COPD: it is time to change!

Figures & data

Table 1 Functional aspects of patients with prevalent chronic bronchiolitis

Patients with prevalent chronic bronchiolitis (± centrilobular emphysema mild-to-moderate)

Severity

FEV1/VC, FVC, FEV1 reduced

FRC increased, IC reduced (dynamic hyperinflation)

RV increased

Phenotype

MEF/MIF 50% ratio normal or slightly low

Normal static pulmonary compliance (normal K and elastic recoil at 90% TLC)

TLC not increased

DLCO and KCO normal or slightly reduced (ventilation inhomogeneity)

More frequent significant acute bronchoreversibility (after 400 μg albuterol)

More frequent aspecific airway hyperresponsiveness

Greater bronchodilating effect of deep inhalation (after methacholine)

Rare and later resting expiratory flow limitation in supine position

Abbreviations: FEV₁, forced expiratory volume in 1 second; VC, vital capacity; FVC, forced vital capacity; MEF, mean expiratory flow; MIF, mean inspiratory flow; RV, residual volume; TLC, total lung capacity; FRC, functional residual capacity; IC, inspiratory capacity; DLCO, diffusing capacity of the lung for carbon monoxide; KCO, transfer coefficient of the lung for the carbon monoxide.

Table 2 Functional aspects of patients with prevalent emphysema

Patients with prevalent emphysema (panlobular emphysema or chronic bronchiolitis with confluent centrilobular emphysema)

Severity

FEV1/VC, FVC, FEV1 reduced

FRC increased, IC reduced (static and dynamic hyperinflation)

RV increased

Phenotype

MEF/MIF 50% ratio low or very low

High static pulmonary compliance (high K, reduced recoil at 90% TLC)

TLC increased (overinflation)

DLCO and KCO decreased (loss of alveolar surface and capillary density)

No significant acute bronhcoreversibility (after 400 μg albuterol)

No or mild aspecific airway hyperresponsiveness

Decreased bronchodilating effect of deep inhalation (after methacholine)

Frequent and earlier resting expiratory flow limitation in supine position

Abbreviations: FEV₁, forced expiratory volume in 1 second; VC, vital capacity; FVC, forced vital capacity; MEF, mean expiratory flow; MIF, mean inspiratory flow; RV, residual volume; TLC, total lung capacity, FRC, functional residual capacity; IC, inspiratory capacity; DLCO, diffusing capacity of the lung for carbon monoxide; KCO, transfer coefficient of the lung for the carbon monoxide.

Figure 1 The baseline pharmacological approach to COPD according to the prevalent underlying disease.

Notes: ^aJudged according to persistence of daytime and/or nighttime symptoms, resting dynamic hyperinflation, lung function deterioration (in terms of FEV₁ annual decline and plethysmographic lung volume changes) and limited exercise tolerance (based on patient’s lifestyle). ^bIf eosinophilic inflammation (or surrogates: significant acute reversibility of airway obstruction, presence of airway hyperresponsiveness, high FENO); fluticasone dipropionate: high dose =1,000γ equivalent/daily; low dose =500γ equivalent/daily.
Abbreviations: bid, twice daily; FEV₁, forced expiratory volume in 1 second; ICS, inhaled corticosteroids; FENO, fractional exhaled nitric oxide; LABA, long-acting beta-adrenoceptor agonist; LAMA, long-acting muscarinic antagonist; U-LABA, ultralong-acting beta-adrenoceptor agonist; U-LAMA, ultralong-acting muscarinic antagonist.

Figure 2 The different preventive approach to acute exacerbation in COPD.

Notes: ^aIf eosinophilic exacerbations only. ^bIf chronic bronchitis, if environmental pollution, if still current smoker (carbocistein – N-acetyl carbocysteine high doses). ^cIf bacterial AECOPD, expected in the presence of bronchiectasis, chronic bronchitis, and bacterial colonization (macrolides). ^dOther causes of exacerbations (not infectious, not eosinophilic, and not induced by oxidative stress) according to etiology.
Abbreviations: AECOPD, acute exacerbations of chronic obstructive pulmonary disease; vit, vitamin; ICS, inhaled corticosteroids; C-PAP, continuous positive airway pressure.