Current initiatives in the management of patients with chronic obstructive pulmonary disease: the NICE Guidelines and the recent evidence base

Chronic obstructive pulmonary disease (COPD) is a major cause of hospital admission, morbidity disability and high healthcare usage in old age. Worldwide prevalence of COPD is estimated at 9.3 per 1000 males and 7.3 per 1000 females in all age groups. COPD has been projected to increase in prevalence to become the fifth leading cause of disability and fourth leading cause of mortality by 2020. A recent study of the economic burden of COPD in developed countries estimated the annual societal cost (indirect cost including loss of productivity) at $3511 per patient in the UK. The report also confirmed COPD as being relatively undiagnosed in the elderly, especially in the UK compared with other countries. Acute exacerbations (AECOPD) are a common cause of hospital admission in patients with COPD. A patient with moderate to severe COPD is most likely to have on average three exacerbations per year with an average length of hospital stay of 11 days, corresponding to a million hospital bed days in UK hospitals. There were approximately 10,000 AECOPD admissions per million population of 75-84 year olds in England in 2000, 10 times the corresponding figure for 45-64 year olds. A wide range of other factors have been reported as predictors of hospital admissions in COPD patients: these include low forced expiratory volume, impaired quality of life, physical disability and clinical anxiety as well as atmospheric pollution and flu outbreaks. Length of hospital stay is predicted by depression, number of co-morbidities and advanced age. The aims of this review are to explore recent initiatives in the management of patients during acute exacerbations and in the stable condition in moderate to severe chronic obstructive pulmonary disease. The review is timely given the current interest in COPD management as highlighted by the very recent publication of the National Institute of Clinical Excellence (NICE) guidelines for the management of the condition