The Lancet COPD Commission: broader questions remain

We thank Paulo CRP Corrêa for his interest in the Commission1Stolz D Mkorombindo T Schumann DM et al.Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission.Lancet. 2022; 400: 921-972Summary Full Text Full Text PDF PubMed Google Scholar and wholeheartedly agree that the absence of meaningful tobacco control is unacceptable and in no way aimed to diminish its importance. In addition, we take no issue with the assertion that continued smoking among people with established chronic obstructive pulmonary disease (COPD) accounts for much of the disease burden. However, we think it is important to recognise that factors other than tobacco are increasingly accountable for incident cases of COPD, including e-cigarette use as Corrêa highlights. Indeed, analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study shows that in 2019, pollution from ambient particulate matter and occupational exposure to particulate matter, gases, and fumes accounted for 36·3% of the attributable risk for COPD compared with 46% of cases attributable to smoking.2Yang IA Jenkins CR Salvi SS Chronic obstructive pulmonary disease in never-smokers: risk factors, pathogenesis, and implications for prevention and treatment.Lancet Respir Med. 2022; 10: 497-511Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 3Safiri S Carson-Chahhoud K Noori M et al.Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990–2019: results from the Global Burden of Disease Study 2019.BMJ. 2022; 378e069679PubMed Google Scholar, 4Zou J Sun T Song X et al.Distributions and trends of the global burden of COPD attributable to risk factors by SDI, age, and sex from 1990 to 2019: a systematic analysis of GBD 2019 data.Respir Res. 2022; 23: 90Crossref PubMed Scopus (8) Google Scholar In addition, since 1990, the risk for COPD attributable to smoking has declined globally while that related to ambient and occupational exposures has continued to increase, particularly in low-income and lower-middle-income countries.3Safiri S Carson-Chahhoud K Noori M et al.Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990–2019: results from the Global Burden of Disease Study 2019.BMJ. 2022; 378e069679PubMed Google Scholar, 4Zou J Sun T Song X et al.Distributions and trends of the global burden of COPD attributable to risk factors by SDI, age, and sex from 1990 to 2019: a systematic analysis of GBD 2019 data.Respir Res. 2022; 23: 90Crossref PubMed Scopus (8) Google Scholar Although never-smokers with COPD tend to have milder respiratory symptoms, less emphysema, and less lung function impairment, exacerbations can still be frequent.2Yang IA Jenkins CR Salvi SS Chronic obstructive pulmonary disease in never-smokers: risk factors, pathogenesis, and implications for prevention and treatment.Lancet Respir Med. 2022; 10: 497-511Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar One objective of the Commission was to highlight the changing epidemiology of COPD risk factors, not to detract from efforts to control tobacco and support smoking cessation, but to raise awareness of what might be the next drivers of the COPD epidemic. In addition, we argue it is improbable that the pathobiology of the five COPD types we propose is the same, and that these risk factors will cause disease with differing preventive and therapeutic strategies. Positioning COPD as caused solely by smoking, as we have done for decades, is far more likely to do harm than acknowledging the heterogeneity of the disease. Jordan A Guenette and colleagues correctly highlight the tremendous value of cardiopulmonary exercise testing and, in particular, the insights it has recently provided about the presence and extent of physiological abnormalities in patients with mild or even no airflow limitation as assessed by spirometry. As such, we would fully support the inclusion of cardiopulmonary exercise testing in the list of additional tests that could be useful in the evaluation of patients with early COPD. Nayia Petousi and colleagues argue that we did not adequately address the potential causative role of type-2 eosinophilic inflammation in driving lung function decline, nor the possibility that this easily identified endotype could be incorporated into an assessment of early airway changes and then targeted with existing drugs. Although there are no controlled trials to suggest that early intervention with inhaled corticosteroids or biologics in people with type-2 predominant disease reduces the risk of progressive lung function loss, we agree that the observational data are compelling and suggest that such studies should be done. We also support the concept that a broader phenotypic and biological characterisation of patients with COPD both at stable state and at exacerbation will be a crucial step in the development of novel biomarkers of risk as well as new treatments and this approach would include measures of type-2 inflammation. Until such characterisation is done, progress will be restricted by our reliance on spirometry to define disease, establish prognosis, and develop treatments. MTD reports grants or contracts from the American Lung Association, the US Department of Defense, and the US National Institutes of Health; consulting fees from AstraZeneca, GlaxoSmithKline, Novartis, Pulmonx, and Teva; and support for attending meetings from Pulmonx. DS reports a grant from the Swiss National Foundation (SNF 320030_189280); unrestricted grants from Curetis, AstraZeneca, and Boston Scientifics (paid to their institution); honoraria for participation in data safety monitoring or advisory boards or talks for CSL Behring, Berlin-Chemie Menarini, Novartis, GlaxoSmithKline, AstraZeneca, Vifor, Merck, Sanofi, Merck Sharp & Dohme, Boehringer Ingelheim, and Chiesi; and is the current Global Initiative for Chronic Obstructive Lung Disease representative for Switzerland, the immediate past Education Council Chair of the European Respiratory Society, and current President of the Education Committee of the Swiss Respiratory Society. The Lancet COPD Commission: broader questions remainWe would like to congratulate Daiana Stolz and colleagues1 for a comprehensive and authoritative Commission that undoubtedly constitutes an important landmark in the field. The emphasis on recognising risk and causative factors for chronic obstructive pulmonary disease (COPD) beyond tobacco smoking, such as other environmental exposures and early-life events as drivers of disease and lung function decline, is pivotal for the success of the mission towards earlier diagnosis and improved global prevention and treatment strategies. Full-Text PDF The Lancet COPD Commission: broader questions remainDaiana Stolz and colleagues1 in their proposed diagnostic algorithm (figure 11 of the Commission) list several alternative tests to aid in the diagnosis of chronic obstructive pulmonary disease (COPD) in people who have a forced expiratory volume in 1 s to forced vital capacity ratio of greater than or equal to 0·7, including diffusion, resistance, nitrogen washout, pathology, and the forced oscillation technique. Unfortunately, the authors did not include cardiopulmonary exercise testing (CPET) in this important list despite the growing body of literature showing that CPET can reveal considerable abnormalities in people with mild COPD and even in smokers with normal spirometry relative to healthy age-matched controls. Full-Text PDF The Lancet COPD Commission: broader questions remainI have read with interest the comprehensive Commission on chronic obstructive pulmonary disease (COPD) by Daiana Stolz and colleagues.1 The authors report that “The most efficient way to reduce the burden of COPD is to ban cigarette smoking in all its forms.” However, only a few sentences later the authors downplay the importance of smoking: “risk factors unrelated to tobacco are increasingly responsible for the burden of COPD, and are likely to surpass the risk attributable to smoking within the next two decades”. Full-Text PDF Towards the elimination of chronic obstructive pulmonary disease: a Lancet CommissionDespite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Full-Text PDF