COPD Management for Primary Care Physicians Part IV: Exacerbations and the Future of COPD

Published Online: Wednesday, November 16, 2011

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Approximately 12 million Americans suffer from chronic obstructive pulmonary disease (COPD); in addition, 12 million may remain undiagnosed. COPD is a debilitating disease characterized by airflow obstruction resulting from involvement of the airways and/or pulmonary parenchyma. Symptoms may include shortness of breath, chronic cough, poor exercise tolerance, wheezing, and respiratory failure.

Since many patients with COPD seek treatment from their primary care physician or from hospitalists after they suffer a worsening of symptoms, those clinicians should have the latest information on best practices for diagnosis and treatment. For this article, MD Magazine: Peers & Perspectives convened three COPD experts to discuss the detection and treatment of the condition.

Our panel was moderated by Peter Salgo, MD, professor of anesthesiology and internal medicine at Columbia University in New York City. The panel included three of the country’s leading COPD specialists: Antonio R. Anzueto, MD, of the University of Texas Health Science Center at San Antonio; Ravi Kalhan, MD, of the Northwestern University Feinberg School of Medicine, Evanston, Ill.; and Barbara Yawn, MD, of the Olmsted Medical Center in Rochester, Minn.

Exacerbations and the Future of COPD

Like all conditions, COPD can progress and become worse despite treatment. This often results in exacerbations, episodes of worsening respiratory symptoms, including increased cough, discolored sputum, or increased dyspnea. Exacerbations tend to become more frequent as COPD progresses, but this is not always the case. What is a given is that exacerbations are a major cause of morbidity and mortality.

“I think it’s a missing component of the message about COPD that exacerbations, and especially exacerbations severe enough to result in a hospitalization, are extremely important watershed events in the life of a COPD patient,” Kalhan said. “The one-year mortality following a hospitalization for COPD, depending on the study you read, is between 15% and 25%. That’s enormous.”

Salgo said he had hot heard that number before and called it “shocking.”

“It’s extremely high,” Kalhan said, “and that should result in optimization of management, implementation of an exacerbation reduction strategy so people don’t have recurrent exacerbations and hospitalization. I think it probably should result in extremely high consideration for referral to a pulmonary specialist.”

One good thing is that new pharmacologic options are in development. Anzueto pointed to several combination products in the works that bring together long-acting beta₂ agonists with long-acting antimuscarinic agents for a synergistic effect, resulting in even higher levels of bronchodilation than with present drugs.

Yawn said roflumilast, the new PDE4 inhibitor, is very interesting, but she is particularly excited about new drugs being tested to work against other aspects of the inflammatory cascade. “I think that’s what we have to look at, and I’m hoping there is a disease-altering drug on the horizon that’s going to deal with some of the cytokines and other things that actively destroy lung tissue.”

But in the end, no matter which drug is being used, the best thing clinicians can do is ask the right questions. “‘Are you short of breath,’ is not a good enough question,” Kalhan said. “The message has to be that the disease is absolutely, positively treatable, that the exacerbations can be prevented, that quality of life can be improved, and that we need to apply treatment to patients in the context of viewing the whole patient in a multiple, systematic way.”

Anzueto said the main message needs to be that COPD is a treatable disease if patients receive proper therapy. “By therapy, I mean there is a partnership that would involve smoking cessation, exercise, and pharmacotherapy. With all these three legs together, the disease can be impacted, exacerbations can be decreased, and we may decrease mortality.”

In the end, Yawn said, the most important thing for clinicians to do is to use the tools available to them, whether that is a focused set of questions, pre- and post-bronchodilator spirometry, patient education, or adequate patient followup. “You can’t just start therapy and say, ‘Well, I’ll see you whenever.’ They need to know they have to come back,” she said.

“I think they also need to find a pulmonologist colleague that they can talk with and they’re comfortable with. Whether you’re in a rural area and you have to do it by telephone, or there is one across the street, find a pulmonologist that you are comfortable with and they will answer your occasional questions by e-mail or phone,” she added. “I find that is just so much more comfortable for me than feeling like I have to do this all myself.”

To read exclusive Web content on pulmonary rehab and smoking cessation as treatment for COPD, click here.

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