Chronic obstructive lung disease by luckboy

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									Clinical care focus: respiratory care

GLOBAL DEVELOPMENTS AND CHALLENGES IN CARE FOR COPD
ARTICLE BY RONALD DAHL

Abstract CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD) IS A SLOW AND PROGRESSIVE IRREVERSIBLE DESTRUCTION OF AIRWAYS AND LUNG TISSUE. THE DISEASE IS INCREASINGLY COMMON IN ALL COUNTRIES AND IS A MAJOR CAUSE OF MORBIDITY AND MORTALITY. EARLY DIAGNOSIS IS IMPORTANT AS INTERVENTIONS ARE AVAILABLE, ESPECIALLY SMOKING CESSATION. REDUCING INDOOR AND OUTDOOR AIR POLLUTION AND TOBACCO SMOKING WILL GREATLY REDUCE THE INCIDENCE AND EVENTUALLY THE PREVALENCE OF COPD. SYMPTOMATIC PATIENTS SHOULD HAVE OPTIMUM TREATMENT WITH BRONCHODILATORS AND FREQUENTLY INHALED CORTICOSTEROID. REHABILITATION PROGRAMMES SHOULD BE AVAILABLE TO ALL IN ORDER TO IMPROVE MUSCLE FUNCTION, PHYSICAL FITNESS, NUTRITIONAL STATUS AND COPING WITH COPD. A MOST PRESSING ISSUE IS A RESTRUCTURING OF HEALTHCARE FOR CHRONIC ILLNESSES, INCLUDING COPD.

hronic obstructive lung disease (COPD) is a chronic respiratory disorder which is often progressive. At present it is estimated that about 44 million people worldwide suffer from COPD. It is anticipated that the number of patients with COPD will increase further during the next decades in affluent as well as in less privileged countries. COPD will become the third most frequent cause of death and give rise to incredible human suffering because of the continuous and progressive loss of lung function and the consequences with progressive limitations in physical functioning over several years. The burden of illness to the individual, their families and to society is very large. In most countries COPD is the most frequent cause for acute admission for inpatients to a medical hospital ward.1 The best intervention would be to prevent COPD developing in the first place. This is readily possible through prevention of exposure to inhaled toxic substances in indoor and outdoor air. The most significant cause of COPD is tobacco smoking and the pollution of indoor air with tobacco smoke making bystanders into passive smokers. Bad ventilation in houses with indoor use of biomass and other materials for heating and cooking are also important. Workplace exposure and

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outdoor air pollution are also important targets to be reduced.2 It is possible through public information and legislation to substantially reduce exposure to toxic substances in the air and a good example is the workplace ban of tobacco smoking. Ireland was the first European Union (EU) State to bring in this legislation, followed by Italy, Norway and Sweden. Many more EU States are in the process of bringing in legislation that eliminates passive smoking. The fight against tobacco gained strength through a very important World Health Organization (WHO) initiative – “The Framework Convention on Tobacco Control (FCTC)” which all 192 Member States agreed to in 2003, and which has since been ratified by more than 50 Member States. This will lead to national legislation to inhibit tobacco use and limit what is probably the biggest preventable killer today.3 In recent years the attitude towards COPD has changed from pessimism to a realistic optimism. COPD patients were previously often neglected as the opinion held was that nothing could be done and that development of the disease was the patients’ own fault. Today several medications have proven effective as symptom relievers and possibly also result in fewer exacerbations, including

inhaled corticosteroids and long acting bronchodilators (anticholinergics, beta2-agonists). New pharmacological treatments are being sought, including medications to reduce loss of lung function and also to restore lost tissue.4 An important issue is to detect COPD at an early stage in order to make interventions including tobacco cessation. For many years COPD is a silent disease that people cope with and do not realise is there. When diagnosed, it is usual for a COPD patient to have already lost more than 50% of their respiratory capacity. We need to introduce an active attitude and mobilize primary care doctors to perform spirometry in all cases of smokers of more than 35 years of age with the slightest respiratory symptom. This is the only way to diagnose and take care of the huge number of COPD patients before too much lung function has been lost. This is a reasonable activity because there are effective interventions available that benefit the individual.5 It is important that society and the medical care system can adequately take care of COPD patients, reduce their symptoms and improve their quality of life. Around the world, the rapidly shifting balance between acute and chronic health problems is placing new and different

106 International Hospital Federation Reference Book 2005/2006

Clinical care focus: respiratory care

The management of chronic conditions and COPD is not about what happens at doctor visits or hospital admissions, but how the patient manages his daily life

demands on the healthcare workforce. Chronic disorders today account for 60% of deaths and 80% of health expenditure. To provide effective healthcare for chronic conditions, the skills of health professionals must be expanded to meet these new complexities. This requires a change in the organization and delivery of healthcare and even in medical education. Today most medical and nursing schools are focused on acute conditions, including acute worsening of chronic illnesses. The management of chronic conditions and COPD is not about what is happening at doctors visits or hospital admissions, but how the patient manages his daily life. For too long the care of patients with chronic conditions has taken place in a compartmentalized fashion, often with significant differences in the care plans of hospital, clinic and different health professionals for the same patient. We need to see the healthcare system from the patient’s point of view and our COPD patients should feel that they have the services of one cooperating healthcare system with common goals and common understanding of the condition and interventions necessary. A WHO initiative called the “Innovative Care for Chronic Conditions Framework” 6 points out that the care should be provided as patientcentered care. This implies that we have to make a shift from provider-centered care. This must allow for patients’ values, preferences and needs, with expertise to direct care for the chronic condition with which they live. This innovative view on chronic care has the potential to transform today’s healthcare to a new structure and function including the use of information and communication technology between healthcare professionals and also involving patients and their families. We need to engage patients in the long term management of their condition by partnering and always looking for

developments and quality improvement. In COPD as in any chronic disease it is important to mobilize a patient’s own resources and achieve as optimal a physical, psychical and social functioning. This is done through COPD rehabilitation programmes that usually include physical training to improve the physical condition and thereby improve work capacity including walking distance, daily activity functions etc. An evaluation of the nutritional status and intervention in case of under-nutrition and loss of muscle mass is important. Smoking cessation, optimization of pharmacological treatments, physiotherapy, patient information and education are also components in COPD rehabilitation. This type of intervention does not influence mortality but does greatly influence quality of life and reduce the overall cost of the disease, mainly because of shorter hospital stays. COPD rehabilitation should be available as an option to all patients with reduced physical functioning due to exertional dyspnoea. It should be delivered through a team of healthcare professionals usually consisting of a medical doctor, respiratory nurse, a physiotherapist, a dietitian and a psychologist. COPD rehabilitation highlights that COPD can also become a systemic disorder and that organs other than the lungs may be affected. These should not be overlooked, and depression, malnutrition, sleep apnea syndrome, and other problems should be actively looked for.7 J

References
European respiratory Society, European Lung Foundation. European Lung White Book. The first comprehensive survey on respiratory health in Europe. Sheffield, ERSJ Ltd. 2003. 2. Tobacco or Health in the European Union. The Aspect Consortium. Office for official publications of the European Communities, 2004. 3 Resolution of the 56th world health assembly. Agenda item 13. WHO Framework Convention of Tobacco Control. 21 May 2003. 4. Celli B R & MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932–946. 5. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004 Feb;59 Suppl 1:1-232 6. Preparing a healthcare workforce for the 21st century, the challenge of chronic conditions. World Health Organization 2004. 7. Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a diseasespecific self management intervention. Arch Intern Med 2003;163:585–591.
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Author
Ronald Dahl, Professor of Respiratory Medicine at Aarhus University Hospital Denmark, has been a board member of several national and international societies of respiratory diseases and allergy including president of the European Respiratory Society 2004–2005 and present vice-chair of the WHO’s Global Alliance against Respiratory Diseases and Allergy (GARD).

Contact
Department of Respiratory Diseases Aarhus University Hospital NBG DK 8000 Aarhus C Denmark Telephone: +45 89492085 Fax: +45 89492110 E-mail: rdahl@as.aaa.dk

108 The International Hospital Federation Reference Book 2005


								
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