Changing how we see COPD

Chronic 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. The Lancet Commission on COPD, published in 2022, outlined the importance of classifying COPD by risk factors to explore different causal mechanisms of disease that could translate into distinct disease courses and treatment considerations. An example of this classification is discussed in a Personal View by Simpson and colleagues on the early-life risk factor of premature birth. Atypical lung development, reduced peak lung function, and potential for accelerated physiological lung function decline places infants born prematurely at an increased risk of developing COPD earlier in life. The authors highlight the necessity to better understand the mechanisms of prematurity-associated lung disease, and the part played by structural and inflammatory components, so that early recognition and treatments can hopefully alter disease trajectories. Alongside external risk factors, endogenous factors including genetics and biological traits are important. Studies have shown that baseline eosinophil count has been linked to the development of obstructive lung disease and raised eosinophils are now being used to guide personalised treatment in patients with COPD. The STARR2 trial reported by Ramakrishnan and colleagues showed that in patients with COPD exacerbations treated in primary care, blood eosinophil count identifies patients who would benefit most from systemic glucocorticoids and could help to reduce the systemic exposure and toxicity of universal prednisolone therapy. In our inaugural issue of The Lancet Respiratory Medicine in 2013, we published a Review on COPD and comorbidities. 10 years later, we recognise again the importance of coexisting disease and have published a paper that argues for a shift from the current notion of COPD as a single disease with comorbidities to a syndemics approach in which COPD is managed as a component of multimorbidity and common disease pathways are considered. Our 2016 Commission on COPD care delivery in the USA highlighted diagnostic delays, poor care coordination, low use of spirometry, and insufficient funding for COPD research. Sadly, in 2023, these issues remain and, in this issue, Bhatt and colleagues present a statement from the COPD Foundation Medical and Scientific Advisory Committee calling on stakeholders to improve access to spirometry and screening, improve education and awareness about COPD, and increase specific funding mechanisms to address this huge public health problem. Nearly 90% of COPD deaths in people younger than 70 years occur in low-income and middle-income countries (LMICs). A study published in The Lancet Global Health estimated that COPD will cost the world economy INT$4·326 trillion (international dollars) in 2020–50 and that China and the USA will face the largest economic burdens from COPD, accounting for an estimated INT$1·363 trillion and INT$1·037 trillion, respectively. The Lancet Respiratory Medicine is therefore planning its next Commission on COPD in China, which accounts for a quarter of the global COPD population. The Commission will consider risk factors for COPD, explore unmet needs in the diagnosis and assessment of COPD, and consider what is needed to build a modern public health system for COPD care in China. The Lancet Respiratory Medicine remains committed to publishing high-quality research in the area of COPD to improve understanding of disease pathogenesis and strategies for primary prevention, to promote tobacco control, to increase awareness and timely diagnosis of disease, and to support the development of treatment options that could halt or reverse the disease process. We ask the respiratory community to join us in our mission and submit COPD research to be considered for publication in a COPD special issue of the journal in October, 2024. The deadline for submission would be the end of April, 2024. There has been real progress in COPD research in the past 10 years, but a lot of work remains to be done to reduce the global burden of COPD. Together, the wider respiratory community can keep up the momentum and give COPD research the attention that it needs and deserves. Chronic obstructive pulmonary disease: hiding in plain sight, a Statement from the COPD Foundation Medical and Scientific Advisory CommitteeChronic obstructive pulmonary disease (COPD) is a major public health problem that remains largely neglected; there is perhaps no single disease that is as frequently ignored at such scale by patients, providers, payers, and funders. The burden of COPD in the USA and worldwide has remained high over the past several decades, resulting in high morbidity and mortality. It is the third leading cause of death, with more than 3 million deaths attributed to COPD worldwide in 2019.1 In the USA, data from two National Health and Nutrition Examination Surveys (NHANES 1988–94 and 2007–12) indicate that the prevalence of persistent airflow obstruction—compatible with a diagnosis of COPD—is approximately 15% and has remained stable over the past 20 years. Full-Text PDF Towards the elimination of chronic obstructive pulmonary disease: a Lancet CommissionDespite 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). Full-Text PDF Meeting the challenge of COPD care delivery in the USA: a multiprovider perspectiveThe burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders—patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry—to understand barriers to care delivery and propose potential solutions. Full-Text PDF COPD and multimorbidity: recognising and addressing a syndemic occurrenceMost patients with chronic obstructive pulmonary disease (COPD) have at least one additional, clinically relevant chronic disease. Those with the most severe airflow obstruction will die from respiratory failure, but most patients with COPD die from non-respiratory disorders, particularly cardiovascular diseases and cancer. As many chronic diseases have shared risk factors (eg, ageing, smoking, pollution, inactivity, and poverty), we argue that a shift from the current paradigm in which COPD is considered as a single disease with comorbidities, to one in which COPD is considered as part of a multimorbid state—with co-occurring diseases potentially sharing pathobiological mechanisms—is needed to advance disease prevention, diagnosis, and management. Full-Text PDF The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in 2020–50: a health-augmented macroeconomic modelling studyThe macroeconomic burden of COPD is large and unequally distributed across countries, world regions, and income levels. Our study stresses the urgent need to invest in global efforts to curb the health and economic burdens of COPD. Investments in effective interventions against COPD do not represent a burden but could instead provide substantial economic returns in the foreseeable future. Full-Text PDF Open Access