By Anand S. Iyer, MD, MSPH1,2,3
and R. Chad Wade, MD1
Chronic obstructive pulmonary disease (COPD) is a serious respiratory illness that impacts over 15 million Americans and an estimated 380,000 Alabamians. Navigating the world of COPD treatments can be complicated, and clinicians may feel that treatment options are limited for people as the disease progresses. However, there is a lot we can still offer and much to come on the horizon.
First, COPD Basics
A diagnosis of COPD requires three elements: 1) exposure, 2) symptoms, and 3) spirometry. Smoking remains an important cause of COPD and accelerates loss of lung function over time. However, smoking is just one of the many causes of COPD. An estimated 50 percent of COPD results from smaller lungs. The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) highlighted this through a new classification system for COPD that includes different exposure domains such as the environment (air pollution), genetic causes (alpha-1 antitrypsin deficiency), and early developmental abnormalities. Clinicians should think broad about potential exposures that can lead to COPD. When it comes to symptoms, hallmark COPD symptoms include progressively debilitating breathlessness and chronic cough, but clinicians should consider other conditions such as interstitial lung disease or bronchiectasis, which cause similar symptoms as COPD. Measuring symptoms using the Medical Research Council Dyspnea scale (mMRC) and COPD Assessment Test (CAT) surveys is important to help quantify and track symptoms and should be implemented at all clinic visits. It is also important to document exacerbations, which increase the risk of death, cause significant burden for patients and their families, and are important factors in COPD staging. Finally, a diagnosis of COPD requires post-bronchodilator spirometry with airflow obstruction (defined by FEV1/FVC <0.70). Spirometry helps quantify the severity of COPD and helps clinicians decide on treatment. Furthermore, inhalers are unlikely to benefit people who do not have a clear COPD diagnosis, so spirometry is key to establishing a firm diagnosis. The debate over fixed airflow obstruction versus lower limit of normal criteria for diagnosing COPD is important but is a topic for another time.
Updates on Treatment
– GOLD 2023
GOLD 2023 guidelines focus on treating the whole patient and taking into account comorbidities, which can be many in someone living with COPD. When it comes to treatment, clinicians must engage their patients in tobacco cessation counseling from the beginning, refer to accredited pulmonary rehabilitation across COPD stages and ages, and keep patients up to date on vaccinations. Other updates include new letter groupings (from GOLD Groups A, B, C, and D to Groups A, B, and E), and treatment recommendations that emphasize starting with combined long-acting bronchodilator inhalers (long acting muscarinic +/- long acting beta-agonist) for those with a high symptom burden and not using an inhaled corticosteroid initially. When symptoms or exacerbations get worse (i.e. GOLD Group E), then we recommend adding an inhaled corticosteroid for those with a high serum eosinophil count (>300 cells/µL) and generally try to minimize how long someone stays on this due to important side effects. If patients continue to experience high symptom burden or exacerbations, clinicians can add oral anti-inflammatory agents such as roflumilast or azithromycin for select people. Finally, supplemental oxygen therapy should be started for those with severe hypoxemia and stopped when no longer meeting criteria. For those who meet criteria (e.g. hyperinflation), clinicians should consider referring patients to a center that performs bronchoscopic or surgical lung volume reduction.
For those still getting worse despite maximum therapies, a “treatable traits” approach can be considered. In this model, clinicians reframe someone as person with “end-stage COPD” to a person with COPD and set of traits each with unique treatment approaches, e.g. refractory breathlessness, emotional symptoms, frequent exacerbations, hyperinflation, or chronic respiratory failure. Utilizing this approach can help clinicians proactively implement interprofessional strategies to help these patients which include referral to specialists in geriatrics and palliative care, nutritional support, psychosocial counseling, and others.
On the Horizon
– UAB’s Lung Health
Center Leading the Way
The future of COPD will focus on identifying distinct disease subtypes and personalized treatment strategies. The Lung Health Center at the UAB is at the forefront of investigating novel pharmaceutical, device, and behavioral interventions to change the trajectory of COPD. Actively enrolling studies include trials attempting to gain further insight into emphysema progression or muscle wasting, cutting edge bronchoscopic interventions to reduce mucous production and improve airway obstruction, disease phenotyping using novel diagnostic imaging modalities, and behavioral interventions. Exciting treatments in the pipeline include AIRFLOW-3, which is investigating the use of targeted bronchoscopic lung denervation to improve airflow obstruction and reduce exacerbation risk, Ensifentrine, a novel drug targeting inflammatory pathways to alleviate symptoms and reduce healthcare utilization, and Dupilumab, which recently demonstrated tremendous benefit in exacerbation reduction and quality of life improvement. In addition to cutting-edge basic science and clinical COPD research, UAB also has a Southeast Institute for Innovation in Palliative and Supportive Care, and we are actively conducting research on geriatrics and palliative care in COPD to help patients age successfully in their communities and improve quality of life for patients and their families.
Dr. Iyer and Dr. Wade are pulmonologists at the UAB Division of Pulmonary, Allergy, and Critical Care Medicine and the UAB Lung Health Center. Their clinical interests and research focus are on COPD. Dr. Iyer also directs clinical pulmonary services for Cooper Green Mercy Health Services Authority. Inquiries about UAB Lung Health Center studies or referrals can be emailed to lunghealth@uabmc.edu or call to (205) 934-5555.
