Introduction

Management of Mild to Moderate COPD (Stages I and II) involves the avoidance of risk factors to prevent disease progression and pharmacotherapy as needed to control symptoms. Severe disease (Stage III) often requires the integration of several different disciplines, a variety of treatment approaches, and a commitment of the clinician to the continued support of the patient as the illness progresses. In addition to patient education, health advice, and pharmacotherapy, COPD patients may require specific counseling about smoking cessation, instruction in physical exercise, nutritional advice, and continued nursing support. Not all approaches are needed for every patient, and assessing the potential benefit of each approach at each stage of the illness is a crucial aspect of effective disease management.

An effective COPD management plan includes four components:

1. Assess and Monitor Disease

2. Reduce Risk Factors

3. Manage Stable COPD

4. Manage Exacerbations.

While disease prevention is the ultimate goal, once COPD has been diagnosed, effective management should be aimed at the following goals:

· Prevent disease progression.

· Relieve symptoms.

· Improve exercise tolerance.

· Improve health status.

· Prevent and treat complications.

· Prevent and treat exacerbations.

· Reduce mortality.

These goals should be reached with minimal side effects from treatment, a particular challenge in COPD patients because they commonly have co-morbidities. The extent to which these goals can be realized varies with each individual, and some treatments will produce benefits in more than one area. In selecting a treatment plan, the benefits and risks to the individual, and the costs, direct and indirect, to the individual, his or her family, and the community must be considered.

Patients should be identified as early in the course of the disease as possible, and certainly before the end stage of the illness when disability is substantial. However, the benefits of community-based spirometric screening, of either the general population or smokers, are still unclear. Educating patients and physicians to recognize that cough, sputum production, and especially breathlessness are not trivial symptoms is an essential aspect of the public healthcare of this disease.

Reduction of therapy once symptom control has been achieved is not normally possible in COPD. Further deterioration of lung function usually requires the progressive introduction of more treatments, both pharmacologic and non-pharmacologic, to attempt to limit the impact of these changes. Acute exacerbations of signs and symptoms, a hallmark of COPD, impair patients’ quality of life and decrease their health status^1,2. Appropriate treatment and measures to prevent further exacerbations should be implemented as quickly as possible.

Important differences exist between countries in the approach to chronic illnesses such as COPD and in the acceptability of particular forms of therapy. Ethnic differences in drug metabolism, especially for oral medications, may result in different patient preferences in different communities. Little is known about these important issues in relationship to COPD.

References

1. O’Brien C, Guest PJ, Hill SL, Stockley RA. Physiological and radiological characterization of patients diagnosed with chronic obstructive pulmonary disease in primary care. Thorax 2000; 55:635-42.

2. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 161:1608-13.

Course