Best intervention for COPD patients? 'Stop smoking!'

Oct. 19, 2002

ASSEMBLY EDITION • SAN DIEGO

Best intervention for COPD patients? 'Stop smoking!'

BY DENNIS CONNAUGHTON

Helping patients to stop smoking is the single most effective intervention family physicians can provide for patients with chronic obstructive pulmonary disease, according to Gene Kallenberg, M.D.

Smoking cigarettes causes a long list of devastating health problems, but COPD is one of the most insidious, said Kallenberg, chief of the family medicine division at the University of California, San Diego, in his clinical seminar on "The ABCs of COPD." The seminar was presented Wednesday and repeats today from 8:30 to 10:30 a.m.

"Ironically, only 20 percent to 25 percent of smokers develop COPD. The ones who do have an exaggerated protective inflammatory response to inhaled toxic particles.

-- Gene
Kallenberg, M.D.

Smoking accounts for more than 90 percent of all COPD cases, Kallenberg said. And while smoking has declined overall in the United States in the past 20 years, it remains popular with young people, making tobacco use the fourth leading cause of death among Americans under 45.

Inflammatory process

What exactly is COPD? "It's chronic inflammation that results in varying proportions of narrowing and remodeling of the small airways -- termed obstructive bronchiolitis -- and parenchymal destruction of the gas-exchanging alveolar surfaces, or emphysema," Kallenberg said.

Cigarette smoke and other inhaled toxins activate macrophages to mediate inflammation by producing tumor necrosis factor-alpha, interleukin 8 and leukotriene B4, which then recruit neutrophils, Kallenberg said. During exacerbations of COPD, neutrophils and eosinophils are increased. Eventually, CD8+ cytotoxic lymphocytes may destroy alveolar epithelial cells. This excessive inflammatory response causes obstructive bronchiolitis and may lead to the destruction of lung parenchyma.

Ironically, only 20 percent to 25 percent of smokers develop COPD. The ones who do have an exaggerated protective inflammatory response to inhaled toxic particles.

The symptoms of COPD precede abnormal lung function, sometimes by years, he said. These symptoms include cough, sputum production and dyspnea on exertion. They predict risk of developing COPD, but not all patients who have symptoms progress to abnormal lung function.

Stages of COPD

Spirometry is the best available diagnostic test for patients with symptoms, risk factors or a family history of COPD, Kallenberg said. The disease has four stages:

Stage 0 defines patients at risk for COPD who have symptoms of chronic cough and sputum production.
Stage I defines mild COPD in which the patient has mild airflow limitation with FEV1/FVC less than 70 percent but with FEV1 greater than 80 percent.
Stage II defines moderate COPD in which airflow limitation worsens to FEV1 less than 80 percent but greater than 30 percent.
Stage III defines severe COPD in which FEV1 is less than 30 percent. In addition, patients have cor pulmonale or respiratory failure. At this stage, exacerbations can be life threatening.

Treatment

Patients with moderate disease require bronchodilators, Kallenberg said. All patients should receive influenza and pneumococcal vaccinations to help reduce serious complications.

COPD exacerbations require high-dose bronchodilators, antibiotics if infections are present, systemic steroids, and oxygen and ventilatory assistance if needed, he said.

For patients with moderate to severe disease, consider prescribing long-term oxygen therapy at home and pulmonary rehabilitation. Bullectomy, lung-volume reduction surgery and lung transplantation are treatments of last resort, Kallenberg said.

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