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Treatment Options for Stable Chronic Obstructive Pulmonary Disease: Current Recommendations and Unmet Needs

January 31, 2018|Cleveland Clinic Journal of Medicine
Barbara Yawn, MD, MSc, FAAFP;Victor Kim, MD
Author and Disclosure Information

Barbara Yawn, MD, MSc, FAAFP
Department of Family and Community Health, University of Minnesota, Blaine, MN

Victor Kim, MD
Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, PA

Dr. Yawn reports receipt of personal payments for COPD- related advisory boards for AstraZeneca; Boehringer Ingelheim Pharmaceuticals, Inc.; and GlaxoSmithKline; and COPD-related research grant funding from Boehringer Ingelheim Pharmaceuticals, Inc. She has served as a content developer and peer reviewer for Medscape and UpToDate, and has grant support from the National Heart, Lung, and Blood Institute and the Patient-Centered Outcomes Research Institute for COPD-related research.

Dr. Kim has attended advisory board meetings for AstraZeneca; Concert Pharmaceuticals Inc.; CSA Medical Inc.; and Gala Therapeutics Inc. He has been a peer reviewer for Medscape, and has received grant support from the National Heart, Lung, and Blood Institute.

Funding for this article was provided by AstraZeneca LP (Wilmington, DE, USA). Medical writing support was provided by Hannah Burke, BSc, of Core (London, UK) and editorial support was provided by Maryam Vahdat, PGDip, of Core (London, UK), which were funded by AstraZeneca LP (Wilmington, DE, USA), in accordance with Good Publication Practice guidelines (Battisti WP et al. Ann Intern Med. 2015;163:461–464. doi: 10.7326/M15-0288).

This article is being co-published in The Journal of Family Practice and Cleveland Clinic Journal of Medicine.

Surgical and bronchoscopic interventions

Surgical and bronchoscopic interventions have the potential to significantly benefit carefully selected patient groups with emphysema.3 LVRS resects parts of the lungs to reduce hyperinflation, and improves lung function and reduces exacerbations in patients with advanced emphysema.3 It can prolong mortality in selected patients,40 but can increase the risk of death in those with low FEV1 and either homogenous emphysema or very low carbon monoxide diffusing capacity.41

Nonsurgical bronchoscopic interventions continue to improve; they have been designed to achieve similar results to LVRS (but with less morbidity), and provide a possible intervention for patients with heterogenous or homogenous emphysema, and significant hyperinflation refractory to optimized medical care.3 Use of endobronchial one-way valves and lung volume reduction coils has resulted in significant improvements in patients’ quality of life, exercise capacity, and pulmonary function for select patients with severe emphysema.42,43 Other therapies, such as adhesives (where a biologic sealant collapses targeted areas of the lung to induce the formation of scar tissue, thus reducing lung tissue volume), and vapor therapy (where heated water vapor is used to deliver thermal energy to the lungs, inducing an inflammatory response that causes contraction fibrosis and atelectasis, and subsequently lung volume reduction) are also in development.44 Consideration of surgical or nonsurgical interventions require referral to a pulmonologist.

Lung transplantation may be an option for patients with very severe COPD without significant comorbidities. Lung transplantation improves quality of life, but does not prolong survival.3,45,46 The procedure is limited by donor availability, high cost, and potential complications.3 

COPD Foundation guidelines

COPD Foundation treatment guidelines
The COPD Foundation guidelines provide recommendations for first- and second-line therapy based on diagnosis, and the assessment of severity domains (spirometry grade, regular symptoms, high exacerbation risk, oxygenation status, emphysema, chronic bronchitis, and comorbidities; Table 1).47,48 Each of the domains requires separate treatment consideration. These guidelines align well with the GOLD recommendations for assessment of symptoms, exacerbations, chronic bronchitis, and comorbidities in all patients with COPD. The COPD Foundation also provides useful tools for health care professionals, most notably the Pocket Consultant Guide (PCG) for the Diagnosis and Management of COPD (Figure 3). Last updated in November 2016, the PCG serves as a resource to help physicians in a point-of-care context.

Figure 3. COPD Foundation Pocket Consultant Guide.
Figure 3. COPD Foundation Pocket Consultant Guide.
The COPD Foundation and GOLD make similar treatment recommendations, but there are a number of differences between the 2 guidelines. For example, GOLD is most suited as a desk reference, whereas the COPD Foundation guidelines and PCG are designed for use at the bedside; therapy recommendations are based on the ABCD methodology in GOLD, whereas the COPD Foundation’s management approach requires evaluation of seven severity domains (Table 1); spirometry grades are also organized differently.

The COPD Foundation guidelines note that some spirometry results are normal, but do not rule out the presence of chronic bronchitis, emphysema, or other lung disease; or are neither normal nor consistent with COPD or other lung disease. The guidelines therefore define 2 additional spirometric grades, referred to as SG 0 (representing patients with normal spirometry) and SG U (representing patients who have a FEV1/FVC ratio >0.7 but FEV1 <80% predicted). At present, neither SG 0 nor SG U are associated with therapeutic options distinct from other spirometric grades, but this may change as we learn more from clinical studies.47,48

Importance of managing COPD comorbidities

Comorbidities are common among patients with COPD, and COPD itself may increase the risk of developing other diseases.3,49-52 It can be difficult to recognize the many comorbidities in patients with COPD, due to the diverse nature of these comorbidities, a lack of understanding of their underlying causes, patients’ failure to recognize or share symptoms, or misdiagnosing them as adverse effects associated with COPD medication.53 Failure to recognize and treat comorbidities can increase risk of hospitalizations or exacerbations, worsen prognosis, increase morbidity, lower the chances of treatment adherence, and place a greater burden on the patient, family, and health care resources.51,52,54-56 Common comorbidities include cardiovascular disease, musculoskeletal dysfunction, metabolic syndrome, anxiety/depression, osteoporosis, lung cancer, and heart failure.3,51,52

The value of effectively managing comorbidities in improving outcomes and adherence to therapy is well documented. For example, personalized management of patients with COPD and comorbid anxiety and/or depression has been shown to reduce both the mental health symptoms and COPD-related outcomes (eg, exercise tolerance, disability).57-59

Comorbidity burden may impact adherence to COPD medication. Depression, for instance, is a known risk factor for nonadherence to treatment. Patients with multiple untreated or uncontrolled comorbid conditions may also be less likely to benefit from pulmonary rehabilitation.60 It is therefore important that comorbidities are managed effectively to improve adherence to therapy, and enhance the benefits of pulmonary rehabilitation.

Patient monitoring

Routine follow-up of patients with COPD is essential as lung function may worsen over time, even with the best available care.3 Worsening of symptoms, activity limitation, and disease progression should be monitored closely to determine when to modify management/pharmacotherapy, and to identify any complications and/or comorbidities that may develop.3 When patients with COPD do not receive the appropriate level of treatment or monitoring, it can be due to:  under-reporting of disease severity, symptoms, and exacerbations during consultation; lack of information on the impact of the disease on the patient’s quality of life; and failure to recognize comorbidities.23,25,53 Continued use of the patient questionnaires described previously is recommended, and the GOLD strategy advises that symptoms are assessed at each visit. These follow-up visits also provide an opportunity to monitor patients with COPD for key comorbidities, including heart failure, ischemic heart disease, arrhythmias, osteoporosis, depression/anxiety, and lung cancer, as well as to determine a patient’s current smoking status, taking appropriate action as needed.3

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