New understandings of diagnosis, treatment and prevention of COPD

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has released new standards for the diagnosis, management and prevention of chronic obstructive pulmonary disease (COPD).

The latest recommendations emphasize the importance of proper diagnosis, assessment of the disease's severity, and the need for a better understanding of co-morbidities to improve treatment of disease.

The GOLD report is updated annually online, but this is the first “complete makeover” since its initial publication in 2002. “This is an absolutely up-to-date summary of all the available evidence on the diagnosis, management and prevention of COPD,” said Klaus Rabe, M.D., Ph.D., lead author of the report.

The executive summary of the updated GOLD report appears in the second issue for September of the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

According to the report, COPD is the fourth leading cause of death in the U.S. and is projected to be fifth worldwide by 2020. It currently affects 15 to 25 percent of adults over the age of 40, says Dr. Rabe, of the Department of Pulmonology at the Leiden University Medical Center in the Netherlands. Yet in spite of the prevalence and seriousness of COPD as a public health threat, COPD is relatively unknown and ignored by the public as well as by health officials.

The new standards reflect the evolution of current scientific and medical thought. “One of the most important points is that we now say COPD is preventable and treatable,” said Dr. Rabe. “There are steps we can take to prevent it, and it is no longer viewed with therapeutic nihilism.”

Other updates include:

• New staging guidelines for determining the severity of COPD;
• Management recommendations for exacerbations including the use of antibiotics; and
• Recommendations for identifying and building the comprehensive healthcare teams that are necessary for the coordinated treatment of patients with COPD, who frequently present with co-morbidities.

Unfortunately, despite the significant progress that has been made in the understanding and management of the disease, the behavioral and cultural factors that have pushed the disease into the top-five list of killer diseases worldwide remain largely unchanged.

Cigarette smoking and secondhand smoke exposure are the most commonly encountered risk factors for COPD in the developed world. In developing countries, COPD arises primarily from long-term exposure to smoke from biomass fuel used for indoor cooking and heating. Women, who began smoking in higher numbers after World War II, and who bear the brunt of indoor exposures in developing countries, are now more likely to die of the disease than men. Furthermore, because COPD generally develops over a period of decades, the current rise in cases is unlikely to abate soon.

“The prevalence and burden of COPD are projected to increase in the coming decades due to continued exposure to COPD risk factors and the changing age structure of the world's population,” wrote the researchers.

While the new guidelines represent a significant step toward more comprehensive treatment and understanding of COPD, they are also a work in progress. “Continuous updates of the literature provide the opportunity to identify areas of weakness,” noted Leonardo M. Fabbri, M.D., who wrote an editorial on the report in the same issue of the journal. As examples, he cited areas of COPD research that require more investigation and further refinement, including the need to improve methods for determining the severity of the disease, and developing a more comprehensive approach to assessing co-morbidities.