A Clinical Review on Chronic Obstructive Pulmonary Disease

Abstract

Chronic Obstructive Pulmonary Disease (COPD) is a prevalent and progressive respiratory disorder characterized by persistent airflow limitation, often associated with chronic bronchitis and emphysema. This abstract provides a comprehensive overview of COPD, emphasizing its clinical significance and impact on global health. COPD represents a significant public health concern, with escalating prevalence and mortality rates worldwide. Understanding epidemiological trends and risk factors is crucial for effective disease management and prevention strategies. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines serve as a compass in COPD management. It provides a comprehensive overview of the GOLD guidelines, elucidating their role in risk stratification, treatment escalation, and personalized care for individuals across varying disease severities. The management of COPD involves a multidimensional approach targeting symptom relief, improving lung function, and enhancing overall quality of life. Pharmacological interventions, such as bronchodilators and anti-inflammatory agents, play a pivotal role. Beyond conventional pharmacological treatments, various traditional therapies have gained attention in COPD management. These may include complementary and alternative medicine practices, such as acupuncture, herbal supplements, and yoga. While evidence supporting the efficacy of these interventions is still evolving, exploring their potential benefits. A comprehensive and integrative approach is crucial for optimizing COPD care and improving the lives of individuals affected by this intricate respiratory condition. This abstract concludes by encouraging continued collaboration among clinicians and patients to shape the future of COPD care. Ultimately fostering hope for improved outcomes and an enhanced prospect for those living with severe respiratory ailments.

Keywords

COPD / Epidemiology / Diagnosis / Exacerbation / Global Initiative for Chronic Obstructive Lung Disease / BOLD / Herbal supplements

Acknowledgments

The authors would like to thank the Management of KMCH Col-lege of Pharmacy, for the continuous encouragement, support, and assumed facilities to carry out the study.

Funding

No funding was received for this study.

Conflict of interest

The authors declare that they have no competing interests.

Author contributions

Study impression and outline (SS, SR, RA and TV); review of lit-erature, perusal and clarification (SR, SS and TV); draft of manu-script (SS and SR); manuscript writing (SR and SS); critical revi-sion (SS, RA and TV); administrative support (RA, SS and TV). All the authors reviewed the literature, compiled the data and ap-proved the final version of the manuscript.

References

[1] Matsunaga K, Harada M, Suizu J, Oishi K, Asami-Noyama M, Hi-rano T. Comorbid Conditions in Chronic Obstructive Pulmonary Dis-ease: Potential Therapeutic Targets for Unmet Needs. J Clin Med 2020; 9(10):3078. doi:10.3390/jcm9103078,PMID:32987778.

[2] World Health Organization. Chronic obstructive pulmonary disease. Geneva: World Health Organization; 2023.

[3] Tsutsumi A, Chubachi S, Irie H, Sasaki M, Yamada Y, Sugiura H, et al. Characteristics of chronic obstructive pulmonary disease pa-tients with robust progression of emphysematous change. Sci Rep 2021; 11(1):9548. doi:10.1038/s41598-021-87724-8,PMID:33953210.

[4] May SM, Li JT. Burden of chronic obstructive pulmonary disease: healthcare costs and beyond. Allergy Asthma Proc 2015; 36(1):4-10. doi:10.2500/aap.2015.36.3812,PMID:25562549.

[5] Wang H, Ye X, Zhang Y, Ling S. Global, regional, and national burden of chronic obstructive pulmonary disease from 1990 to 2019. Front Physiol 2022;13:925132. doi:10.3389/fphys.2022.925132,PMID:36017339.

[6] Wheaton AG, Liu Y, Croft JB, VanFrank B, Croxton TL, Punturieri A, et al. Chronic Obstructive Pulmonary Disease and Smoking Status - United States, 2017. MMWR Morb Mortal Wkly Rep 2019; 68(24):533-538. doi:10.15585/mmwr.mm6824a1,PMID:31220055.

[7] Szalontai K, Gémes N, Furák J, Varga T, Neuperger P, Balog JÁ, et al. Chronic Obstructive Pulmonary Disease: Epidemiology, Biomarkers, and Paving the Way to Lung Cancer. J Clin Med 2021; 10(13):2889. doi:10.3390/jcm10132889,PMID:34209651.

[8] GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med 2020;8(6): 585-596. doi:10.1016/S2213-2600(20)30105-3, PMID:32526187.

[9] McKay AJ, Mahesh PA, Fordham JZ, Majeed A. Prevalence of COPD in India: a systematic review. Prim Care Respir J 2012; 21(3):313-321. doi:10.4104/pcrj.2012.00055,PMID:22790612.

[10] Buist AS, McBurnie MA, Vollmer WM, Gillespie S, Burney P, Mannino DM, et al. International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet 2007; 370(9589):741-750. doi:10.1016/S0140-6736(07)61377-4, PMID: 17765523.

[11] Alam DS, Chowdhury MA, Siddiquee AT, Ahmed S, Clemens JD. Preva-lence and Determinants of Chronic Obstructive Pulmonary Disease (COPD) in Bangladesh. COPD 2015; 12(6):658-667. doi:10.3109/15412555.2015.1041101,PMID:26263031.

[12] Adhikari TB, Acharya P, Högman M, Neupane D, Karki A, Drews A, et al. Prevalence of Chronic Obstructive Pulmonary Disease and its As-sociated Factors in Nepal: Findings from a Community-based House-hold Survey. Int J Chron Obstruct Pulmon Dis 2020; 15:2319-2331. doi:10.2147/COPD.S268110,PMID:33061350.

[13] Park J, Kim HJ, Lee CH, Lee CH, Lee HW. Impact of long-term expo-sure to ambient air pollution on the incidence of chronic obstruc-tive pulmonary disease: A systematic review and meta-analysis. Environ Res 2021;194:110703. doi:10.1016/j.envres.2020.110703,PMID:33417909.

[14] Varmaghani M, Dehghani M, Heidari E, Sharifi F, Moghaddam SS, Farzadfar F. Global prevalence of chronic obstructive pulmonary dis-ease: systematic review and meta-analysis. East Mediterr Health J 2019; 25(1):47-57. doi:10.26719/emhj.18.014,PMID:30919925.

[15] Islam MS, Hossain MM, Pasha MM, Azad AK, Murshed KM. Prevalence and risk factors of chronic obstructive pulmonary disease (COPD) in Dhaka city population. Mymensingh Med J 2013; 22(3):547-551. PMID:23982547.

[16] GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 coun-tries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159): 1923-1994. doi:10.1016/S0140-6736(18)32225-6, PMID:30496105.

[17] Jarhyan P, Hutchinson A, Khaw D, Prabhakaran D, Mohan S. Preva-lence of chronic obstructive pulmonary disease and chronic bron-chitis in eight countries: a systematic review and meta-analysis. Bull World Health Organ 2022; 100(3):216-230. doi:10.2471/BLT.21.286870,PMID:35261410.

[18] Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsada-phan N, Inchai J. A comparative study of COPD burden between urban vs rural communities in northern Thailand. Int J Chron Ob-struct Pulmon Dis 2015; 10:1035-1042. doi:10.2147/COPD.S82303,PMID:26082627.

[19] Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I, et al. Glob-al, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med 2022;10(5):447-458. doi:10.1016/S2213-2600(21)00511-7, PMID:35279265.

[20] Carlson SA, Wheaton AG, Watson KB, Liu Y, Croft JB, Greenlund KJ.Ge-ographic Differences in Sex-Specific Chronic Obstructive Pulmonary Disease Mortality Rate Trends Among Adults Aged ≥25 Years - United States, 1999-2019. MMWR Morb Mortal Wkly Rep 2022; 71(18):613-618. doi:10.15585/mmwr.mm7118a1, PMID:35511711.

[21] Millard E. Are Allergies Making Your COPD Worse? Health Central; 2023.

[22] Ruppel GL, Enright PL. Pulmonary function testing. Respir Care 2012; 57(1):165-175. doi:10.4187/respcare.01640,PMID:22222135.

[23] Hopkinson NS, Molyneux A, Pink J, Harrisingh MC, Guideline Commit-tee (GC). Chronic obstructive pulmonary disease: diagnosis and man-agement: summary of updated NICE guidance. BMJ 2019;366:l4486. doi:10.1136/bmj.l4486,PMID:31358491.

[24] George MD, Shah R, Kreider M, Miller WT Jr, Merkel PA, Werth VP. Pulmonary function tests, interstitial lung disease and lung func-tion decline in outpatients with classic and clinically amyopathic dermatomyositis. Br J Dermatol 2017; 176(1):262-264. doi:10.1111/bjd.14771,PMID:27229750.

[25] Kim Y, Hyon Y, Jung SS, Lee S, Yoo G, Chung C, Ha T. Respiratory sound classificationfor crackles, wheezes, and rhonchi in the clinical field using deep learning. Sci Rep 2021; 11(1):17186. doi:10.1038/s41598-021-96724-7,PMID:34433880.

[26] Lynch DA. Functional imaging of COPD by CT and MRI. Br J Radiol 2022; 95(1132):20201005. doi:10.1259/bjr.20201005,PMID:34541865.

[27] Li F, Huang ZW, Wang XF, Xu HW, Yu H, Chen YB, et al. Safety and use of pulmonary function tests: a retrospective study from a single cent-er over seven years' clinical practice. BMC Pulm Med 2019; 19(1):259. doi:10.1186/s12890-019-1019-z,PMID:31864318.

[28] Stephanie W. What Is Pulse Oximetry? WebMD; 2023.

[29] Amalakanti S, Pentakota MR. Pulse Oximetry Overestimates Oxygen Saturation in COPD. Respir Care 2016; 61(4):423-427. doi:10.4187/respcare.04435,PMID:26715772.

[30] Bhatt SP, Sieren JC, Dransfield MT, Washko GR, Newell JD Jr, Stin-son DS, et al. Comparison of spirometric thresholds in diagnosing smoking-related airflow obstruction. Thorax 2014; 69(5):409-414. doi:10.1136/thoraxjnl-2012-202810,PMID:23525095.

[31] Christopher DJ, Oommen AM, George K, Shankar D, Agrawal A, Thangakunam B. Prevalence of Airflow Obstruction as Measured by Spirometry, in Rural Southern Indian Adults. COPD 2020; 17(2):128-135. doi:10.1080/15412555.2020.1723074,PMID:32020813.

[32] Ranu H, Wilde M, Madden B. Pulmonary function tests. Ulster Med J 2011; 80(2):84-90. PMID:22347750.

[33] Centers for Disease Control and Prevention. Respiratory Health -Bronchodilator Procedures Manual 2008;AtlantaCDC.

[34] Whittaker HR, Jarvis D, Sheikh MR, Kiddle SJ, Quint JK. Inhaled corti-costeroids and FEV(1) decline in chronic obstructive pulmonary dis-ease: a systematic review. Respir Res 2019; 20(1):277. doi:10.1186/s12931-019-1249-x,PMID:31801539.

[35] Mohamed Hoesein FA, Zanen P, Lammers JW. Lower limit of normal or FEV1/FVC < 0.70 in diagnosing COPD: an evidence-based review. Respir Med 2011; 105(6):907-915. doi:10.1016/j.rmed.2011.01.008,PMID:21295958.

[36] James R. How Do X-Rays Help Diagnose COPD? Healthline; 2023.

[37] Khatib S, Sabobeh T, Jaber F, Abdalla K, Singh S, Salzman G. Use of Laboratory Tests and Their Prognostic Value in Patients with Stable Chronic Obstructive Pulmonary Disease. Mo Med 2022; 119(6):545-552. PMID:36588649.

[38] Newell JD Jr, Fuld MK, Allmendinger T, Sieren JP, Chan KS, Guo J, et al. Very low-dose (0.15 mGy) chest CT protocols using the COPDGene 2 test object and a third-generation dual-source CT scanner with cor-responding third-generation iterative reconstruction software. In-vest Radiol 2015; 50(1):40-45. doi:10.1097/RLI.0000000000000093,PMID:25198834.

[39] Levy PT, Patel MD, Choudhry S, Hamvas A, Singh GK. Evidence of Echo-cardiographic Markers of Pulmonary Vascular Disease in Asympto-matic Infants Born Preterm at One Year of Age. J Pediatr 2018; 197:48-56. e2. doi:10.1016/j.jpeds.2018.02.006,PMID:29625733.

[40] Gupta NK, Agrawal RK, Srivastav AB, Ved ML. Echocardiographic eval-uation of heart in chronic obstructive pulmonary disease patient and its co-relation with the severity of disease. Lung India 2011; 28(2):105-109. doi:10.4103/0970-2113.80321,PMID:21712919.

[41] Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, et al. Electrocardiographic characteristics of patients with chronic obstruc-tive pulmonary disease. COPD 2013; 10(1):62-71. doi:10.3109/15412555.2012.727918,PMID:23413894.

[42] Sattar Y, Chhabra L. Electrocardiogram. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.

[43] Obaseki DO, Akanbi MO, Onyedum CC, Ozoh OB, Jumbo J, Akor AA, et al. Peak expiratory flow as a surrogate for health related quality of life in chronic obstructive pulmonary disease: a preliminary cross sectional study. Ghana Med J 2014; 48(2):85-90. doi:10.4314/gmj.v48i2.5,PMID:25667555.

[44] Moore VC.Spirometry: step by step. Breathe (Sheff) 2012; 8:232-240. doi:10.1183/20734735.0021711.

[45] Brat K, Svoboda M, Zatloukal J, Plutinsky M, Volakova E, Popelkova P, et al. Prognostic Properties of the GOLD 2023 Classification System. Int J Chron Obstruct Pulmon Dis 2023; 18:661-667. doi:10.2147/COPD.S410372,PMID:37114105.

[46] Turan PA, Turan O, Güldaval F, Anar C, Polat G, Büyükşirin M. Tran-sitions between COPD groups: A cross-sectional study in Turkey. Respir Med 2021;178:106310. doi:10.1016/j.rmed.2021.106310,PMID:33529994.

[47] Cavaillès A, Brinchault-Rabin G, Dixmier A, Goupil F, Gut-Gobert C, Marchand-Adam S, et al. Comorbidities of COPD. Eur Respir Rev 2013; 22(130):454-475. doi:10.1183/09059180.00008612,PMID:24293462.

[48] Putcha N, Drummond MB, Wise RA, Hansel NN. Influ-ence on Outcomes, and Management. Comorbidities and Chronic Obstructive Pulmonary Disease: Prevalence, Semin Respir Crit Care Med 2015; 36(4):575-591. doi:10.1055/s-0035-1556063,PMID:26238643.

[49] Raherison C, Ouaalaya EH, Bernady A, Casteigt J, Nocent-Eijnani C, Falque L, et al. Comorbidities and COPD severity in a clinic-based cohort. BMC Pulm Med 2018; 18(1):117. doi:10.1186/s12890-018-0684-7,PMID:30012144.

[50] Chetty U, McLean G, Morrison D, Agur K, Guthrie B, Mercer SW. Chron-ic obstructive pulmonary disease and comorbidities: a large cross-sectional study in primary care. Br J Gen Pract 2017; 67(658):e321-e328. doi:10.3399/bjgp17X690605,PMID:28450344.

[51] Bollmeier SG, Hartmann AP. Management of chronic obstruc-tive pulmonary disease: A review focusing on exacerbations. Am J Health Syst Pharm 2020; 77(4):259-268. doi:10.1093/ajhp/zxz306,PMID:31930287.

[52] Wang MT, Lai JH, Huang YL, Kuo FC, Wang YH, Tsai CL, et al. Use of antidiabetic medications and risk of chronic obstructive pulmonary disease exacerbation requiring hospitalization: a disease risk score-matched nested case-control study. Respir Res 2020; 21(1):319. doi:10.1186/s12931-020-01547-1,PMID:33267895.

[53] Rhee CK, Yoshisue H, Lad R. Fixed-Dose Combinations of Long-Acting Bronchodilators for the Management of COPD: Global and Asian Per-spectives. Adv Ther 2019; 36(3):495-519. doi:10.1007/s12325-019-0893-3,PMID:30742242.

[54] Wang MT, Liou JT, Lin CW, Tsai CL, Wang YH, Hsu YJ, et al. Associa-tion of Cardiovascular Risk With Inhaled Long-Acting Bronchodila-tors in Patients With Chronic Obstructive Pulmonary Disease: A Nested Case-Control Study. JAMA Intern Med 2018; 178(2):229-238. doi:10.1001/jamainternmed.2017.7720,PMID:29297057.

[55] Barjaktarevic IZ, Milstone AP. Nebulized Therapies in COPD: Past, Pre-sent, and the Future. Int J Chron Obstruct Pulmon Dis 2020; 15:1665-1677. doi:10.2147/COPD.S252435,PMID:32764912.

[56] Wedzicha JA, Calverley PM, Rabe KF. Roflumilast: a review of its use in the treatment of COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:81-90. doi:10.2147/COPD.S89849,PMID:26792988.

[57] Koczulla AR, Schneeberger T, Jarosch I, Kenn K, Gloeckl R. Long-Term Oxygen Therapy. Dtsch Arztebl Int 2018; 115(51-52):871-877. doi:10.3238/arztebl.2018.0871,PMID:30765024.

[58] Kim Y, Park HY, Rhee CK, Min KH, Yoo KH, Lim SY, et al. Ambulatory oxygen therapy with documented self-monitoring of oxygen use im-proves health status among patients with chronic obstructive pul-monary disease. J Thorac Dis 2022; 14(5):1353-1359. doi:10.21037/jtd-21-1878,PMID:35693613.

[59] Shah NM, D’Cruz RF, Murphy PB. Update: non-invasive ventilation in chronic obstructive pulmonary disease. J Thorac Dis 2018; 10(Suppl 1):S71-S79. doi:10.21037/jtd.2017.10.44,PMID:29445530.

[60] LaCrone ME, Buening N, Paul N. A Retrospective Review of an Inhaler to Nebulizer Therapeutic Interchange Program Across a Health System. J Pharm Pract 2023; 36(5):1211-1216. doi:10.1177/08971900221101761,PMID:35603944.

[61] Mathioudakis AG, Janssens W, Sivapalan P, Singanayagam A, Drans-field MT, Jensen JS, et al. Acute exacerbations of chronic obstruc-tive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax 2020; 75(6):520-527. doi:10.1136/tho-raxjnl-2019-214484,PMID:32217784.

[62] GBD 2015 Chronic Respiratory Disease Collaborators. Global, region-al, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis for the Global Bur-den of Disease Study 2015. Lancet Respir Med 2017;5(9): 691-706. doi:10.1016/S2213-2600(17)30293-X, PMID:28822787.

[63] Nogimura A, Noguchi T, Otani T, Kamiji K, Yasuoka M, Watanabe R, et al. Chronic obstructive pulmonary disease and the mortality risk in male older adults: Role of socioeconomic factors. Arch Geron-tol Geriatr 2022;102:104741. doi:10.1016/j.archger.2022.104741,PMID:35691277.

[64] Park SC, Kim DW, Park EC, Shin CS, Rhee CK, Kang YA, et al. Mortality of patients with chronic obstructive pulmonary disease: a nationwide populationbased cohort study. Korean J Intern Med 2019; 34(6):1272-1278. doi:10.3904/kjim.2017.428,PMID:31610634.

[65] Sikjær MG, Hilberg O, Ibsen R, Løkke A. Trends in COPD mortality from 1983 to 2018: protocol for a population-based cohort study in Denmark. BMJ Open 2024; 14(1):e076936. doi:10.1136/bmjo-pen-2023-076936,PMID:38184314.

[66] LiverTox: Clinical and Research Information on Drug-Induced Liver In-jury. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012.

[67] Dale K, Alyssa N. Herbs and Supplements for COPD. Healthline; 2023.

[68] Lyu YR, Lee SW, Kim SY, Han HB, Yang WK, Kim SH, et al. Herbal Medicines for the Treatment of Chronic Obstructive Airway Diseas-es (Asthma or Chronic Obstructive Pulmonary Disease): A Prospec-tive Observational Study. Evid Based Complement Alternat Med 2022; 2022:3485757. doi:10.1155/2022/3485757,PMID:35677382.

[69] Safari S, Davoodi P, Soltani A, Fadavipour M, Rezaeian A, Heydari F, et al. Curcumin effects on chronic obstructive pulmonary disease: A systematic review. Health Sci Rep 2023; 6(3):e1145. doi:10.1002/hsr2.1145,PMID:36890804.

[70] Moghaddam SJ, Barta P, Mirabolfathinejad SG, Ammar-Aouchiche Z, Garza NT, Vo TT, et al. Carcinogenesis. 2009; 30(11):1949-1956. doi:10.1093/carcin/bgp229,PMID:19793800.

[71] Zhang Q, Shi Y. Therapeutic effect on chronic obstructive pulmonary disease of lung qi deficiency at the stable stage treated with ginger-separated moxibustion and Chinese herbal medicine atomization Zhongguo Zhen Jiu 2020; 40(9):933-8. doi:10.13703/j.0255-2930.20190903-0002,PMID:32959586. (in Chinese).

[72] Huang C, Kuo S, Lin L, Yang Y. The efficacy of N-acetylcysteine in chronic obstructive pulmonary disease patients: a meta-analysis. Ther Adv Respir Dis 2023; 17:17534666231158563. doi:10.1177/17534666231158563,PMID:36927162.

[73] Fernández-Jané C, Vilaró J, Fei Y, Wang C, Liu J, Huang N, et al. Acu-puncture techniques for COPD: a systematic review. BMC Comple-ment Med Ther 2020; 20(1):138. doi:10.1186/s12906-020-02899-3,PMID:32375775.

[74] Daniel Y. Acupuncture for COPD: Can It Be Helpful? Healthline; 2022.

[75] Yue JH, Golianu B, Zeng XX, Yuming W. Acupuncture for urinary reten-tion after stroke: a protocol for systematic review. Eur J Bio Med Res 2015; 1:7-11. doi:10.18088/ejbmr.1.2.2015.pp7-11.

[76] Feng J, Wang X, Li X, Zhao D, Xu J. Acupuncture for chronic obstructive pulmonary disease (COPD): A multicenter, randomized, sham-con-trolled trial. Medicine (Baltimore) 2016; 95(40):e4879. doi:10.1097/MD.0000000000004879,PMID:27749542.

[77] Shih CC, Liao CC, Sun MF, Su YC, Wen CP, Morisky DE, et al. A Ret-rospective Cohort Study Comparing Stroke Recurrence Rate in Ischemic Stroke Patients With and Without Acupuncture Treat-ment. Medicine (Baltimore) 2015; 94(39):e1572. doi:10.1097/MD.0000000000001572,PMID:26426630.

[78] Gao J, Ouyang B, Sun G, Dejun Z, Jinquan X. The effect of warm ac-upuncture on lung function and quality of life for stable COPD pa-tients. Chin Acupunct Moxibustion 2011; 31:893-897.

[79] Ngai SP, Jones AY, Cheng EK. Lung meridian acupuncture point skin impedance in asthma and description of a mathematical relation-ship with FEV1. Respir Physiol Neurobiol 2011; 179(2-3):187-191. doi:10.1016/j.resp.2011.08.004,PMID:21856454.

[80] Carly Werner RD. 10 Yoga Practices to Help You Breathe Better with COPD. Healthline; 2024.

[81] Benralizumab (Fasenra) for Severe Eosinophilic Asthma. JAMA 2018; 319(14):1501-1502. doi:10.1001/jama.2018.3609,PMID:29634828.

[82] Ortega HG, Liu MC, Pavord ID, Brusselle GG, FitzGerald JM, Chetta A, et al. Mepolizumab treatment in patients with severe eosinophilic asthma. N Engl J Med 2014; 371(13):1198-1207. doi:10.1056/NEJ-Moa1403290,PMID:25199059.

[83] Reslizumab (Cinqair) for severe eosinophilic asthma. Med Lett Drugs Ther. 2016; 58(1497):81-82. PMID:27305070.

[84] Mayo Clinic.Anti-interleukin-5 therapy for severe asthma:A new therapeutic option. Mayo Clinic; 2019. Available from:

[85] Taylor SP, Sellers E, Taylor BT. Azithromycin for the Prevention of COPD Exacerbations: The Good, Bad, and Ugly. Am J Med 2015; 128(12):1362.e1-6. doi:10.1016/j.amjmed.2015.07.032,PMID:26291905.

[86] Vogelmeier C, Hederer B, Glaab T, Schmidt H, Rutten-van Mölken MP, Beeh KM, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011; 364(12):1093-1103. doi:10.1056/NEJMoa1008378,PMID:21428765.

[87] Rodrigo GJ. Inhaled therapy for acute adult asthma. Curr Opin Allergy Clin Immunol 2003; 3(3):169-75. doi:10.1097/00130832-200306000-00004,PMID:12840699.

[88] Hajek P, Phillips-Waller A, Przulj D, Pesola F, Smith KM, Bisal N, et al. E-cigarettes compared with nicotine replacement therapy within the UK Stop Smoking Services: the TEC RCT. Health Technol Assess 2019; 23(43):1-82. doi:10.3310/hta23430,PMID:31434605.

[89] Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global strategy for the diagnosis, management, and preven-tion of chronic obstructive pulmonary disease: GOLD executive sum-mary. Am J Respir Crit Care Med 2013; 187(4):347-365. doi:10.1164/rccm.201204-0596PP, PMID:22878278.

[90] Agusti A, Böhm M, Celli B, Criner GJ, Garcia-Alvarez A, Martinez F, et al. GOLD COPD DOCUMENT 2023: a brief update for practicing cardi-ologists. Clin Res Cardiol 2024; 113(2):195-204. doi:10.1007/s00392-023-02217-0,PMID:37233751.

[91] Davis KJ, Landis SH, Oh YM, Mannino DM, Han MK, van der Molen T, et al. Continuing to Confront COPD International Physician Survey: physician knowledge and application of COPD management guide-lines in 12 countries. Int J Chron Obstruct Pulmon Dis 2015; 10:39-55. doi:10.2147/COPD.S70162,PMID:25565799.

[92] MacLeod M, Papi A, Contoli M, Beghé B, Celli BR, et al. Chronic obstructive pulmonary disease exacerbation fundamentals: Di-agnosis, treatment, prevention and disease impact. Respirology 2021; 26(6):532-551. doi:10.1111/resp.14041,PMID:33893708.

[93] Kristeen C. 12 Tips for Preventing COPD and Avoiding Flare-Ups. Healthline 2022;.

[94] Van Schayck OCP, Williams S, Barchilon V, Baxter N, Jawad M, Kat-saounou PA, et al. Treating tobacco dependence: guidance for prima-ry care on life-saving interventions. Position statement of the IPCRG. NPJ Prim Care Respir Med 2017; 27(1):38. doi:10.1038/s41533-017-0039-5,PMID:28600490.