Non-pharmacological management of chronic obstructive pulmonary disease.

Chronic Obstructive Pulmonary Disease (COPD) is the most common lung disease in the world1. It accounts for the highest rate of hospital admissions among major chronic illnesses in Canada and1 is currently the fourth leading cause of death in the world2. By 2020, it is expected to be the third leading cause of death in the world3. Given its overwhelming prevalence in society, it carries with it a significant economic, social and personal burden. The key to decreasing the burden of COPD is modification of environmental exposures, including domestic, industrial, vehicular and personal tobacco exposure. Risk factor modification, including smoking cessation may be more powerful than aggressive testing strategies. Currently, the focus of treatment is appropriate bronchodilator therapy; however, non-pharmacological management must not be forgotten. Much like bronchodilator therapy, non-pharmacological therapy provides symptomatic improvement and better quality of life. In fact, some of the non-pharmacologic strategies, such as smoking cessation and long term oxygen, can prolong life expectancy, a feat that pharmacological therapies have yet to achieve. COPD is characterized by incompletely reversible airflow limitation4 and is often associated with a smoking history and increasing age. Because of its insidious onset and the non-specific nature of its symptoms (cough, slow and progressive dyspnea), the effects of COPD are not often noticed until years after the disease has begun. This often leads to the diagnosis of COPD in the advanced stages, limiting interventions and treatment options5. It has been shown by Tantucci et al that the most rapid decline in lung function occurs early in the disease course, particularly GOLD Stages II and III6. Thus, early diagnosis and intervention is essential to try and prevent rapid decline in FEV1. Aggressive testing strategies, smoking cessation efforts, and initiation of treatments may be beneficial during these early stages7-10. Because patients do not often perceive symptoms of early or worsening disease, or they attribute them to deconditioning and increasing age, primary care providers need to screen those at risk for COPD and be sure to ask patients about their symptoms at routine visits11. Smoking is the leading risk factor for the development of COPD5 and is a key component on history that should trigger further questioning to elucidate symptoms suggestive of this disease. The GOLD Strategy suggests that COPD should be suspected in anyone over the age of forty, who has dyspnea, chronic cough or sputum production with appropriate risk factors. Risk factors include a family history of COPD, tobacco exposure, exposure to cooking or home heating fuels or occupational dusts/chemicals2 (Table ​(Table11). Table 1: Key indicators that increase the pre-test probability of COPD Once a patient has been identified as having symptoms and risk factors suggestive of COPD, formal diagnosis is of the utmost importance. The gold standard for the diagnosis of COPD is based on spirometry. Given that COPD is characterized by airflow limitation that is not fully reversible, spirometry will demonstrate a post-bronchodilator FEV1/FVC of <0.7. The severity of COPD is largely based on FEV1 and differs according to different guidelines (GOLD vs ATS) (Table ​(Table2)2) However, given the heterogeneity of symptoms for a given FEV1, GOLD has developed groups A, B, C, D which help categorize severity based on multiple factors, including FEV1, number of exacerbations and level of symptoms based on MRC dyspnea scale or CAT score2. Table 2: Spirometric Classification of COPD Once COPD has been diagnosed, the focus must switch to decreasing the rate of decline in lung function including modification of risk factors and management of symptoms. These goals are achieved by both pharmacological and nonpharmacological therapy. The mainstay of pharmacological therapy is bronchodilators, while non-pharmacological methods include smoking cessation, pulmonary rehabilitation, immunizations and long term oxygen among others. While physicians are good at initiation of bronchodilator therapy, non-pharmacologic management is often forgotten despite these modalities providing symptomatic improvement and mortality benefits. This article will focus on nonpharmacological interventions and their beneficial impact on those with COPD.