Prof. Cheng Shih-Lung
Chief, Department of Pulmonary Medicine, Far Eastern Memorial Hospital, Taiwan
Chief, The Center of Evidence-Based Medicine, Far Eastern Memorial Hospital, Taiwan
Deputy Director, The Airway Assembly, Taiwan Society of Pulmonary and Critical Care Medicine, Taiwan
Deputy Head, Asthma Assembly, Asian Pacific Society of Respirology (APSR), Taiwan
Professor, Yuen Ze University, Taiwan
Secretary General, Taiwan Respiratory Health Promotion Society, Taiwan

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, and was ranked as one of the leading causes of death.¹ COPD is a heterogenous disease deriving from causes including poor lung development, reduced lung growth in early life, lung damage related to exposure to cigarette smoke, air pollution, infections, and airway remodelling.² Complexities in the molecular and clinical presentation of COPD creates challenges for making an early and accurate diagnosis and for defining robust therapeutic strategies to which patients are willing to adhere long-term.

Prof. Cheng Shih-Lung, from Taiwan, discusses the latest research and clinical management guidelines for COPD, and discusses the role for antibiotics such as fluoroquinolone.

Q1: COPD remains one of the leading causes of death in Taiwan.³ What are the key barriers to optimal COPD management in clinical practice?

The first key barrier relates to difficulties and challenges around the diagnosis of COPD. Spirometry, also known as lung (pulmonary) function test, is the gold standard for making the initial diagnosis of COPD according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines.⁴ Notably, forced expiratory volume (FEV₁) and the forced vital capacity (FVC), and their ratio may vary over time, even in healthy individuals, changing to above or below the cut-off point. For example, the variability of the annual rates of change reported for the FEV₁ and the FVC is ± 15%.⁵ This may contribute to uncertainty of clinical diagnosis and underdiagnosed cases, whereby symptomatic patients with smoking history were not being diagnosed with COPD due to seemingly normal lung function test results.

A second barrier relates to limitations to the currently available treatments of COPD. Bronchodilators are the cornerstone for COPD treatment and its complications, which improve symptoms and quality of life and prevent exacerbations. However, a bronchodilator does not effectively halt disease progression. There is an unmet need for treatments aimed at the underlying mechanism of the disease.⁶

Q2: What is the current guidance in Taiwan for the management of COPD? Do you foresee changes to COPD management recommendations as COVID-19 transitions from a pandemic to an endemic?

In Taiwan, the management of patients with COPD follows the GOLD report and local Taiwanese guidelines.^{4, 7} Minimising the risk of an exacerbation is the main goal of therapy for COPD patients, with or without COVID-19. The management of COPD in the context of COVID-19 pandemic should follow the usual approach. Owing to concerns about the transmission of COVID-19 in hospitalised patients, nebulised drug administration should be avoided unless nebulised in an ‘airborne infection isolation room’ with necessary precautions.⁸ If this is unavailable, a metered dose inhaler (MDI) is recommended as the preferred route of administration for treating COPD patients with acute exacerbations.

Q3: What is the role and benefit of antibiotic therapy in the management of COPD?

The pathophysiology of approximately 50% of acute exacerbations of COPD is bacterial infections.^{9, 10, 11} Hence, patients with acute exacerbation are likely to benefit from treatment with antibiotics. In a 2018 Cochrane systematic review, the use of antibiotics in patients with severe exacerbations reduced the occurrence of treatment failure, defined as a lack of improvement in symptoms, deterioration, a need for further antibiotics or death due to exacerbation.¹² Furthermore, a reduction in length of time in the intensive care unit (ICU) was observed in admitted patients who were treated with antibiotics.¹² For antibiotic treatment of acute exacerbations of COPD, levofloxacin and beta-lactam are recommended.^{13, 14}

Q4: When selecting a suitable antibiotic treatment regimen, what are the key patient, disease or treatment considerations that impact decision-making?

The decision to administer antibiotics in COPD patients with acute exacerbation is based on the severity of the COPD and patient performance status, clinical symptoms (increased dyspnea, sputum volume and sputum purulence), severity of current and previous exacerbations (moderate [outpatient] to severe [inpatient]), comorbidities and smoking history.¹⁵ Antibiotic treatment must consider coverage for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in all cases, but other bacteria (such as Gram-negative bacteria) may also need to be targeted depending on the clinical condition of the patient.¹⁵ In our clinical practice, the most commonly used antibiotic to treat exacerbations of COPD is levofloxacin owing to its broad-spectrum activity against relevant pathogens. Typically, the duration of antibiotic treatment should be about 5–7 days.

References

1. Adeloye D, et al. Lancet Respir Med. 2022;10(5):447–458.
2. Fazleen A, Wilkinson T. Ther Adv Respir Dis. 2020; 14: 1753466620942128.
3. Cheng SL, et al. J Formos Med Assoc. 2021;120(10):1821–1844.
4. Global Initiative for Chronic Obstructive Lung Disease – GOLD. SPIROMETRY FOR HEALTH CARE PROVIDERS Global Initiative for Chronic Obstructive Lung Disease (GOLD). Available from: https://goldcopd.org/wp-content/uploads/2016/04/GOLD_Spirometry_2010.pdf. Accessed 5 December 2022.
5. Reyes-Garcia A, et al. Rev Invest Clin. 2019;71(1):28–35.
6. de Lucas Ramos P, et al. Arch Bronconeumol. 2010;46 Suppl 10:8–13.
7. Cheng SL, Lin CH. Diagnostics (Basel). 2021;11(7):1153.
8. Hasan SS, et al. Respir Med. 2020; 170: 106045.
9. Macfarlane JT, et al. Lancet. 1993;341(8844):51–4.
10. Miravitlles M, et al. Chest. 1999;116(1):40–6.
11. Patel IS, et al. Thorax. 2002;57(9):759–64.
12. Vollenweider DJ, et al. Cochrane Database Syst Rev. 2018;10(10):CD010257.
13. Bagge K, et al. Respir Res. 2021;22(1):11.
14. Minov J, et al. Health Prim Car. 2020;4: doi: 10.15761/HPC.1000184.
15. Butorac-Petanjek B, et al. J Chemother. 2010;22(5):291–7.