Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate. Classification of COPD: fostering prevention and precision medicine in the Lancet Commission on COPDChronic obstructive pulmonary disease (COPD) is a highly prevalent and heterogeneous chronic disease of the lower airways and lungs that is associated with huge morbidity, disability, and mortality worldwide and disproportionately affects poor and vulnerable people.1 Pathologically, COPD is characterised by variable degrees of chronic inflammation and remodelling of small airways (bronchiolitis) and destruction of alveolar walls (emphysema).2 Diagnosis of COPD relies on respiratory symptoms and the presence of spirometric airflow limitation. Full-Text PDF COPD: from an end-stage disease to lifelong lung healthChronic obstructive pulmonary disease (COPD) has for too long been seen as a self-inflicted progressive disorder of smokers towards the end of life with few treatment options beyond symptom control. There has been no major progress in treatment or prevention for decades. The global burden of COPD is predicted to continue to increase in the future. To achieve better outcomes and ultimately prevent at least some forms of COPD, a complete rethink is needed. A new Commission published in The Lancet, Towards the elimination of chronic obstructive pulmonary disease, provides the framework. Full-Text PDF Daiana Stolz: transforming the agenda for lung healthWhen I meet Daiana Stolz over videocall, she has travelled from the University of Freiburg, Germany, where she is Director and Chair of the Clinic of Respiratory Medicine in the Faculty of Medicine, to University Hospital Basel, Switzerland, where she is Professor and Attending for Respiratory Medicine and Research Group Leader of Pulmonary Medicine in the Clinic of Respiratory Medicine and Pulmonary Cell Research. “I'm currently balancing between the two research groups”, she says. At these institutions, she does clinical and translational research focusing on chronic obstructive pulmonary disease (COPD), asthma, and respiratory infection. Full-Text PDF Mark Dransfield: breathing new ideas into COPDA new Lancet Commission report, Towards the Elimination of Chronic Obstructive Pulmonary Disease, is not a comforting read. The Commission's account of the failure of respiratory medicine to make advances in chronic obstructive pulmonary disease (COPD) comparable to those seen in other common conditions, such as heart disease and cancer, will strike many readers as bleak. “It is bleak”, says Mark Dransfield, Professor of Pulmonary, Allergy and Critical Care Medicine at the University of Alabama at Birmingham (UAB), AL, USA, Medical Director of its Lung Health Center, and a Co-Chair of this Commission. Full-Text PDF COPD in ColombiaHuge numbers of Colombian's have chronic obstructive pulmonary disease (COPD), driven by tobacco use and air pollution. Joe Parkin Daniels reports from Bogotá. Full-Text PDF The Lancet COPD Commission: broader questions remain – Authors' replyWe thank Paulo CRP Corrêa for his interest in the Commission1 and wholeheartedly agree that the absence of meaningful tobacco control is unacceptable and in no way aimed to diminish its importance. In addition, we take no issue with the assertion that continued smoking among people with established chronic obstructive pulmonary disease (COPD) accounts for much of the disease burden. However, we think it is important to recognise that factors other than tobacco are increasingly accountable for incident cases of COPD, including e-cigarette use as Corrêa highlights. Full-Text PDF The Lancet COPD Commission: broader questions remainI have read with interest the comprehensive Commission on chronic obstructive pulmonary disease (COPD) by Daiana Stolz and colleagues.1 The authors report that “The most efficient way to reduce the burden of COPD is to ban cigarette smoking in all its forms.” However, only a few sentences later the authors downplay the importance of smoking: “risk factors unrelated to tobacco are increasingly responsible for the burden of COPD, and are likely to surpass the risk attributable to smoking within the next two decades”. Full-Text PDF The Lancet COPD Commission: broader questions remainDaiana Stolz and colleagues1 in their proposed diagnostic algorithm (figure 11 of the Commission) list several alternative tests to aid in the diagnosis of chronic obstructive pulmonary disease (COPD) in people who have a forced expiratory volume in 1 s to forced vital capacity ratio of greater than or equal to 0·7, including diffusion, resistance, nitrogen washout, pathology, and the forced oscillation technique. Unfortunately, the authors did not include cardiopulmonary exercise testing (CPET) in this important list despite the growing body of literature showing that CPET can reveal considerable abnormalities in people with mild COPD and even in smokers with normal spirometry relative to healthy age-matched controls. Full-Text PDF The Lancet COPD Commission: broader questions remainWe would like to congratulate Daiana Stolz and colleagues1 for a comprehensive and authoritative Commission that undoubtedly constitutes an important landmark in the field. The emphasis on recognising risk and causative factors for chronic obstructive pulmonary disease (COPD) beyond tobacco smoking, such as other environmental exposures and early-life events as drivers of disease and lung function decline, is pivotal for the success of the mission towards earlier diagnosis and improved global prevention and treatment strategies. Full-Text PDF Changing how we see COPDChronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, with 3·23 million deaths reported in 2019. For a long time, COPD was seen as a disease of smokers—a terminal disease, diagnosed in older people, with few treatment options. Through dedicated research, the COPD community has shown that disease processes can begin in early life, that there is a complex interplay of a range of risk factors in addition to smoking—including genetics, respiratory infections, and air pollution—and that COPD is a spectrum of lung disease that needs personalised treatment approaches. Full-Text PDF