About 400,000 people in Switzerland suffer from chronic obstructive pulmonary disease (COPD), which accounts for about 2.6% of all hospitalizations. COPD accounts for 50% of all deaths associated with respiratory diseases. Although COPD is so common, much of its treatment is still suboptimal. The 2023 GOLD recommendations seek to facilitate treatment choices with one change.
Last year, study has shown that bronchodilators in smokers with symptoms (cough, dyspnea) but preserved lung function has no statistically significant difference between treatment and placebo group in terms of SGRQ or CAT score. “Bronchodilators need bronchial obstruction, otherwise they cannot exert their effect,” PD Dr. Daniel Franzen, Department Head and Chief Physician, Department of Medical Disciplines, Uster Hospital, explained this lack of effect [1]. Not least for this reason, the expert took up the cudgels for spirometry, which is also becoming easier to implement in practice thanks to ever smaller devices.
With spirometry, he said, it is relatively safe to make the diagnosis of COPD based on a postbronchodilator FEV1/FVC ratio of <0.7. Also, this allows assessment of airflow limitation into GOLD stages I-IV. Dr. Franzen pointed out that there is a new feature compared to previous years in the 2023 GOLD Report of the Global Initiative for Chronic Obstructive Lung Disease gives: When assessing symptomatology or risk of exacerbation, the classification is no longer A, B, C, and D, but now A, B, and E, with E combining the previous C and D groups and including patients who exacerbate frequently (Fig. 1) [2]. The reason for this was primarily the fact that it made no difference therapeutically whether a patient was defined in group C or D, but it very much made a difference whether he belonged to group E or not.
For group E, the new guidelines recommend starting therapeutically immediately with a combination of a long-acting beta agonist (LABA) and a long-acting muscarinic antagonist (LAMA). A single inhaler is simpler and better for patient adherence, but such a fixed combination is not approved in Switzerland. “You have to give the single substance first, and only when it proves insufficient may you upgrade to combination drugs,” Dr. Franzen reminded the audience. In addition, for blood eosinophils ≥300, triple therapy of LABA/LAMA plus an inhaled corticosteroid (ICS) may be considered.
Lost in Translation
Together with Aja Ruoss from the Department of Pneumology, University Hospital Zurich, Dr. Franzen conducted a survey among primary care physicians to investigate whether physicians and patients speak the same language when referring to the term exacerbation [3]. It was found that patients often use a different vocabulary and understand an exacerbation not only as (increased) dyspnea, but to a large extent also as an exacerbation of the overall condition, (increased) cough, or even bronchitis (Fig. 2). “It is therefore important to get on the same linguistic level when communicating with your patients,” the pulmonologist cautioned.
However, the physicians’ responses to the question as to which factors influence the choice of therapy were sometimes curious: The blood count (i.e. eosinophilia) was included in the decision by only 12% of the colleagues with a clear yes, and for 29% it played no role at all. This is quite a remarkable result, especially since this point has been anchored in the GOLD guidelines for quite some time. “The eosinophils should already be determined multiple times, and in the normal state, not in the exacerbation, – that is, when the primary care physicians see the patients in the office, not when we have them in the clinic.” If the Eos are <100, ICS is more likely not indicated. In such cases, other factors must be looked for instead, e.g., bacterial colonization, smoking history, or exposure to toxic substances may be possible. In this context, Dr. Franzen referred to an American study that investigated the effect of indoor air purification in ex-smokers with COPD with regard to the number of exacerbations [4]. Subjects were given either an active or a placebo device that did not purify the air. It turned out that participants in the placebo group suffered from significantly more exacerbations. An air purification device is thus an adequate means for patients in fine-dust polluted environments, but currently they have to pay for it privately, the speaker concluded.
Take-Home Messages
- No bronchodilators without obstruction
- Focus on COPD: exacerbation history
- Role of eosinophils → ICS
- Exacerbations in normal eosinophils:
– Bacteria?
– Rheoplasty?
– Air purifier?
Source: FomF WebUp 6 Highlights in 60 minutes “Update Pneumology”, Jan. 30, 2023.
Literature:
- Franzen DP: Lecture “Update COPD”. FomF WebUp 6 Highlights in 60 Minutes “Update Pneumology,” Jan. 30, 2023.
- GOLD Report 2023, www.goldcopd.org.
- Ruoss A, Franzen D: What is an acute COPD exacerbation? Results of a survey of primary care physicians in German-speaking Switzerland. Practice 2022; 111: 910-916; doi: 10.1024/1661-8157/a003955.
- Hansel NN, Putcha N, Woo H, et al: Randomized Clinical Trial of Air Cleaners to Improve Indoor Air Quality and Chronic Obstructive Pulmonary Disease Health: Results of the CLEAN AIR Study. AJRCCM 2022; 205: 421-430; doi: 10.1164/rccm.202103-0604OC.
InFo PNEUMOLOGIE & ALLERGOLOGIE 2023; 5(1): 34–36
