Annals of Long Term Care

Meeting: Toronto, Canada, May 16-21, 2008

The American Thoracic Society (ATS) held its annual meeting in Toronto, Canada, hosting over 16,000 physicians, scientists, and other respiratory healthcare providers from all over the world. There were no major or landmark studies presented at this meeting, but it was a very interesting update on research and clinical advances in respiratory diseases. Highlights from the meeting are presented below, and abstracts from the entire program can be viewed at the ATS website:

http://www.abstracts2view.com/ats08.

Burden of Lung Disease Study

The very large and ambitious worldwide study, the Burden of Lung Disease (BOLD), on the prevalence of chronic obstructive pulmonary disease (COPD) was completed last year, and the main results were published in The Lancet in September 2007. The study measured lung function by spirometry in a representative sample of the population of every major country in the world, and using consistent definitions and measurements it objectively defined, for the first time, the prevalence of COPD by country worldwide.

There were many interesting sub-analyses of the BOLD study presented at this meeting. The variation in prevalence was quite surprising, from a high of 25% of the population in South Africa to a low of 5% in Mexico. In only four countries in the world, women had higher rates of COPD than men (USA, Austria, Iceland, and Australia), but the projected trends suggest that women worldwide are increasing in prevalence, so COPD can be added to the list of “women’s health issues.” Another interesting finding of the study was the higher than expected incidence of COPD in persons who had never smoked, about 15% of all COPD worldwide. COPD in non- smokers appears to be due to the genetic predisposition to the disease coupled with passive smoke or air pollution exposure. One of the most common pollution exposures in the developing world is the indoor pollution of heating and cooking with biomass fuels. There are an estimated 1.9 million excess deaths per year in China due to passive smoke and pollution exposure.

Reducing Acute Exacerbations in COPD

Several conference sessions and one evening seminar focused on the prevention of acute exacerbations (AEs) as the most important intermediate goal in managing COPD. Clinical guidelines for management of COPD list a number of therapeutic goals, including improving physical function and quality of life, reducing hospitalizations and emergency visits, and decreasing cost of care and mortality. Frequency of AEs is highly correlated with other adverse outcomes and appears to be the best predictor of the course of the disease. Pulmonary function measurements before and after AEs indicate that there is often an accelerated and permanent loss of lung parenchyma, and persons with COPD will often deteriorate in a stair-step fashion with each occurrence of an AE.

Patient education in COPD should include recognition of the signs of AE: (1) increased shortness of breath; (2) increased sputum production; and (3) change in sputum to a more purulent appearance. Early treatment of AEs with systemic corticosteroids and antibiotics if sputum is purulent can decrease the severity and recovery time from an AE.

Persons with COPD who have had AEs should be considered for preventive maintenance therapy using a combination of inhaled corticosteroids and a long-acting bronchodilator.

One clinical trial specifically targeted prevention of AEs in persons with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage III COPD (FEV1 < 50% predicted) and a history of more than one AE in the previous year. It compared treatment with a bronchodilator alone, salmeterol (SAL) 50 mcg twice daily, versus the combination of salmeterol 50 mcg and fluticasone 250 mcg (SFC) twice daily.