Current trends in COPD

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Chronic Obstructive Pulmonary Disease (COPD), a condition common among smokers, remains a major public health problem. Worldwide it kills more than 2.75 million people each year and is projected to rank fifth in 2020 in the global burden of disease. In the Middle East, where smoking is growing increasingly prevalent, the disease is thought to be on the rise too. But like elsewhere, it remains vastly under-diagnosed and under-treated.

While breathing in pollution, dust or chemicals may produce or contribute to COPD, tobacco smoking is by far the most common cause, says Christopher H. Fanta, MD, Director of the Partners Asthma Center, member of the Pulmonary and Critical Care Division at Brigham and Women's Hospital, and Associate Professor of Medicine at Harvard Medical School. About 80% to 90% of COPD cases are caused by smoking, and a smoker is 10 times more likely than a non-smoker to die of COPD, a term used to describe the combination of chronic bronchitis and emphysema.

Smoking damages the lungs in two ways, explains Fanta. In chronic bronchitis, there is narrowing and clogging of the bronchi (airway tubes). In emphysema, the alveoli (air sacs) become enlarged and destroyed, which reduces the lungs' elasticity making them less "springy."

The reason so many patients with COPD go undiagnosed is that the term is not generally recognized by patients, says Fanta. Even more than that, patients can have COPD for years without noticing.

A mostly sedentary society combined with the lungs' excess breathing capacity (when healthy) make it possible for adults to lose up to 40% of their lung capacity without feeling the effects, he explains. As a result, the disease remains hidden until it is fairly advanced.

Further hindering diagnosis, few primary care physicians' offices are equipped with Spirometry - the tool used to measure breathing function. So testing is not routine. This is unfortunate, because when COPD is caught early, patients have a much better chance of quitting smoking and getting treatment at a stage of their illness that would allow them to lead a longer, healthier life.

Fanta suggests sending all patients who have smoked for 10 years or more for Spirometry.

In this In Practice, Fanta, who is also a co-author of "The Harvard Medical School Guide to Taking Control of Asthma: A Comprehensive Prevention and Treatment Plan for You and Your Family," (Free Press, January 2004), discusses current trends in treating COPD, including new tools to aid in smoking cessation, and the latest thinking on medication, oxygen supplementation, surgery, and rehabilitation.

Smoking Cessation

By far, the best way to prevent COPD is to figure out how to prevent kids from taking up smoking, and helping smokers to quit, says Fanta.

Public health efforts aimed at smoking cessation can go a long way. In the U.S., for example, smoking is now banned in public buildings and restaurants. Over the past 50 years, the percentage of adults who smoke has gone from 50% of men and over 40% of women to just under 25%. Short of spearheading a widespread public health initiative, physicians can do their part by asking all patients whether they smoke and, if so, whether they are interested in quitting. If they express a desire to quit, says Fanta, there are a number of aids that can be offered that have been shown to work well.

Effective smoking cessation aids include:

• Nicotine replacement therapy

• Smoking cessation counseling programs

• Buproprion, an antidepressant approved in the US to help people quit smoking

• Varenicline, the first approved nicotinic acetylcholine receptor antagonist (and partial agonist)

Medication

Bronchodilators remain the mainstay of medical therapy for patients with COPD. These drugs, which include long-acting inhaled beta-agonists and the long-acting anticholinergic agent, tiotropium, can be taken as easily as only once or twice a day.

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