The Confronting COPD International Survey: patients hardly know they have COPD

An important part of the daily clinical practice of the pulmonologist is related to patients with chronic obstructive pulmonary disease (COPD). Management of stable COPD includes recommendations regarding lifestyle and physical exercise, and optimal individually tailored pharmacotherapy will be considered satisfactory by the physician if lung function decline is limited and frequent and/or severe exacerbations are prevented. Many international and national guidelines have been developed, which include practical issues regarding management, monitoring etc. [1, 2]. Research in COPD has expanded rapidly in recent years. Its main aims have been to unravel the pathobiology, to explore similarities and differences compared to asthma, to find noninvasive biomarkers that indicate the presence and severity of inflammation and oxidative stress, and to analyse the short- and longterm efficacy of therapeutic interventions. Relatively little is known about the patient9s own perception of their health status with regard to COPD. Obviously, it is important to explore this significant issue because there may be a discrepancy between the doctor9s perception of the impact of COPD in the patient and the patient9s own perception of their health status. A clear example of such a discrepancy was recently shown in the Asthma Insights and Reality in Europe (AIRE) study [3], showing that the impact of asthma was much larger from the patient9s perspective than many doctors would have anticipated. In the present issue of the European Respiratory Journal ,R ENNARD et al. [4] show real-life data collected from subjects with a known or suspected diagnosis of COPD. One of the interesting conclusions from this "Confronting COPD International Survey" is that subjects with COPD underestimate their morbidity, as evidenced by a high proportion of subjects with limitations in daily life activities, a marked loss of work, and frequent use of health services. A remarkable finding was that patients tend to underestimate the severity of the disease, as evidenced by the discrepancy between breathlessness score and their own estimation of severity. The prevalence of COPD in the population of smokerso45 yrs of age appeared to be y4%, with relatively little variation among the countries surveyed. How should these data be interpreted and put into perspective? The data reported on limitations in daily life are impressive, but, as a consequence of the design of the survey, they are not accompanied by lung function data. About 80% of the studied population underwent some kind of lung function testing in the previous year, but only 55% underwent any tests other than peak flow registration. In view of the significant limitations in daily life activities reported in the present study, the disease state may have been underdiagnosed and/or the severity underestimated. As would be expected, only y55% of the subjects reported use of inhaled bronchodilators. This strongly suggests underestimation of the severity of the disease state and undertreatment in these subjects, despite significant complaints and limitations. The extent of this misclassification and undertreatment cannot be assessed in the present study design, but might be quite large.