Management of Stable Chronic Obstructive Pulmonary Disease

• What is the current scope of lung transplantation in the management of severe COPD?

There is a indisputable role for lung transplantation in end-stage COPD. However, lung transplantation does not benefit all COPD patients. There is a subset of patients for whom the treatment provides a survival benefit. It has been reported that 79% of patients with an FEV1 < 16% predicted will survive at least 1 year additional after transplant, but only 11% of patients with an FEV1 > 25% will do so [118]. The pre-transplant BODE (body mass index, airflow obstruction/FEV1, dyspnea, and exercise capacity) index score is used to identify the patients who will benefit from lung transplantation [119,120]. International guidelines for the selection of lung transplant candidates identify the following patient characteristics [121]:

• The disease is progressive, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy
• The patient is not a candidate for endoscopic or surgical LVRS
• BODE index of 5 to 6
• The partial pressure of carbon dioxide is greater than 50 mm Hg or 6.6kPa and/or partial pressure of oxygen is less than 60 mm Hg or 8kPa
• FEV1 of 25% predicted

The perioperative mortality of lung transplantation surgery has been reduced to less than 10%. Risk of complications from surgery in the perioperative period, such as bronchial dehiscence, infectious complications, and acute rejection, have also been reduced but do occur. Chronic allograft dysfunction and the risk of lung cancer in cases of single lung transplant should be discussed with the patient before surgery [122].

• How can we incorporate palliative care into the management plan for patients with COPD?

Among patients with end-stage COPD on home oxygen therapy who have required mechanical ventilation for an exacerbation, only 55% are alive at 1 year [123]. COPD patients at high risk of death within the next year of life as well as patients with refractory symptoms and unmet needs are candidates for early palliative care. Palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members and is recommended by multiple international societies for patients with advanced COPD [124,125]. In spite of these recommendations, the utilization of palliative care resources has been dismally low [126,127]. Improving physician-patient communication regarding palliative services and patients’ unmet care needs will help ensure that COPD patients receive adequate palliative care services at the appropriate time.

Conclusion

COPD is a leading cause of morbidity and mortality in the United States and represents a significant economic burden for both individuals and society. The goals in COPD management are to provide symptom relief, improve the quality of life, preserve lung function, and reduce the frequency of exacerbations and mortality. COPD management is guided by disease severity that is measured using the GOLD multimodal staging system and requires a multidisciplinary approach. Several classes of medication are available for treatment, and a step-wise approach should be applied in building an effective pharmacologic regimen. In addition to pharmacologic therapies, nonpharmacologic therapies, including smoking cessation, vaccinations, proper nutrition, and maintaining physical activity, are an important part of long-term management. Those who continue to be symptomatic despite appropriate maximal therapy may be candidates for lung volume reduction. Palliative care services for COPD patients, which can aid in reducing symptom burden and improving quality of life, should not be overlooked.

Corresponding author: Abhishek Biswas, MD, Division of Pulmonary and Critical Care Medicine, Rm. M452, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, abiswas@ufl.edu.

Financial disclosures: None.