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A Journal on Diseases of the Respiratory System
Official Journal of the Italian Society of Thoracic Endoscopy
Indexed/Abstracted in: EMBASE, Scopus, Emerging Sources Citation Index
Minerva Pneumologica 2010 March;49(1):1-16
Modern management of chronic obstructive pulmonary disease
Ora J., O’donnell D. E.
Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen’s University and Kingston General Hospital
Kingston, Ontario, Canada
Chronic obstructive pulmonary disease (COPD) is a common and often disabling inflammatory condition of the airways that in many can lead to early mortality. The cardinal pathophysiological features of COPD are expiratory flow limitation and lung hyperinflation. The main clinical consequences of these physiological abnormalities are subjective dyspnea, activity limitation and an increased propensity for recurrent exacerbations. Collectively, these contribute to an impoverished quality of life. In mild COPD relatively preserved measurements of forced expiratory flow rates (by simple spirometry) can obscure extensive inflammatory injury to the small airways, lung parenchyma and the pulmonary vasculature. Evidence is accumulating that these physiological derangements may have important clinical consequences that, until recently, have been underestimated. Thus, beyond the imperative of smoking cessation, active treatment may be justified in selected patients with mild COPD and persistent activity-related dyspnea. We now better understand how, with advancing COPD, the progressive impairment of respiratory mechanics and pulmonary gas exchange results in critical escalation of morbidity and mortality. In particular, we understand the central role of dynamic lung hyperinflation as a source of dyspnea and exercise intolerance. In this review we consider how we can best manipulate the physiological derangements of COPD so as to improve clinical outcomes. We will demonstrate how modern pharmacological combinations can effectively relieve symptoms, improve exercise capacity and reduce the frequency and severity of exacerbations in a manner that is truly unprecedented. Finally, we will consider how new scientific evidence from clinical trials is likely to influence our approach to providing optimal medical care to patients with more moderate COPD.