Living with advanced COPD in 2002
While in training to become a respiratory physician, a 57 year old formerly smoking man with severe chronic obstructive pulmonary disease (COPD) and chronic respiratory failure frequently visited my outpatient clinic in Maastricht University Medical Center (MUMC), the Netherlands.
Despite regular treatment with a long-acting beta2-agonist and short-acting bronchodilators on an as-needed basis, he was persistently dyspnoeic and had a reduced exercise capacity. The very pronounced degree of lung hyperinflation probably contributed to his burden of disease.
Since he had been treated with antibiotics and oral glucocorticosteroids for several exacerbations in the last year and the degree of chronic airflow limitation was severe, I initiated a trial of several months with inhaled glucocorticosteroids (ICS) to identify whether he might benefit from this approach. He was severely dyspnoeic during endurance training, resulting in poor programme compliance and thus pulmonary rehabilitation did not result in symptomatic improvement.
In order to increase his life expectancy, long-term oxygen therapy was prescribed. In the years I treated him, until his death from an incident comorbid disease, I observed his progressive deterioration but had no additional treatment options.
Improved care for COPD
The Global Burden of Disease (GBD) 2015 study reported a modest increase in global death rates attributable to COPD from 2005-2015 (1). While population growth and ageing accounted for the increased overall mortality, I was intrigued by the finding that age-standardized and COPD-specific death rates fell by approximately 30% over this period (1).
Thus, the GBD study showed that the life expectancy of patients with COPD of a certain age has substantially improved over the last decade. Several factors may explain this improved survival, including improvements in the socio-demographic development of multiple countries and regions of the world, improvements in public health programmes and access to medical care, and reductions of inequalities within societies.
However, the results made me consider the actual improvements in medical care for COPD patients over the last decades and how these may, to a limited extent, contribute to the reduced mortality rates.
The first Workshop Summary of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was published in 2001 (2). By then, COPD was defined as a disease state characterized by airflow limitation that was not fully reversible and usually progressive. From the perspective of our current knowledge and management of the disease (3), diagnostics, classification and understanding of COPD pathophysiology have obviously progressed.
As none of the existing medications had been shown to modify the long-term decline in lung function that was considered the hallmark of COPD, pharmacotherapy was prescribed to reduce symptoms and bronchodilator treatments consisting of beta2-agonists, anticholinergics, theophylline, and a combination of one or more of these drugs were considered central to the symptomatic management.
The beneficial effects of inhaled bronchodilators on lung hyperinflation and exacerbation frequency had not been established and many new bronchodilator drugs and inhaler devices have become available over the last decades. GOLD 2001 recommended regular treatment with ICS for symptomatic patients with a documented spirometric response to ICS or for those with severe disease and repeated exacerbations (2).
Evidence for increased treatment effects when combining difference classes of inhaled medications was limited. Also, use of antibiotics other than in treating infectious exacerbations was not recommended and no anti-inflammatory agents were available.
Although pulmonary rehabilitation was considered beneficial for COPD, its role in the post-exacerbation period and its potential to reduce hospitalisation and mortality rates was unrecognized (4).
While long-term administration of oxygen to COPD patients with chronic respiratory failure had been shown to increase survival (5), long-term mechanical ventilatory support and lung volume reduction surgery for very severe disease were not recommended (2).
The contribution of cardiovascular and other comorbidities (6) to COPD morbidity and mortality was unknown and no attention was directed to comorbidity management.