Commentary

Introduction

Despite being mostly preventable and treatable, chronic obstructive pulmonary disease (COPD) is now one of the top three causes of death worldwide and represents a major public health challenge [1]. In 2019, COPD was responsible for an estimated 3.23 million deaths, equivalent to approximately 9000 cases each day [2]. In the next few decades, the global burden of COPD is expected to increase further because of ageing of the population and continued exposure to risk factors [3]. The increased global burden of COPD has occurred despite advancements in available treatments, so it is time to reconsider treatment standards and goals for this progressive, inflammatory condition.

Our Current Approach to COPD Care

Goals for treatment of COPD, outlined in The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report [1], are centred around two key components: symptom improvement and prevention of future risk (Fig. 1). The former includes strategies to improve exercise tolerance and overall health status, while the latter is focussed on ways to reduce risk earlier in disease management, including exacerbation frequency, disease progression and mortality [1].

Fig. 1
figure 1

GOLD treatment goals for COPD [1]

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Evidence from several studies suggests that current treatment goals in COPD may not always be optimally translated into clinical practice. In one survey (conducted in North America and Europe) of 3265 subjects with a diagnosis of COPD, more than one-third of those with mild-to-moderate symptoms reported being too breathless to leave the house [4, 5]. Shortness of breath has been reported as one of the COPD symptoms with the greatest impact on wellbeing, along with coughing, fatigue and sputum production [6, 7]. These symptoms can progressively compromise the ability of patients to conduct day-to-day activities, and an increased symptom burden is a cause of anxiety and depression [7]. It has also been shown that patients with COPD who have an exacerbation are more likely to have another exacerbation in the future; however, exacerbation prevention does not seem to be enough of a priority given the frequency of exacerbations observed in population studies of patients with COPD [8].

Unmet Needs in COPD Care

Without appropriate treatment, outcomes such as lung function decline, repeated exacerbations and accumulated tissue damage contribute to the unpredictable and unstable nature of COPD [1, 9, 10]. These outcomes are linked to, and impact, one another: a single exacerbation can substantially accelerate the rate of lung function decline [11]; any decrease in lung function has been shown to negatively impact health status scores; a decline in forced expiratory volume in 1 s (FEV1) has been shown to be associated with an increase in the annual rate of moderate-to-severe exacerbations compared with no change or an increase in FEV1 [12]. COPD exacerbations have immediate and sustained impacts on health-related quality of life (HRQoL) and lead to increased healthcare utilisation and mortality risk [1, 11, 13, 14]. The unpredictable nature of COPD therefore imposes a substantial burden on patients, caregivers and healthcare systems, highlighting the need for more ambitious implementation of current management options.

Reducing symptom burden (or slowing symptom deterioration) to improve HRQoL, reducing risk by preventing exacerbations and stabilising lung function are central to achieving treatment goals set out in GOLD [1]. Subsequently, keeping patients with COPD stable over time may require a holistic, multi-faceted approach to their care (Fig. 2). As part of this, patients should be educated on the importance of good adherence to treatment, smoking cessation, keeping up to date with vaccinations, regular exercise, weight control and healthy eating. At the point where the maximum improvement possible for an individual has been achieved through this holistic approach, the aim should be stability and predictability to prevent worsening (Fig. 3).

Fig. 2
figure 2

Key considerations for keeping patients with COPD stable over time

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Fig. 3
figure 3

Schematic of disease stability, a framework that aligns to current treatment recommendations by GOLD

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The Patient Perspective

The perspective of patients is increasingly important to consider in COPD care. A series of authentic patient interviews conducted with the assistance of The Global Allergy and Airways Patient Platform (GAAPP) provide insight into the impact of COPD on patients’ daily lives as well as their aspirations for COPD care. Concerns were raised regarding the unstable nature of the disease (‘There’s a constant fear that you’re not going to be able to breathe at a moment’s notice’) and the impact of the unpredictable nature of COPD on daily routines (‘My daily routine has been affected pretty seriously by the unpredictability of how I feel on a daily basis. I can’t say, well, on this day of the week, Wednesday, I’m going to go to the farmer’s market’). One patient highlighted an individual disease goal was to slow the rate of disease progression (‘What I wish for my disease in the long term is, if not to have improvement, to at least stop or greatly slow down the progression. That’s what I’m hoping for’). Others highlighted the positive impact that having more stability would have on their daily lives (‘It would make my day so much better. I’d be able to get a lot more done because I wouldn’t be taking naps’; ‘If I managed to get that stability controlled within my illness, which I don’t have now, I would feel more free. I wouldn’t need to think first about my illness before deciding to make a trip, going for a walk, or going to the cinema’). Based on these insights, addressing the unstable and unpredictable nature of COPD is an important part of the discussion between patients and healthcare professionals.

Summary

Achieving and maintaining stability and predictability in COPD after maximum improvement has been reached has the potential to substantially improve the lives of patients (and their families) living with the disease and reduce the burden of COPD on healthcare services. By setting and achieving more ambitious treatment goals, we can aim to give patients the opportunity to do more while living with COPD.