The underdiagnosed and poor management of COPD exacerbations represents a missed opportunity to prevent patient deterioration through proactive treatment approaches.
Chronic obstructive pulmonary disorder (COPD) remains a leading cause of poor health and mortality the world over.
COPD describes a group of progressive lung conditions characterised by inflammation and airflow obstruction to and from the lungs. Common symptoms of COPD include shortness of breath, a persistent cough often with mucus, and wheezing.
The condition mainly affects smokers or those who have smoked above the age of 35. Sometimes COPD can manifest in non-smokers and in these instances causative factors include exposure to air pollution, fumes or dust, genetic factors such as alpha-1 antitrypsin deficiency or a history of asthma in childhood.
Another feature of the condition is the sudden worsening of respiratory symptoms termed exacerbations, which when severe often lead to hospitalisation. In the US alone there are estimated to be more than 700,000 hospitalisations each year due to COPD. Frequent COPD exacerbations can result in a decline in lung function and a worse quality of life and in some instances can be fatal.
The burden COPD places on healthcare resources across the globe is enormous. In the US direct medical costs for treating COPD patients are estimated to exceed $10,000 per annum. According to most recent estimates COPD in total costs the US $32 billion in direct costs each year and $20 billion in indirect costs. These costs occur primarily as a result of hospital stays which become more frequent as the disease progresses.
In high income countries the prevalence of COPD has remained high over the last decade and is likely to continue on this course due to increases in the ageing population and continued exposure to risk factors. In low-middle income countries, where outcomes are far worse the problem is likely to get worse as life expectancy increases.
According to recent estimates more than 15 million people in the US alone are currently living with COPD. The true prevalence of COPD may however be even higher as a result of under recognition and underdiagnosis. With 150,000 deaths in the US each year due to COPD it remains a leading and critical global health challenge.
But what is needed to meet this challenge?
A diagnosis of COPD is currently made based on exposure to risk factors, presenting symptoms and a confirmatory spirometry test. A spirometry test can provide a measure of lung function based on the following two parameters;
- Forced expiratory volume in one second (FEV1), the volume of air that can be breathed out in the first second of a breath
- Forced vital capacity (FVC), the volume of air that can be breathed out in a single breath
An FEV1/FVC ratio below 0.7 following the administration of bronchodilator is considered diagnostic for COPD.
Often COPD is not diagnosed at an early stage due to the asymptomatic nature of the disease in its early stages, lack of use of spirometry and its similarity to other respiratory diseases in particular asthma. One study found that COPD may be misdiagnosed or undiagnosed in as many as 80% of patients.
With an estimated 8 out of 10 COPD cases caused by smoking, smoking cessation is particularly important at an early stage for preventing further declines in lung function. Smoking cessation was reported to halve the rate of decline in FEV1 in patients with mild-to-moderate COPD, compared with patients who continued to smoke.
Initially patients experience few symptoms however as the disease progresses, patients begin to experience more and more frequent and severe exacerbations, which lead to more rapid and obvious declines in lung function and reduce quality of life. Exacerbations when severe often require hospitalisation and may be fatal in around 2% of patients making them a major cause of healthcare utilisation in COPD patients.
Often the treatment of COPD exacerbations is not optimal because it consists of rescue therapy typically involving the use of inhaled bronchodilators or oral corticosteroids following the event with no follow-up. As a result, readmission rates are relatively high with one study in the US finding that 23% of COPD patients are readmitted to hospital within 30 days following an exacerbation.
There is an urgent need to develop solutions that can enable the early diagnosis of COPD as any delays in the diagnosis of COPD represent a missed opportunity to slow disease progression through preventative interventions. Smoking cessation alone could save as many as 120,000 lives per year in the US alone.
Current means of screening for COPD would involve primary care physicians screening either asymptomatic individuals or alternatively high-risk asymptomatic individuals using spirometry. This would then have to be confirmed by more diagnostic COPD testing in a primary care setting. However, the routine use of spirometry for the mass screening of COPD is not practical or cost effective.
There is also a need to move COPD treatment toward a more preventive care approach through enhanced patient monitoring. Earlier prediction of COPD exacerbations would enable the better use of treatments that aim to prevent or reduce the severity of these exacerbations.
Potential solutions to these problems will undoubtedly involve remote digital monitoring technologies capable of measuring respiratory parameters that are indicative of declines in lung function as these are more scalable and cost effective than other methods.
These solutions could enable clinicians to diagnose COPD earlier in the disease course and take a more preventative approach to COPD exacerbations which could have a significant impact on patient quality of life, disease progression and ultimately COPD patient prognosis and mortality.
Photo: milan2099, Getty Images