Cardiopulmonary Collaboration in Respiratory Care: Shifting the Paradigm

Abstract

In recent years, the management of chronic obstructive pulmonary disease (COPD) has evolved from a symptom driven focus to prioritizing the reduction of exacerbations, with a view to preventing morbidity and mortality. This treatment landscape continues to evolve, with biologic therapies on the horizon that promise to substantially alter the current paradigm centred on inhaled therapies. While other jurisdictions have approved dupilumab and mepolizumab as add-on therapies to prevent COPD exacerbations, these options are not yet approved for use in Canada. Regardless of regulatory status, the foundation of COPD therapy remains the same: triple inhaled therapy, combined with inhaled corticosteroids, long-acting anti-muscarinic agents, and long‑acting beta-agonists. At the time of enrolment in the studies, single inhaler triple therapy (SITT) was not yet the standard of care; however, the majority of enrolled patients (over 98%) were receiving all three components. While multiple inhaler triple therapy was permitted, both studies demonstrated a statistically significant reduction in COPD exacerbations. Biologics are intended as an add-on to baseline therapy, yet many patients remain undertreated and lack access to SITT.

Our Canadian COPD guidelines have emphasized a clear preference for SITT, advocating for its rapid initiation in highly symptomatic patients, and those at increased risk of exacerbations. SITT has been demonstrated to reduce exacerbations and mortality, contributing to a reduction in hospitalizations and emergency department visits. Nevertheless, many patients remain on inadequate therapy and continue to face an elevated risk of exacerbations, thus predisposing them to increased mortality. In both the ETHOS and IMPACT trials, the most commonly adjudicated causes of death were cardiopulmonary in nature.

Single inhaler therapy has been shown to be safe, effective, and economical. The number needed to treat (NNT) to prevent a moderate or severe COPD exacerbation is 1:4, while the number needed to harm (NNH) for pneumonia is 1:33. Despite this favourable profile, there appears to be hesitancy regarding initiation of therapy. Whether this stems from regulatory barriers regarding access to medication, hesitancies based on risk perception pertaining to pneumonia or other adverse events, or gaps in knowledge, this is a situation which deserves urgent attention, in light of the simplicity and effectiveness of this intervention.