A New National Strategy for COPD

Do your patients at risk know their lung numbers?

Abstract: Disturbing trends in the epidemiology of chronic obstructive pulmonary disease (COPD) and results of the Lung Health Study recently led the National Heart, Lung, and Blood Institute to convene a planning workshop on COPD. Workshop participants recommended a widespread campaign to educate both the general public and health care professionals about the importance of early detection and management of COPD. Key to this campaign B which will be called the National Lung Health Education Program B will be the widespread use of relatively inexpensive handheld spirometers to detect early signs of impaired lung function among smokers and others at risk for COPD. Also key will be the active involvement of primary care physicians and lung disease specialists in intervening to halt the progression of COPD. (J Respir Dis 1997;18(4):365-369)

by: Thomas L. Petty, M.D.

Chronic obstructive pulmonary disease (COPD) is now the fourth most common cause of death in the United States.1 Some 100,000 deaths from COPD have been predicted to occur in 1997 alone.

    The prevalence of COPD B which encompasses chronic obstructive bronchitis, emphysema, and asthmatic bronchitis B has been estimated to be more than 16 million cases.2 However, it is highly likely that an equal number of cases (those in patients with minimal or no symptoms at all) are undiagnosed. Thus, the true prevalence of COPD may be as high as 30 to 35 million cases.

    The risk factors for COPD are known. They are primarily smoking, a familiar predisposition, and a few dusty occupations.

    Given these facts, there is a great need to identify and treat COPD at the earliest possible time in its natural history, which may cover some 30 to 40 years. Unfortunately, the diagnosis of COPD is too frequently made when patients are in their late 50s or early 60s, when the forced expiratory volume in 1 second (FEV1) is in the symptomatic range of 1 to 1.5 L, and when quality of life is rapidly deteriorating.

    We can B and must B do a better job of educating the public about COPD and implementing early detection and treatment in our own offices. In this article, I will describe a new national initiative designed to meet those goals.

Cardiovascular disease: A model for COPD
One of the greatest public health success stories of our time if the major reductions we have achieved in premature morbidity and mortality from heart attack and stroke. These accomplishments (which can be attributed in large part to national health education programs sponsored by the National Heart, Lung, and Blood Institute [NHLBI]) resulted from an increase in awareness among both physicians and patients about the dangers of undetected and under-treated hypertension and high blood cholesterol levels.

    For example, from 1971 to 1991, patients= awareness of hypertension increased from 51% to 84% and the percentage of patients treated for hypertension rose from 36% to 83%.3 Most patients now know their Ablood pressure numbers,@ both systolic and diastolic. Similarly, most patients now know their Acholesterol numbers.@

    But how many patients at risk for COPD know their Alung numbers@ (FEV1 and forced vital capacity [FVC])? Probably very few. And how many physicians know the Alung numbers@ of their patients at risk for COPD? Once again, the answer is probably not very many.

The scientific basis
The Lung Health Study has now provided us with a new scientific basis for early identification of and intervention in COPD.4,5 This multicenter study prospectively evaluated the effect of intensive smoking cessation efforts on the decline in lung function over 5 years in 5,887 relatively young smokers.

    Investigators in the Lung Health Study found that middle-aged patients (average age, 48.5 years) with only mild degrees of COPD (average FEV1:FVC ratio of 63.5%) at first had a slight improvement in airflow and then only a minimal decline in FEV1 for the 5 years of follow-up B if they stopped smoking. By contrast, patients who continued to smoke had accelerated losses in FEV1.

    A second important finding from the Lung Health Study was the high prevalence of lung cancer; with 57 deaths at 5 years, compared with only 37 deaths from heart attack and stroke and 55 deaths from all other causes. Thus, it can be reasonably concluded that spirometric abnormalities are important surrogate indicators of other lethal diseases.6-11

The National Lung Health Education Program (NLHEP)
The hard facts about the epidemiology of COPD and the results of the Lung Health Study led to an important planning workshop on COPD. This workshop was sponsored by the Division of Lung Diseases of the NHLBI and was held in Bethesda, Maryland, in August 1995.

    The proceedings of the workshop led to the publication of a special communication (see AWhat the NHLBI workshop on COPD recommended@).12 The proceedings also led to the formation of the NLHEP.

    The NLHEP is jointly sponsored by the NHLBI and the National Cancer Institute. This partnership is appropriate because of the high association of occult lung cancer with even early stages of airflow obstruction. In addition, the NLHEP is co-sponsored by the two major pulmonary associations in this country B the American College of Chest Physicians and the American Thoracic Society B as well as by the American Association for Respiratory Care and the American Association for Cardiovascular and Pulmonary Rehabilitation.

    Recently, the American College of Physicians became a co-sponsor of the NLHEP. It is hoped that other societies of pulmonary care physicians (including the American Academy of Family Physicians), as well as societies representing nurse practitioners, physician assistants, dentists, and pharmacists, will join in this grass-roots effort to promote early identification of and intervention in COPD. Ideally, the NLHEP will include public service announcements, press releases, and other public relations efforts to stimulate interest in identifying patients at risk for premature morbidity and mortality from COPD and related disorders.

Reinventing spirometry
A major need for successful implemention of the NLHEP is the development of a simple, handheld spirometer with accuracy meeting current standards. Such a device which might be marketed for $100 to $200, need only display the three basic spirometric values: FEV1 (flow test), FVC (volume test), and the ratio between the two.

    Such devices are already in prototype stages and will likely be ready for marketing by mid-1997. Thus, spirometry will migrate outside the pulmonary function laboratory of hospitals into clinics, physicians= offices, patients= homes, and even ambulances.13 Clearly, we are entering a new era of widespread use of spirometry.14,15

    With the advent of handheld spirometers, all smokers should have spirometry done as part of a clinical database early in life. Also, any patient with chronic cough, dyspnea, mucus production, or wheeze should receive spirometry. Patients with abnormal findings should have appropriate interventions, which in most cases would begin with smoking cessation.

    However, only 22% of the Aspecial-care@ patients in the Lung Health Study were successful in sustaining smoking cessation during the 5-year follow-up period. And the patients receiving Ausual care@ achieved a quit rate of only about 5%. Thus, we have a tremendous challenge in encouraging smokers with early degrees of airflow obstruction to stop smoking. The availability of various forms of nicotine replacement, including those available over the counter (both gums and patches), may assist in this part of the NLHEP=s national education effort.

Role of primary care physicians in the NLHEP
As with hypertension, asthma, diabetes, arthritis, and other common chronic diseases, primary care physicians must be actively involved in the diagnosis and management of COPD. About 70% of the nation=s tobacco users consult a physician at least once a year for something; often, they contact their primary care physician with a complaint related to one of the smoking-related diseases.

    Even if these patients do not present with a smoking-related problem, they frequently come to primary care physicians for periodic check-ups, management of acute illnesses, and follow-up of non-smoking-related chronic illnesses. Primary care physicians are therefore in an ideal position of being able to prevent COPD and to diagnose and management it in its early stages. This includes offering help with smoking cessation, prescribing drug and nondrug therapies to maintain the patient=s quality of life, and giving influenza and pneumococcal vaccines.

    Thus, primary care physicians (and other Afrontline@ health care providers) will play a crucial role in the success of the NLHEP.

Role of specialists in the NLHEP
Why should pulmonologists and other specialists help to promote the NLHEP? The answer is simple. Patients with few or no symptoms of COPD, including most smokers, are simply not referred to pulmonologists, allergists, or other specialists unless an occult abnormality can be identified by a primary care physician.

    If patients= lung function is found to be abnormal on simple spirometric testing, they will be candidates for consultation with or referral to specialists. This will especially be the case if such patients are unable to quit smoking or if there is a high suspicion of lung cancer (as there would be with a chest film abnormality or a family or occupational risk heightening the likelihood of lung cancer).

    The NLHEP may also allow pulmonologists to participate in a new frontier of pulmonary medicine B early identification of and intervention in lung cancer that is still roentgenographically occult. Early detection could be accomplished by means of sputum tests to identify either cancer cells or cancer molecular markers when exfoliative cytologic morphology is only in the mild to moderate dysplastic stages. These stages are commonly a prelude to the development of high degrees of dysplasia, carcinoma in situ, and invasive carcinoma.

When successfully implemented, the NLHEP can make major contributions to improving the health of our nation by identifying patients in the early stages of COPD who absolutely must stop smoking. Spirometric abnormalities will also help identify those at risk for lung cancer, heart attack, and stroke, for whom appropriate surveillance, behavior modification, and smoking cessation are critical.

    The NLHEP will help us build a foundation for healthy living. If we fail to act, current trends in premature morbidity and mortality from smoking-related diseases will only continue.

What the NHLBI workshop on COPD recommended
As a follow-up to the Lung Health Study, the National Heart, Lung, and Blood Institute=s Division of Lung Diseases organized a workshop of experts and other interested parties to review the latest scientific and clinical information on chronic obstructive pulmonary disease (COPD).12 This workshop was held in August 1995, and a representative of the Journal of Respiratory Diseases was invited.

    The purpose of the workshop was to develop a strategy for dealing with the public health threat posed by COPD and to lay the foundation for a concerted national effort to identify COPD and intervene before symptoms appear. The following is a distillation of the workshop proceedings.

Definition of COPD
Workshop participants considered ACOPD@ to be an umbrella term used to describe several respiratory conditions that may be present separately or together, such as chronic bronchitis, chronic obstructive bronchitis, emphysema, and asthmatic bronchitis. Except perhaps for simple chronic bronchitis, all of these conditions may limit airflow, which medication does not improve in any major way.

    The risk of and mortality rate from COPD have almost always been reported to be higher in men that in women, but such reports may not have accounted for greater levels of smoking and occupational exposures among men. Recent data indicate that, puff for puff, women are at least as vulnerable as men to the development of COPD.

The Lung Health Study
The major scientific underpinning of the workshop and its recommendations was the Lung Health Study.4.5 This multicenter, randomized, 5-year prospective study focused on COPD=s early course and prognosis and whether and how they can be modified.

    The 5,887 patients enrolled in the study were smokers who had a ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 70%. Two thirds of the patients were randomized into special care (an aggressive smoking cessation program); the other third received usual care from their own physicians. The special-care group was further randomized to receive either ipratropium or placebo.

    Of those in the special-care group, 22% quit smoking cigarettes for the full 5 years; in contrast, only 5% of patients in the usual-care group quit smoking for the entire study period. Except for the first year; FEV1 declined much more slowly in abstainers than in those who kept smoking. Ipratropium did not add to smoking cessation=s beneficial effect on the course of COPD.

    The rate of FEV1 decline, a powerful prognostic indicator; was reduced no matter when a smoker quit. Smoking cessation was judged the only sure way to protect lung function in persons at high risk for developing COPD symptoms.

Detection of early COPD
Measurement of FEV1 and FVC is the only simple and easy method of spotting early COPD. Such measurement is most useful when obtained in the context of an environmental risk factor, such as smoking, or when a patient already has symptoms. Even a slight reduction in the FEV1:FVC ratio (in other words, to less than 75%) points to early COPD.

    Workshop participants recommended a widespread campaign to educate both the general public and health care professionals about the importance of early detection. The campaign would include a project testing the feasibility of screening for early COPD in primary care offices.

Treatment of early COPD
The best weapon against COPD is prevention, achieved through avoidance or cessation of smoking. Physicians can help patients quit smoking by offering education and counseling and, if indicated, by prescribing nicotine patches to ease withdrawal.

    Many drugs are valuable for the symptomatic treatment of COPD, but none are currently known to arrest the course of the disease over the long term. Ipratropium did not keep lung function from declining in the Lung Health Study (although a more recent analysis did suggest such a benefit16); B-agonists remain to be tested for this purpose. Also being evaluated for effectiveness in slowing lung function decline are inhaled glucocorticoids and , in patients with a1-antitrypsin deficiency, replacement therapy.

    Workshop participants advised giving the influenza vaccine each fall and the pneumococcal vaccine every 5 to 6 years to patients with early or symptomatic COPD.

Management of symptoms
Most patients with COPD show at least some symptomatic response to inhaled bronchodilators, either anticholinergic or B-agonist, given separately or together. Theophylline may help maintain some patients with COPD, and oral corticosteroids may be valuable for exacerbations. Broad-spectrum antibiotics, given empirically, may be useful in patients with purulent infections.

    In advanced COPD, transtracheal oxygen helps some patients live longer and feel better. And pulmonary rehabilitation in patients with COPD seems to improve their exercise tolerance and symptoms.

Practice considerations
As a common, costly, preventable, and detectable disease, COPD is amenable to preventive measures by all health care providers, regardless of the reimbursement schemes under which they practice. Major elements in a prevention program include tracking every patient=s smoking behavior and offering smokers support and formal programs to help them quit. Patients who currently smoke, are pregnant, or have established COPD or cardiovascular disease should be the focus of even more intensive forms of smoking cessation assistance.

    Smoking cessation leads to short-term as well as long-term cost savings. For example, former smokers have lower health care costs then continuing smokers as soon as 4 years after they quit.17

Outlook for the future
Intensive research was urged on a variety of fronts, ranging from learning more about the basic biology and pathophysiology of COPD to developing more effective means to help people quit smoking. Workshop participants also recommended development of a national program to educate the public on COPD and to involve more physicians in early detection and management.

Dr. Petty is chairman of the National Lung Health Education Program, professor of medicine at the University of Colorado School of Medicine, and faculty consultant for the HealthONE center for health sciences education in Denver.


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