Optimal Treatment of Chronic Obstructive Pulmonary Disease: The Search for the Magic Combination of Inhaled Bronchodilators and Corticosteroids

Chronic obstructive pulmonary disease (COPD) is an international disease: Not only does it affect 10 to 24 million adults in the United States (1), but it is also the fourth leading cause of death in both the United States and the world (2). The global burden of COPD will increase dramatically in the coming years (3). A recent assessment by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) projects that COPD will be the fifth leading cause of disease worldwide and the third leading cause of death by 2020 (3).

Chronic obstructive pulmonary disease is costly. In 2000, COPD caused 8 million office visits, 1.5 million emergency department visits, 726 000 hospitalizations, and 119 000 deaths in the United States (1). It is responsible for $15 billion in direct health care costs (4) and approximately $10 billion in lost work productivity each year (5). These statistics underestimate the human and financial burdens of COPD, because the disease is inextricably associated with other serious causes of illness, death, and health expenditures—especially cardiac disease and stroke.

Exacerbations account for most of the morbidity, mortality, and costs associated with COPD. Exacerbations are to COPD what myocardial infarctions are to coronary artery disease: They are the acute, often trajectory-changing, and sometimes deadly manifestations of a chronic disease. Exacerbations of COPD have been reported to cause frequent hospital admissions, relapses, and readmissions (6); contribute to death during hospitalization or shortly thereafter (6); dramatically reduce the quality of life (6, 7); consume financial resources (6, 8); and hasten a cardinal feature of COPD: progressive decline in pulmonary function.

Unlike heart attacks, however, many risk factors, symptoms, treatments, and outcomes related to exacerbations of COPD remain unclear. Consensus groups have defined a COPD exacerbation as “an event in …