Elsevier

The Lancet

Volume 364, Issue 9434, 14–20 August 2004, Pages 613-620
The Lancet

Seminar
Burden and clinical features of chronic obstructive pulmonary disease (COPD)

https://doi.org/10.1016/S0140-6736(04)16855-4Get rights and content

Summary

Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality and represents a substantial economic and social burden throughout the world. It is the fifth leading cause of death worldwide and further increases in its prevalence and mortality are expected in the coming decades. The substantial morbidity associated with COPD is often underestimated by health-care providers and patients; likewise, COPD is frequently underdiagnosed and undertreated. COPD develops earlier in life than is usually believed. Tobacco smoking is by far the major risk for COPD and the prevalence of the disease in different countries is related to rates of smoking and time of introduction of cigarette smoking. Contribution of occupational risk factors is quite small, but may vary depending on a country's level of economic development. Severe deficiency for alpha-1-antitrypsin is rare and the impact of other genetic factors on the prevalence of COPD has not been established. COPD should be considered in any patient presenting with cough, sputum production, or dyspnoea, especially if an exposure to risk factors for the disease has been present. Clinical diagnosis needs to be confirmed by standardised spirometric tests in the presence of not-fully-reversible airflow limitation. COPD is generally a progressive disease. Continued exposure to noxious agents promotes a more rapid decline in lung function and increases the risk for repeated exacerbations. Smoking cessation is the only intervention shown to slow the decline. If exposure is stopped, the disease may still progress due to the decline in lung function that normally occurs with aging, and some persistence of the inflammatory response.

Section snippets

Definition

For years, clinicians, physiologists, pathologists, and epidemiologists have struggled with the definitions of disorders associated with chronic airflow limitation. The definition of COPD as given by GOLD is now rapidly gaining general acceptance: “COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.” 3

Chronic

Prevalence

COPD prevalence and morbidity data probably greatly underestimate the true burden of the disease, because it is not usually recognised until it is clinically apparent and moderately advanced. Studies of COPD prevalence have used self-reported respiratory symptoms, physician diagnosis of COPD, or the presence of airflow limitation as criteria. Use of self-reported symptoms will include people with chronic bronchitis but without airflow limitation.

More recent epidemiological surveys have used

Economic burden

Because of the high prevalence of the disease and the potential for severe disability, COPD represents a substantial economic and social burden. It is, therefore, surprising how little information is available on the direct and indirect costs resulting from morbidity and premature death from COPD.

Some countries have attempted to assess the economic burden of COPD, separating costs directly and indirectly attributable to the disease. Data from developing countries are not yet available, but data

Risk factors

Most evidence about exogenous risk factors for COPD comes from cross-sectional epidemiological studies that identify associations rather than links between cause and effect3 (figure 4).

Clinical features

COPD should be considered in any patient presenting with cough, sputum production, or dyspnoea, especially if the patient has been exposed to risk factors for the disease. Clinical diagnosis is confirmed by standardised spirometric tests that show the presence of airflow limitation (ie, postbronchodilator FEV1<80% of the predicted value in combination with an FEV1/FVC <0·7). Clinical symptoms and signs, such as abnormal shortness of breath and increased forced expiratory time, can be used to

Cough and sputum

Cough may initially occur intermittently but it is usually the first symptom of COPD to develop.37 It may be unproductive38 and is frequently neglected as a clinical sign by patients. Regular production of sputum for 3 months or more in 2 consecutive years has been the epidemiological definition of chronic bronchitis39 for many years but this pattern of sputum production is not really the same as that seen in COPD patients, which is generally very variable and sometimes difficult to assess.4

Dyspnoea

Natural history

Studies on the natural history of COPD show that it is usually a progressive disease, although differences exist between individuals. Continued exposure to noxious agents promotes a more rapid decline in lung function and increases the risk for repeated exacerbations (figure 5). If exposure to noxious agents is stopped, the disease may still progress because of the age-related decline in lung function, and the persistence of aspects of the inflammatory response.58 Nevertheless, efforts need to

Search strategy

The material covered in this review is based on an extensive literature search and participation in expert meetings during the writing and updating of the GOLD guidelines, and on many years of research in the subject. We did a systematic MEDLINE search for articles in English or with English abstracts with keywords COPD, prevalence, morbidity, burden, cost, pollution, occupation, genetic, and severity, up to June, 2004.

Conflict of interest statement

None declared.

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