Un consensus international sur la BPCO et sa prise en charge, GOLD

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 A consensus report provides an update on the management of Chronic Obstructive Pulmonary Disease.

In an original move, an international committee named GOLD (Global Strategy for the Diagnosis, Management, and Prevention of COPD) was created in 2001. This committee was charged with regularly reviewing scientific and medical knowledge on Chronic Obstructive Pulmonary Disease (COPD), one of the least curable, most disabling, fastest-growing and costliest diseases in the world. This committee is composed of internationally-recognized researchers and clinicians. It publishes its report regularly. The most recent report was published in 2013. This Blog en Sante article reviews its key points and recommends the reading of the original report.

The Report Rationale

The Chronic Obstructive Pulmonary Disease (COPD) is the fifth-leading cause of death worldwide. It affects 1.5 million people in France alone. About as many patients are unaware of COPD signs, which they often confuse with those of an occasional bronchitis, or wrongly attribute to fatigue and aging. The later the COPD diagnosis, the greater the loss of autonomy and irreversibility of its effects. This disease is mostly caused by active or passive smoking. It is currently uncurable. Patients usually experience physical and psychosocial deconditioning. Symptoms can be substantially mitigated with proper care. The French Thoracic Society has published recommendations for the management of COPD. A team of international experts convened under the name GOLD now takes its turn.

The Question

What is our current knowledge about COPD and its treatment?

The Method

The content of the report is based on the consensus method. A panel of experts discusses specific issues until it arrives at an opinion shared by all. An Evidence-based Medicine level of proof is assigned to each opinion.

Main results

The 2013 GOLD report first gives an update on COPD, its epidemiology and pathophysiology. According to the GOLD, COPD can be prevented by not smoking. It is “characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to particles or gases.” The authors emphasize that the presence of “exacerbations” and/or “comorbidities” increases the severity of the disease. COPD is caused by inhaled cigarette smoke or other inhaled harmful particles, such as biomass smoke. This disease is underdiagnosed by physicians (a phenomenon which is aggravated by the fact that patients underestimate the severity of their symptoms), and the diagnosis is often too late. Women are suffering from the disease more and more, gradually catching up with men. COPD accounts for 6% of the total health expenditures of European countries, and 56% of the cost of respiratory diseases.

The report then discusses diagnosis. Abnormal shortness of breath upon exertion, persistent cough and sputum production are warning signs, particularly in smokers or in people associating with smokers. This allows doctors to make an accurate diagnosis of COPD and adjust the treatment accordingly. The earlier the diagnosis, the lesser the impact on quality of life and health. Other diseases (also called comorbidities) are often present in patients with COPD, such as cardiovascular disease, muscular dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, or lung cancer.

The report continues with therapeutic strategies, pharmacological interventions as well as Non-Pharmacological Interventions (NPIs). Approaches to smoking cessation, the pharmacological treatment of symptoms, the prevention of exacerbations, health education, rehabilitation and vaccination are all therapeutic priorities. Most of these treatment strategies have been assigned a grade A or B level of evidence according to the principles of Evidence-Based Medicine. When the disease worsens, other treatments can be proposed, such as oxygen therapy, noninvasive ventilation and surgery.

It should be noted that two chapters are specifically devoted to the management of exacerbations and the care of comorbidities. One chapter highlights the need to identify and reduce exposure to risk factors (pollutants, cigarette smoke, dust), to prevent bacterial and viral infections via improved hygiene, to get vaccinated, and to have a physician-reviewed pharmacological or non-pharmacological plan to manage exacerbations. The other chapter points out that other diseases can be present alongside COPD. Most often, cardiovascular diseases such as hypertension coexist. Osteoporosis and depression are inadequately identified by doctors (though they are often responsible for premature death). Finally, lung cancer can also be found.

What it means for Patients

The GOLD alerts clinicians to the fact that there is not just one COPD, but many COPDs, in which comorbidities are intertwined. These must necessarily be taken into account to improve the quality of life and life expectancy of patients.

What it means for Healthcare Professionals

GOLD sensitize clinicians to the fact that there is not a single COPD, but COPD in which comorbidities are intertwined. These must necessarily be taken into account to improve the quality of life of patients and their lifetime.

What it means for Researchers

Any clinical research requires the sound characterization of the sample studied. The GOLD gives an international definition of COPD, updated regularly with the most recent data. Since 2000, this definition has evolved from that of a purely physiological bronchial obstruction disease measured with a single pulmonary indicator, the Forced Expiratory Volume in 1 second (FEV), to that of a complex disease measured with a combination of functional and integrated indicators.

What it means for Policymakers

Just treating COPD no longer seems sensible, inasmuch as comorbidities are usually present. It is therefore necessary to place patients in a long-term care and prevention process to best accompany them according to their specific needs.

The reference

Global Initiative for Chronic Obstructive Lung Disease – GOLD (2011). Global strategy for the diagnosis, management, and prevention of Chronic Obstructive Pulmonary Disease (COPD). Barcelona: GOLD.

To reference this Blog en Sante © article.

Ninot G (2014). International Consensus on COPD. Blog en Sante, A29.

© Copyright 2014 Grégory Ninot. All rights reserved.

Thanks to Syl Billere for the English Revision.