The progressive and as yet incurable lung disease COPD is associated with a high disease burden . According to the WHO, COPD is now the fourth leading cause of death internationally, and in Switzerland alone, more than 400,000 people suffer from this debilitating lung disease. A new position paper provides food for thought and action to improve diagnostic and therapeutic options.
Chronic obstructive pulmonary disease (COPD) is associated with chronic obstructive bronchitis and/or emphysema. The characteristic airway obstruction is usually not completely reversible after administration of bronchodilators. Extent of obstruction, pulmonary hyperinflation, and gas exchange disturbance may vary independently [1]. Prof. Daiana Stolz, M.D., Senior Physician at the Department of Pneumology at the University Hospital Basel and Chief Physician and Director of the Department of Pneumology at the University Hospital in Freiburg im Breisgau (Germany), was appointed three years ago by the Lancet commissioned to assemble a global group of experts to work through how COPD could best be diagnosed, treated, or even eliminated. The 50+ page position paper was published in The Lancet in September (box). [2,3]. “This position paper is courageous and groundbreaking in many respects. It makes clear the enormous epidemiological, social and also economic importance of COPD. It shows, also in comparison with other widespread diseases, how little we have achieved so far in combating it. And most importantly, it proposes concrete solutions as to how we might succeed,” says Prof. Wolfram Windisch, Deputy President of the German Society for Pneumology and Respiratory Medicine (DGP) and Chief Physician of the Cologne-Merheim Lung Clinic. [3,4].
Smoking is not the only risk factor
“COPD is very strongly associated with tobacco smoking by many people. This is also a major risk factor, but there are also other significant factors that we need to monitor closely. That is why we have developed a new classification of five COPD types,” explains Prof. Stolz, first author of the position paper [3,4]. These are the risk factors identified by the experts:
- Genetic factors
- Early childhood events (e.g. premature birth)
- infections experienced
- Smoking
- Environmental factors (e.g. air pollution)
Affected individuals may also be exposed to several risk factors at the same time – for example, if they smoke and also have a genetic predisposition. This further promotes damage to lung health. Depending on these respective risk factors, it is important to find the individual COPD therapy, the experts said.
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Expert committee calls for a rethink The position paper, published in the Lancet, is titled “Towards the elimination of chronic obstructive pulmonary disease.” “COPD is a huge global health burden for people of all countries, socioeconomic groups and ages, with poorer, disadvantaged and vulnerable groups particularly affected,” says Prof. Daiana Stolz, MD, first author of the Lancet paper. Cigarette smoking remains the most common cause of COPD in Europe [5]. But as we now know, there are other risk factors that can play a significant role. Therefore, COPD is proposed to be classified into five different types based on the main risk factor. This is the only way to diagnose the disease at an early stage and to develop a disease-modifying treatment. At least some forms of COPD may be preventable by considering lung health throughout the life course as a guiding principle. “There needs to be a change in thinking. We need to diagnose the diseases earlier, before the organ is finally damaged, and treat them in a more personalized way. That requires targeted research approaches. At the same time, we need to pay more attention to risk factors such as air pollution, prenatal exposures and early childhood infections. Otherwise, we risk losing the progress we have made on smoking elsewhere,” says Prof. Stolz [5]. |
More targeted treatment: More sensitive diagnostic tools are needed
“For decades, COPD diagnostics has been based almost exclusively on spirometry. The problem is that this lung function test cannot reliably detect early stages of COPD, but only advanced – and thus irreversible – disease stages,” says Prof. Stolz [4]. The authors of the position paper therefore advocate, among other things, more sensitive pulmonary function tests, consideration of individual risk factors in the medical history, and also supporting imaging procedures in diagnostics. As for exacerbation of COPD, the experts propose a new definition. Based on objective, measurable criteria, such as specific inflammations, patients could be treated in a much more targeted manner than is currently the case.
Achieving the vision of eliminating COPD in the long term will require coordinated collaboration among international stakeholders, the authors said. “COPD is a global disease that also correlates with poverty: Countries with lower incomes also have more cases. That’s why all levels of society should have access to diagnostics and treatment,” explains Prof. Stolz.
Literature:
- National Health Care Guideline COPD, 2021, 2nd edition, version 1, AWMF registry no. nvl-003.
- “University Hospital Pneumology as a Cover Topic in The Lancet,” University Hospital Basel, Sept. 23, 2022.
- Stolz D, et al: Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. Lancet 2022;400(10356): 921-972.
- “New options for COPD diagnostics and therapy: landmark position paper makes concrete treatment proposals,” German Society of Pneumology and Respiratory Medicine, Sept. 15, 2022.
- “Pulmonary disease COPD: Lancet special publication on diagnosis, therapy, and prevention,” University Medical Center Freiburg (D), Sept. 07, 2022.
- Olschewski H, et al: Chronic obstructive pulmonary disease 2021 – the right therapy for the right patient. Internist 2021; 62: 679-685.
HAUSARZT PRAXIS 2022; 17(10): 22
