Professor Zhang Nuofu
Vice President, the First Affiliated Hospital of Guangzhou Medical University, China
Deputy Director, the National Center for Respiratory Medicine
Professor, Chief Physician, doctoral advisor, post-graduate advisor
Experts with the state council allowance, excellent expert of Guangzhou
Director of Respiratory Ward Three, Guangzhou Institute of Respiratory Health
Deputy Head of Sleep and Respiratory Group, the Respiratory Branch of Chinese Medical Association
Member of the Pulmonary Vascular Disease Group, the Respiratory Branch of the Chinese Medical Doctor Association
Deputy Head of Sleep and Respiratory Group, the Respiratory Branch of Guangdong Medical Association
Chairman of Sleep and Respiratory Physician Branch, Guangdong Medical Doctor Association
Chairman of the Venous Thrombosis and Pulmonary Embolism Prevention Union of Guangdong Province
Leader of the Expert Team, the National Aid Medical Team of the Branch of West District, Wuhan Union Hospital of China
Leader of the ICU medical team of the Branch of West District, Wuhan Union Hospital of China, supported by Guangdong

Chronic Obstructive Pulmonary Disease (COPD) is the most common chronic airway disease. The epidemiology and incidence data of COPD in China was collected and studied mainly by Academician Zhong Nanshan, who took the lead and published the data in the American Journal of Respiratory and Critical Care Medicine¹ in 2007. Along with Academician Wang Chen et al, Zhong completed the research and published it in The Lancet² in 2018.

From an earlier study published in 2000, the prevalence of COPD among 20,045 patients aged 40 years and above was 8.2%. According to the article republished by Academician Wang Chen et al, the prevalence among people aged 40 and above has risen to 13.7%. Despite the different samples analysed, the prevalence of the latter has increased by 67% compared to the former prevalence. In China, nearly 100 million people are suffering from COPD, contributing to the disease burden. In terms of the national strategy, the efforts made to advance the treatment, investment and support for COPD are significantly different from those for cardiovascular and cerebrovascular diseases, diabetes, and other chronic diseases. Through the appeal of Academician Wang Chen et al and promotion by respiratory-related branches of the Chinese Medical Association, COPD has been successfully included in chronic disease management, which is a milestone in the standardized management, diagnosis, and prevention strategies of this disease.

According to the epidemiological data, a vast number of COPD patients in China are underdiagnosed and a multitude of the patients seek community healthcare, which has posed great challenges to the diagnosis and treatment of COPD. One cause of the current situation is the difference between primary hospitals and tertiary hospitals, which can be reflected in the poorer quality of diagnosis measures, treatment measures, and medical equipment available in primary hospitals. In addition, patients admitted to primary hospitals tend to show lower acceptance of disease. As such, the Chinese government and local medical organizations have taken measures to promote the standardized diagnosis and treatment of COPD. First, the nation’s continuous reform of the medical insurance policy and the implementation of rural cooperative medical care have enabled ordinary people to afford and even pay far less for medical treatment than before. Second, local medical organizations have published the guidelines³ for primary care; urban hospitals and the National Respiratory Medicine Center Hospital have held lecture tours and guided primary care physicians to conduct standardized clinical work. Lastly, local medical organizations have implemented health education for grassroots patients through a variety of channels, popularized awareness of disease control, and encouraged patients to correctly use inhalation devices. Although the diagnosis and treatment of COPD in primary hospitals are not as standardized as that in urban hospitals, it is a great step towards gradually increasing the awareness of the disease among ordinary people.

In addition, the controversy over specific treatment measures of COPD also brings challenges to standardized treatment, such as the treatment options of anti-inflammatory drugs and inhaled corticosteroids. The application of systemic hormones should be reviewed from two aspects. On one hand, for acute exacerbations of COPD (AECOPD), current evidence suggests that hormone therapy can be used for 10–14 days⁴; the REDUCE study has confirmed that the duration of treatment can be shortened to 5 days, which not only reduces the risk of intubation but also makes it easier for patients to accept the treatment⁵. There are, of course, some contraindications to hormone therapies; for example, patients with gastrointestinal problems and diabetics should instead be treated with aerosol therapy. On the other hand, since 2017, the GOLD guidelines⁶ have suggested that for patients in stable conditions, inhaled hormone therapy is related to an increased risk of pneumonia, and thus it is recommended to start treatment with single or dual bronchodilators as the standard of care. For patients with stable blood eosinophils >300 cells/ul or >4%, complicated with bronchial asthma or asthmatic features, history of hospitalization for AECOPD, and/or moderate exacerbations > 2 times per year, combined hormone therapy is recommended⁷. In China, however, most patients do not depend on bronchodilators. Overall, despite the regional and national differences in the method of drug use, therapy should be determined on a patient-by-patient basis.

Infection is a compelling cause of AECOPD. The selection of antibacterial drugs should be determined with etiology; however, there are certain differences in etiology between China and other countries. In some countries, for example, the common pathogens in AECOPD are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis⁸. In China, Gram-negative bacteria are the most common ones, and the detection rates of Pseudomonas aeruginosa and Klebsiella pneumoniae are remarkably high⁹. The main reasons contributing to such a contrast is the difference in patient conditions between China and other countries. Most aggravated patients in China are elderly people with poor lung function, high frequency of acute exacerbations, and severe symptoms; many of those patients are intubated. In China, for example, patients in the GOLD C group and the GOLD 4 group account for roughly 82% of cases, while in some countries the percentage is approximately 47%. In China, the average frequency of acute exacerbations is three times per year, which is equivalent to one infection in four months; comparatively, the average frequency of AECOPD in patients is only one to two times per year in other countries.

In the selection of antibiotic regimens for patients with acute COPD exacerbations, oral treatment is recommended in clinical practice. According to the “Guidelines for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (2021 Revision)”, oral quinolones, such as ciprofloxacin and levofloxacin, are recommended for outpatients with risk factors for Pseudomonas aeruginosa and poor prognosis. Although moxifloxacin is a respiratory quinolone, it cannot cover patina, and is thus not recommended by the guidelines. For older patients with AECOPD, the clinical problems caused by pneumonia, heart disease and diabetes in the elderly will be taken into consideration. In terms of safety and efficacy, a quinolone¹⁰ called sitafloxacin can cover a variety of pathogenic bacteria and is deemed as a suitable treatment selection.

In general, with the development of modern technology and government support, the clinical pathways for COPD have been well standardized. It is expected that in the near future, further enhancement of the treatments for COPD will bring clinical benefits to the patients in China.

References

1. Zhong N, Wang C, Yao W et al. Prevalence of chronic obstructive pulmonary disease in China: a large, population-based survey[J]. Am J Respir Crit Care Med. 2007 Oct 15;176(8):753-60.
2. Wang C, Xu J, Yang L, et al. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study[J]. Lancet. 2018 Apr 28;391(10131): 1706-1717.
3. Chinese Medical Association, Journal of Chinese Medical Association, General Practice Branch of Chinese Medical Association, et al. Guidelines for Primary Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (2018) [J]. Chinese Journal of General Practitioners, 2018, 17(11): 856 -870.
4. Expert group for the diagnosis and treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Chinese expert consensus on the diagnosis and treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) (updated in 2017) [J]. International Journal of Respiratory Medicine, 2017, 37(14):1041 -1057.
5. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial [J]. JAMA, 2013, 309 (21): 2223-2231.
6. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2017 report) [EB/OL]. (2017) [2022-08-18]. http://www.goldcopd.org.
7. Chronic Obstructive Pulmonary Disease Group of Respiratory Medicine Branch of Chinese Medical Association. Chronic Obstructive Pulmonary Disease Working Committee of Respiratory Physician Branch of Chinese Medical Doctor Association. Guidelines for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (2021 revision) [J]. Chinese Tuberculosis and Respiratory Medicine Journal, 2021, 44(3): 170-205.
8. Wenzel RP, Fowler AA, Edmond MB, Antibiotic prevention of acute exacerbations of COPD[J]. N Engl J Med, 2012 Jul 26; 367(4): 340-7.
9. Ye F, He LX, Cai BQ, et al, Spectrum and antimicrobial resistance of common pathogenic bacteria isolated from patients with acute exacerbation of chronic obstructive pulmonary disease in mainland of China[J]. Chin Med J (Engl) 2013 Jun;126 (12) : 2207-2214.
10. Wu S, Yang Y, Yan G, et al.  Comparative activities of sitafloxacin against recent clinical isolates in hospitals across China[J]. Eur J ClinMicrobiol Infect Dis. 2021 Nov; 40 (11):2271-2283.