Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease.1 Cigarette smoking is the major cause of the disease and smoking cessation is the most effective intervention in both preventing disease development and progression.2 Alison Bloomer talks to Dr Mona Bafadhel, Senior Lecturer in Respiratory Medicine at the Nuffield Department of Medicine at the University of Oxford and also Honorary Consultant Chest Physician at the Churchill Hospital, about the latest advances in the management of COPD. 

Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory diseases in the UK. It usually affects people over the age of 35 years, although most people are not diagnosed until they are in their 50s. It is thought there are over three million people living with the disease in the UK, of which only about 900,000 have been diagnosed. This is because many people who develop symptoms of COPD do not get medical help because they often dismiss their symptoms as a “smoker’s cough”. COPD affects more men than women, although rates in women are increasing.1

How would you describe COPD?
COPD is an umbrella term for patients who have symptoms of breathlessness, cough, increased sputum and it also fits the remit of patients who have emphysema, chronic bronchitis and sometimes chronic asthma. At the moment we label patients with the term COPD, but I think patients are quite individual in their response to different treatments and therefore management should be individualised.

How is COPD diagnosed?
We can diagnose COPD when patients present with a gradual history of worsening breathlessness. This is done through a spirometry test. This takes two measurements, which are forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). We can pretty much see straight away if a patient has COPD and airways are obstructed.

What is the prevalence in the UK?
COPD is common. We know that there are over a million people in the UK who have been diagnosed with COPD, but there are probably over three million who haven’t been diagnosed. These might be people who haven’t noticed the symptoms or who have just not gone to see their GP for whatever reason. Another problem is that COPD can be misdiagnosed as asthma in some patients when they actually have COPD symptoms. We do know that the majority of patients who have COPD have had a smoking history in the past. This probably means that one in 10 people have COPD in this country although we have not diagnosed everyone yet. There is a big drive currently for smoking cessation with COPD awareness days and campaigns from the British Thoracic Society. There is also NICE guidance on diagnosis that aims to catch the disease early in patients.

What are the risk factors?
The major environmental risk factor for the development of COPD is cigarette smoking. Then there are also environmental triggers such as air pollutants. Domestic and cooking fumes may also be important risk factors, especially in regions where indoor wood stoves are used with poor ventilation.3 COPD is more common in individuals of lower socio-economic status4 and has a poorer prognosis when associated with low body-mass index.5 In addition, there are a small proportion of COPD patients that have a genetic predisposition to COPD. Alpha-1 Antitrypsin Deficiency (AATD) is the most commonly known genetic risk factor for emphysema. Alpha-1 Antitrypsin related COPD is caused by a deficiency of the Alpha-1 Antitrypsin protein in the bloodstream. Without the Alpha-1 Antitrypsin protein, white blood cells begin to harm the lungs and lung deterioration occurs.6

Is COPD more prevalent in women?
The number of women smoking is now catching up with the number of male smokers. The damage is already done so we are now seeing more women being diagnosed with COPD. This will be a leading cause of death by 2020 and so therefore will impact greatly on a lot of people—male and female.

Are there any prevention strategies?
When people present with symptoms we have things that can help improve their quality of life such as inhaled medications. This reduces lung attacks and hospitalisations. People are starting to be more aware of COPD and the burden it places on patients as well as health services. There is a lot of research taking place into which patients COPD affects, how it affects them and also new treatments so we are always learning more about the disease. My research work has focused on how to individualise patients with COPD so can target our treatments.

What new advances have taken place?
There is ongoing research into different inhaled medications and tablets to try and understand how we can prevent the disease from getting worse. The most important thing about treating COPD is about bronchodilation. Inhaled medication should be used in the first instance. We now have new combination formulations that hope to maximise that bronchodilation. Steroids are dominant in asthma management but are also used in COPD to reduce the inflammation in the lungs, which can help reduce the number of lung attacks that patients have. We are trying to revolutionise the way we treat out patients so one person might benefit from steroids but another person might not. Research is looking at that in more detail.

How important is pulmonary rehabilitation?
After smoking cessation, the most effective therapy is pulmonary rehabilitation, a multidisciplinary series of exercise and education sessions, which have been shown to be clinically and cost effective.2 We know that pulmonary rehabilitation really does work for patients with COPD. Age isn’t a limitation and I always recommend exercise to increase muscle strength in my patients who have breathlessness. Patients should undertake exercise simultaneously with inhaled therapy. 

What impact does it have on comorbidities?
COPD is not just a disease of the lungs and it is associated with significant comorbidity. They are common for people with COPD because organ systems work differently when they do not receive enough oxygen. Another factor is that the older population are more likely to be diagnosed with COPD and they might have reduced strength in their hands making it difficult to use conventional inhalers. Recognising that we can’t just give one inhaler to everyone is important and there is a lot more choice of inhalers and devices now available.

What about the future?
We are getting better at diagnosing COPD and we have better treatment algorithms and modulations to manage the disease. Moving forward, it is about looking beyond the title of COPD and looking at individual symptom burden and coming up with individualised therapies.

References
1. http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx
2. Russell R, Norcliffe J, Bafadhel M. Chronic obstructive pulmonary disease. Medicine 2012; 40(5): 262–266
3. Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural community of the Hill region of Nepal. Thorax 1984, 39: 337–39
4. Kauffmann F, Drouet D, Lellouch J, Brille D. Twelve years spirometric changes among Paris area workers. Int J Epidemiol 1979, 8: 201–12
5.` Landbo C, Prescott E, Lange P, et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Resp Crit Care Med 1999, 160: 1856–61
6. http://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx