Changing Directions in COPD Diagnosis and Treatment

Updated Guidelines Endorse a More Personalized Approach

Doctor talking with patient in doctors office
OJO Images/Getty Images

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD), an international committee of medical experts, updated its recommendations on the diagnosis and management of chronic obstructive pulmonary disease (COPD).

Since its previous release in 2012, the committee has made significant changes in how doctors are meant to approach the disease, simplifying definitions and changing the very manner in which symptoms are assessed and drug therapies are prescribed.

As scientists continue to gain insights into the long-term effect and effectiveness of COPD treatments, the focus is being increasingly shifted to the patient, tailoring treatments to the individual rather than to the stage of disease.

Changes in Definition

Among the key changes in the 2017 update is the definition of COPD itself. In the past, the disease was largely defined by its processes, from the mechanisms of inflammation to the manner in which the disease progressed.

No more. In its place, the GOLD committee defines COPD as a "common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation... usually caused by significant exposure to noxious particles or gases."

No longer is the disease described in terms of exacerbations or disease pathways or comorbid illnesses. Instead, it is broken down into a simple cause-and-effect: how exposure to a noxious substance (like cigarettes) can cause persistent respiratory illness.

While this change may seem incidental, it overcomes one of the major challenges in diagnosing and treating COPD. It acknowledges that people with no clinical evidence of airway obstruction can have symptoms of the disease, sometimes severe.

So, rather than weighing lab results against symptoms, doctors now focus on the cause, effect, and patient experience to direct the course of treatment.

Changes in Our Understanding of Disease Development

Equally conflicted has been our understanding of the development of the disease. While we largely associate COPD with smoking (defined by the GOLD committee as "self-inflicted"), the simple fact is that not all smokers get COPD and not all people with COPD are smokers.

The updated GOLD report acknowledges that we yet don't fully know where the tipping point is in relation to who gets COPD and who doesn't. In addition to exposure to cigarettes, the GOLD committee recognizes other possible factors linked to the disease, including:

  • Poor lung growth during gestation and childhood
  • Exposure to noxious chemicals in occupational settings
  • Different types of air pollution
  • Poor socioeconomic status
  • Poorly ventilated dwellings
  • Exposure to burning fuels (including wood fires and cooking fuel)
  • Other lung disorders (such as chronic bronchitis or infections)
  • An abnormal inflammatory response, perhaps congenital or the result of progressive or prior lung injury

What this is simply telling us is that, until we have a better understanding the true pathogenesis (disease pathway) of COPD, we need to look at the disease—and the causes of the disease—from a far broader perspective than cigarettes and cigarettes alone.

Changes in Treatment Practices

In the past, treatment plans were determined by a test known as the post-bronchodilator FEV1. Based on the results, the person's disease would be graded as either A (mild), B (moderate), C (severe), or D (very severe). Treatment would then be prescribed based on the grading.

In their 2012 update, the GOLD committee revised the guidelines so that the ABCD grading was determined by both a review of lab results, including the FEV1, and the individual's history of COPD exacerbations.

The problem with both of these methodologies is that they failed to acknowledge that the symptoms of COPD don't always match the grade.

One the one hand, a person with no evidence of airway obstruction can have severe COPD symptoms. On the other, a person with evidence of moderate obstruction may have few symptoms and manage just fine.

Because of this, the new guidelines recommend that the pharmaceutical treatment of COPD should be guided solely by the symptoms of the individual. Moreover, the determination should be based a self-evaluation by the patient.

Many doctors have already begun to do this using a COPD assessment test (CAT) in which the individual is asked to rate the severity of symptoms or impairment on a scale of zero to five. The test not only aims to establish the severity of symptoms but how "bad" or "good" a person perceives his or her illness to be. These insights can help a doctor predict how a person will cope with treatment, which may include medication, exercise, diet, and smoking cessation.

By shifting the focus back to the patient, the updated GOLD guidelines assert the importance of clinical experience and judgment in directing treatment rather than adherence to a one-size-fits-all playbook.

Source:

Roversi, S.; Corbetta, L.; and Clini, E. "GOLD 2017 recommendations for COPD patients: toward a more personalized approach," COPD Research and Practice. 2017; 3:5. DOI: 10.1186/s40749-017-0024-y.

Continue Reading