COPD—more than just tobacco smoke

On Sept 12–16, Vienna hosts the European Respiratory Society's annual congress, the largest in pulmonary medicine in the world. As a prelude to the meeting, The Lancet today is devoted to chronic obstructive pulmonary disease (COPD). WHO estimates that 210 million people have COPD worldwide. This number could be higher because many people with COPD often do not seek medical help until the disease worsens. COPD is now an umbrella term to cover emphysema and chronic bronchitis, among others, all of which used to be considered separate conditions. The disease is the fourth leading cause of death in the world, but by 2030 it is expected to be the third, behind ischaemic heart disease and cerebrovascular disease. With such a high burden, emphasis on better diagnosis, management, and identification of at-risk groups must be achieved. In today's issue, Joan Soriano and colleagues review spirometry, the mainstay of diagnosis. They call for better screening with spirometry, because early detection correlates with better outcomes. Spirometry is also used to classify COPD into four subgroups—mild, moderate, severe, and very severe. This classification helps guide the type of treatment options offered. For most patients, longacting inhaled β2 agonists, inhaled antimuscarinics, and inhaled corticosteroids in differing combinations are the foundation of effective management. Treatment with the anti-inflammatory phosphodiesterase-4 inhibitor roflumilast is presented in two randomised trials from Peter Calverley's group. The overall findings of the two studies suggest that there is benefit to patients with COPD, with a reduction in exacerbations, and improvement in lung function, when roflumilast is combined with a longacting bronchodilator or longacting inhaled antimuscarinics. For a long time COPD has been thought of as a smokers' disease, and not without reason. Those who smoke damage their lungs and create the pathophysiological environment for this disease. However, as Holger Schünemann points out in a Comment in today's issue, a worldwide ban on tobacco would indeed benefit health substantially both at the population and individual level—yet the world is not ready for such a bold ban. Sundeep Salvi and Barnes explore the aetiology of COPD and highlight the need for greater focus on risk factors other than smoking. They argue that smoking is not the biggest risk factor for COPD, and that this has been reported as early as 1963. Interest in COPD in non-smokers has increased in the past 5 years, although smoking has still remained the emphasis of most research. The Global initiative for chronic Obstructive Lung Disease (GOLD) points out in its guidelines that COPD is caused by “Tobacco smoke, occupational dusts and chemicals, indoor air pollution and outdoor air pollution”, putting these inhalation exposures under one blanket. Salvi and Barnes take this further, listing indoor air pollution from biomass fuel, pulmonary tuberculosis, chronic asthma, and socioeconomic status as additional risk factors in the development of COPD. Previous evidence suggests that occupational exposure to different compounds can lead to long-term severe sequelae in the respiratory system (eg, asbestos and mesothelioma); therefore, it is not a great leap to think that occupational exposures are also important risk factors for COPD. In parts of Africa tuberculosis is synonymous with HIV and therefore a diagnosis of either carries a large stigma. If patients with tuberculosis have an increased risk of COPD, could this population be under-represented in this continent? Will patients who have symptoms not present to health-care providers for fear of a diagnosis of tuberculosis, when in fact it is COPD? Education and increased awareness could be an answer for some of these patients, as well as an increased effort to destigmatise the association of tuberculosis and HIV by those health-care professionals working within this community. Chronic asthma is also of interest because it carries a greater risk of developing COPD than that caused by smoking. If asthma development is on the increase around the world, COPD incidence is likely to increase as well, perhaps even more so than the current predictions. Biomass fuel (coal, wood, and charcoal) has an exposed population of 3 billion, compared with 1 billion for those exposed to tobacco—making such fuel an important target in COPD prevention. This problem is not just one for developing countries. Even if over half of those who have COPD are non-smokers, the battle against smoking and health promotion to quit smoking should continue. However, the identification and education of those who are at risk from other inhalation exposures, both at home and at work, especially in developing countries, also needs to become a priority. From BODE to ADO to outcomes in multimorbid COPD patientsThe resources spent on research and treatment into chronic obstructive pulmonary disease (COPD) seem ludicrous compared with what could be achieved by simple and better legislation. In fact, the world needs to ban tobacco. Unfortunately, partly because many policy makers have failed to act appropriately, reality is different. COPD remains a major public health concern and is high on the priority list of major organisations, such as WHO.1 Full-Text PDF Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trialsSince different subsets of patients exist within the broad spectrum of COPD, targeted specific therapies could improve disease management. This possibility should be explored further in prospective studies. Full-Text PDF Roflumilast in moderate-to-severe chronic obstructive pulmonary disease treated with longacting bronchodilators: two randomised clinical trialsRoflumilast improves lung function in patients with COPD treated with salmeterol or tiotropium, and could become an important treatment for these patients. Full-Text PDF Screening for and early detection of chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease (COPD) is a substantially underdiagnosed disorder, with the diagnosis typically missed or delayed until the condition is advanced. Spirometry is the most frequently used pulmonary function test and enables health professionals to make an objective measurement of airflow obstruction and assess the degree to which it is reversible. As a diagnostic test for COPD, spirometry is a reliable, simple, non-invasive, safe, and non-expensive procedure. Early diagnosis of COPD should provide support for smoking cessation initiatives and lead to reduction of the societal burden of the disease, but definitive confirmation of both proves elusive. Full-Text PDF Chronic obstructive pulmonary disease in non-smokersChronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Tobacco smoking is established as a major risk factor, but emerging evidence suggests that other risk factors are important, especially in developing countries. An estimated 25–45% of patients with COPD have never smoked; the burden of non-smoking COPD is therefore much higher than previously believed. About 3 billion people, half the worldwide population, are exposed to smoke from biomass fuel compared with 1·01 billion people who smoke tobacco, which suggests that exposure to biomass smoke might be the biggest risk factor for COPD globally. Full-Text PDF