Translating new understanding into better care for the patient with chronic obstructive pulmonary disease.

Despite an enormous amount of research and many official statements, the definition, diagnosis, and staging of chronic obstructive pulmonary disease (COPD) remain inconsistent, and we have yet to agree on who should be tested with spirometry or on where and how to do it. We know that inflammation, not just airflow limitation, is important in determining the course of COPD, especially with respect to exacerbations. We can detect and treat alpha-1 antitrypsin deficiency, an under-recognized condition, but whether alpha-1 antitrypsin augmentation therapy affects the disease's clinical course remains unclear. Smoking cessation is the most important of all interventions for COPD, with proven techniques and adjuncts, but implementation remains difficult and success rates are disappointingly low. Similarly, pulmonary rehabilitation has well-documented benefits but is grossly underutilized because it is difficult to pay for and is not made available to most patients. Symptoms, costs, and other outcomes can be improved through comprehensive disease management, including the use of practice guidelines, yet multiple barriers prevent the potential benefits of these interventions to patients from being realized. Many patients who do not meet threshold oxygenation criteria for oxygen therapy during the daytime desaturate during sleep, but evidence that nocturnal oxygen administration benefits these patients is lacking. However, other sleep-related breathing disorders are common in COPD patients. Lung volume reduction surgery has recently been shown to improve function and survival for certain COPD patients, but lung transplantation has generally been disappointing. New pharmaceutical agents are being developed for treating COPD, and at least one of them (tiotropium) should soon be available in the United States. Noninvasive ventilation is effective in treating acute decompensations of COPD and should be the standard of care in that setting; evidence supporting its use in stable patients with end-stage disease is scant. Appropriate palliative care can greatly benefit patients and their families in the terminal phase of COPD and needs to be more widely applied.