratory failure may also lead to effects on the heart such as cor pulmonale (right heart failure). Clinical signs of cor pulmonale include elevation of the jugular venous pressure and pitting ankle oedema. Patients may have very severe COPD even if the FEV1 is >30% predicted, whenever these complications are present. At this stage, quality-of-life is very appreciably impaired and exacerbations may be life-threatening.
 
Management guidelines
As part of the GOLD Initiative, a comprehensive set of COPD management guidelines has been developed, involving leading international respiratory clinicians and organisations. The resulting peer-reviewed document, entitled Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, was developed in collaboration with the National Heart, Lung, and Blood Institute, and WHO.1 This document is available at www.goldcopd.com and was last updated in November 2006.
COPD treatment is principally governed by disease severity at the time of presentation. A summary of disease assessment and stage-dependent recommended treatment strategies are provided in Boxes 2 and 3.

[[nip33_box2_30]]
[[nip33_box3_32]]

Clinical benefits of early intervention
A COPD exacerbation can be defined as a deterioration of a patient's clinical status, with worsening of respiratory symptoms, such as shortness of breath, sputum production, coughing and wheezing.
Typically, COPD patients experience between one and four exacerbations each year, although in some cases patients may experience as many as eight.(10,11) On average, patients take around 10 days to recover from the acute phase of each exacerbation, but full recovery takes even longer. Moreover, after repeated exacerbations, recovery may not be complete.(12,13)
COPD exacerbations account for 2% of all emergency admissions and 10% of all medical admissions.(10) Exacerbations usually occur with increasing frequency as COPD progresses, and/or in patients whose lung function is declining.
A recently published study has shown that the incidence of severe exacerbations is independently negatively correlated with patient prognosis.(10) Specifically, the 304-patient, five-year study showed that:

  • People who suffered one or two hospitalising exacerbations over the five-year study period were twice as likely to die as those who did not suffer a severe acute exacerbation.
  • People who suffered at least three exacerbations were over four times more likely to die than those who did not need emergency medical attention or hospital admission.

The investigators concluded that reducing the frequency of acute exacerbations may potentially reduce mortality.

Can mild COPD be treated effectively?
Although the vast majority of current studies and guidelines concentrate on treating patients with symptomatic COPD (stages two to four), evidence has emerged that suggests that patients with mild (stage one) COPD could also benefit from standard treatment approaches. The first study to show that early treatment of mild COPD can improve lung function was presented at the European Respiratory Society meeting in October 2006.14 This 12-week trial involved 224 patients who were randomised to receive either the long-acting bronchodilator, tiotropium (18g once daily), or placebo. Compared with the placebo group, tiotropium significantly improved FEV1 at a magnitude similar to that observed in patients with moderate-to-severe COPD. Improvements were seen after only 30 minutes and were maintained throughout the study period. Several additional long-term studies are now ongoing, and if successful, could lead to a change in mindset that increasingly focuses upon proactive management of asymptomatic, high-risk patients.

Conclusion
This type of data strengthens the clinical and health-economic arguments for early intervention of patients with mild COPD. The principal challenge for nurses is to proactively identify high-risk patients during routine co-assessments. An obvious starting point is to assess patients presenting at smoking cessation clinics, and/or all new patient presentations. Possible high-risk patients include current and ex-smokers, those aged over 40 years, those presenting with a chesty cough, those who report breathlessness when walking upstairs, or those who report frequent coughs and colds during the winter months. An initial diagnosis can be confirmed via spirometry or lung function testing.

[[nip33_box4_32]]

References

  1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Executive summary. Available from: http://www.goldcopd.com
  2. Ferguson GT, Cherniak RM. Management of chronic obstructive pulmonary disease. N Engl J Med 1993;328:1017-22.
  3. American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152:S77-121.
  4. Murray CJL, Lopez AD, editors. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.
  5. Feenstra TL, van Genugten ML, Hoogenveen RT, et al. The impact of smoking and aging on the future burden of chronic obstructive pulmonary disease: a model analysis in the Netherlands. Am J Respir Crit Care Med 2001;164:590-6.
  6. Brown ML, Fintor L. The economic burden of cancer. In: Greenwald P, Kramer BS, Weed DL, editors. Cancer prevention and control. New York: Marcel Dekker, Inc; 1995.
  7. Brown DM, Everhardt JE. Cost of digestive diseases in the United States. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. NIH publication no. 94-1447. DHHS, PHS, NIH, Washington, DC: US GPO; 1994.
  8. National Heart, Lung and Blood Institute. Morbidity and mortality chart book on cardiovascular, lung and blood diseases. Bethesda: MD: DHHS; 2002.
  9. Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest 2000;117 Suppl 2:5S-9.
  10. Soler-Cataluna JJ, Martinez-Garcia MA, Roman Sanchez P, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60:925-31.
  11. Seemungal TA, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA. Effect of exacerbations on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157:1418-22.
  12. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Resp Crit Care Med 2004;169:1298-303.
  13. Spencer S, Jones PW. Time course of recovery of health status following an infective exacerbation of chronic bronchitis. Thorax 2003;58:589-93.
  14. Johansson G, Lindberg A, Romberg K, et al. Bronchodilator efficacy of tiotropium (TIO) in patients with mild COPD. Poster presented at the European Respiratory Society 2006 Annual Congress, Munich, 5 September 2006.

Resources

British Thoracic Society (BTS) COPD Consortium 
W: www.brit-thoracic.org.uk
Chronic obstructive pulmonary disease (COPD) guidelines available on this website

National Institute for Health and Clinical Excellence (NICE)
W: www.nice.org.uk
Chronic Obstructive Pulmonary Disease - Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care available on this website