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The Early Recognition and Management of Chronic Obstructive Pulmonary Disease

Index:

 Introduction

COPD Definitions and Pathogenesis

The National Lung Health Education Program

Methods of Smoking Cessation

Maintenance Management of Symptomatic COPD

Treatment of Advanced Disease

The New Era

 

 

 


The National Lung Health Education Program

The Lung Health Study is the scientific foundation for the NLHEP. In the Lung Health Study, patients who were successful in stopping smoking had a significant improvement in airflow, followed by a slight decline over five years, compared with those who continued to smoke. Continuing smokers had a much more rapid rate of decline of FEV1. The most common cause of death in the Lung Health Study was not COPD or even heart attack or stroke. It was lung cancer! Thus, spirometric abnormalities are indicative of excess risk for the four most common causes of death in the United States: heart attack, stroke, lung cancer and COPD. The National Lung Health Education Program (see web site www.NLHEP.org) has the mission to develop a program to reduce the impact of COPD and related disorders through education of primary care physicians and public awareness. Another NLHEP mission is to detect COPD and related disorders early in order to reduce costly illnesses (that impact the quality of life) and to minimize premature death from COPD and other diseases.

Pulmonologists should support the NLHEP, because they don’t see patients with early stage disease in the first place. It is the right thing to do; they need to work in concert with their colleagues in primary care. Industry should also support the NLHEP, because it will identify patients in need of pharmacological therapy well before advanced and complex disease processes ensue. Managed care organizations (i.e., HMOs, PPOs, etc.) should also support the NLHEP because the prevention of premature morbidity and mortality due to COPD will ultimately result in a cost savings to them.

We have a powerful armamentarium for the early identification and treatment of COPD. This includes the office spirometer, nicotine withdrawal products, bronchodilators, antibiotics and corticosteroids.

The future challenges for the NLHEP are to implement its concepts and programs at the grass roots level, to promote smoking cessation programs, and to develop systematic therapy plans to stop the progression of the disease. A growing number of pharmacological agents have been released (or are soon to be released) that will probably alter the course and prognosis of COPD.

Prevention

The first essential step in treatment is smoking cessation. This is covered in Section C. The use of influenza vaccine each fall and pneumonococcal vaccine at appropriate intervals will also help prevent these two devastating infections in the majority of individuals.

Simple office spirometers with great accuracy are now available at low cost. The NLHEP recommends spirometric testing of all smokers (current and former) age 45 or older and anyone of any age with dyspnea on exertion, chronic cough, mucus hypersecretion or wheeze. Reimbursement is established for office spirometry. Code 94010 is for simple spirometry; rate of reimbursement is approximately $30. Code 91060 is the code for spirometry with bronchospasm evaluation, with a reimbursement of approximately $57. These reimbursement rates can vary from intermediary-to-intermediary.

We hope that this early approach to diagnosis and treatment will add significantly to your practice.

References

Anthonisen NR, Connett JE, Kiley JP, et al: Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study.  JAMA 1994;272:1497-1505. Results of the Lung Health Study. Lung function improvement in sustained cigarette abstinence compared with decline in continued smokers. Most common cause of death at 5 years was lung cancer!

Barnes PJ: Chronic obstructive pulmonary disease. N Engl J Med 2000;343:269-280. A comprehensive review of pathogenesis and treatment of COPD including novel future therapies.

Birring SS, Brightling CE, Bradding G, et al: Clinical, radiologic, and induced sputum features of chronic obstructive pulmonary disease in non-smokers: a descriptive study. Am J Respir Crit Care Med 2002;166:1078-1083. Evidence of increased sputum neutrophilia in smokers with COPD compared with non-smokers.

Ferguson GT, Enright PL, Buist AS, et al: Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Chest 2000;117:1146-1161. Recommends spirometric testing in all current and former smokers age 45 and older and in anyone with dyspnea on exertion, chronic cough, mucus hypersecretion or wheeze.

Morris JF, Temple W: Spirometric “lung age” estimation for motivating smoking cessation. Prev Med 1985;14:655-662. Normal lung age is that age at which a person’s measurement of FEV1is normal.

National Heart Lung & Blood Institute Data Fact Sheet USDHS – May 2001. The most recent statistics from the NHLBI.

Schoh RJ, Fero LJ, Shapiro H, et al: Performance of a new screening spirometer at a community health fair.  Respir Care 2002;47:1150-1157. A new ultrasonic spirometry had equivalent performance compared with a standard laboratory spirometer.

Silverman EK, Speizer FE: Risk factors for the development of chronic pulmonary disease. Med Clin North Am 1996;80:501-522.

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