Nationally, the agenda for respiratory disease is low on the list of priorities for guidelines or initiatives, even though the most common reason for consultation relates to respiratory illness.
This is perhaps most true of chronic obstructive airways disease (COPD), which impairs the life of sufferers and makes large demands on the NHS. Current costs approach £500 million annually. COPD is responsible for nearly 24000 deaths each year – 14 times the number due to asthma.
The prime objective of the COPD Primary Care Taskforce is to improve awareness of the condition. Nationally the prevalence is thought to be 1%, but detailed case finding in primary care suggests that the true figure may be closer to 1.5%, which means a staggering 900 000 people with the problem.
In line with the British Thoracic Society (BTS) guidelines for COPD,1 the Primary Care Taskforce hopes to raise standards of care by improving diagnosis, achieving best control of symptoms, preventing deterioration and improving quality of life.
Improvement in diagnosis means access to spirometry so that COPD may be accurately differentiated from asthma. Earlier diagnosis will mean screening at-risk populations, mainly smokers or those over the age of 45 years receiving treatment with bronchodilators or inhaled steroids.
The most important outcome measure in COPD is quality of life. This is not easily measured and involves the use of long questionnaires, which are currently only suitable for clinical trials. The simplest and most effective way forward might be to ask the patient what his/her individual objectives are, and measure progress against these.
Management of COPD involves treating the whole person, not simply the lung. Many people with COPD suffer from significant depression and inadequate nutrition, as well as other diseases, and these must all be taken into account when working out a treatment plan.
The BTS COPD guidelines provide a useful framework for care, but things have moved on. There is now clear evidence to support the use of long-acting beta2-agonists and the combination of short-acting beta2-agonists and anticholinergic (ipratropium).
The ISOLDE trial2 provides evidence that fluticasone 500µg bd in those with moderate to severe COPD results in fewer exacerbations and a slower decline in quality of life. There is increasing evidence of the benefits of pulmonary rehabilitation and very recent data suggest that this can be done well in a community setting.
Last year saw the arrival of antiviral agents (zanamivir and oseltmivir) for the treatment of influenza. These drugs may well prove to have a critical role in the prevention of exacerbation of COPD in a flu epidemic. Most primary care teams are now convinced of the value of annual flu vaccination and also ensure that patients are vaccinated against pneumococcal pneumonia.
The secondary objective of the taskforce is to prevent the development of COPD. It almost always but not exclusively occurs secondary to cigarette smoking. Smokers are easy to identify. Primary healthcare teams will be in the foreront of motivating patients to quit, and will have the help of nicotine replacement therapy and bupropion, which is licensed as an adjunct to smoking cessation and boasts quit rates of up to 33% after one year.
The Government is commited to reducing the prevalence of smoking: it would be paradoxical if it made no effort to give us the resources needed to perform our task.
The management of COPD may all seem like hard work, but the evidence indicates that better management leads, in a short space of time, to fewer consultations and improved patient wellbeing. It is a pleasant change to be able to offer our patients constructive interventions.
- BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52 (Suppl 5).
- Burge P, Calverly P, Jones P et al. Randomised double-blind placebo-controlled study of fluticasone proprionate in patients with moderate to severe COPD; the ISOLDE study. Br Med J 2000; 320: 1297-303.