Changing practices in COPD. A new pharmacologic treatment algorithm.

Chronic obstructive pulmonary disease (COPD) is a serious public health problem, due largely to cigarette smoking. COPD is now the fourth-leading cause of death in the United States; more than half of patients with COPD die within 10 years of diagnosis.1 COPD is a progressive disease. Mortality rates are related to level of airway obstruction, and a decline in progressive loss of lung function improves long-term survival rates. Data from the Lung Health Study demonstrate that the rate of decline in lung function in smokers with mild to moderate COPD can be significantly slowed by smoking cessation,2 but not by the anticholinergic bronchodilator ipratropium bromide (Atrovent). In this large clinical trial, ipratropium bromide improved lung function while it was used, corroborating other evidence that it is an effective bronchodilator in COPD.3-5 There are now three main classes of bronchodilators available for the treatment of COPD, each with specific clinical benefits: an anticholinergic (ipratropium bromide), A-agonists (eg, albuterol), and methylxanthines (theophylline). The preferred route of administration for bronchodilator therapy is by inhalation using a metered-dose inhaler (MDI). The MDI allows for direct delivery of drug into the lungs, thus minimizing systemic side effects. Self-treatment with an MDI is not trouble free, as many patients do not use the inhaler properly.6 This seems especially true in the elderly, who often have difficulty coordinating actuation of the spray. Spacer devices may be of use in such patients. If not, the patient can benefit from inhalation therapy by use of the small updraft nebulizers that are now readily available. The introduction in the last decade of ipratropium,