Introductory Chapter: Contextualizing Chronic Obstructive Pulmonary Disease

1. Introduction

Chronic Obstructive Pulmonary Disease (COPD) afflicts more than 390 million people globally [1] and is the third leading cause of death worldwide [2]. COPD is also a heterogeneous and complex malady, varying in severity and clinical presentation. The commonness and the complexity of this disorder require contextualization in balancing global scientific development with the local milieu, and the general aspects of the disease with particular subject characteristics.

2. Evaluating COPD in different contexts

Perhaps more so than other common respiratory disorders such as bronchial asthma, the construal of COPD varies according to demographic, cultural, socioeconomic, geographical, and even political contexts. Patients’ anamnesis and conceptions of the illness not only vary across the world but also according to the chronological period that the disease is diagnosed. Change in nomenclature has contributed somewhat to the latter. Nowadays, terms like “chronic bronchitis” and “emphysema” are less often used in clinical diagnosis, and in their place, the acronym COPD has become widely accepted across the globe by laymen and professionals. The benefit of standard terminology is not solely titular since the definition of the disease can only be agreed upon once everyone has accepted what it should be called, at least in clinical practice. For this, we are heavily indebted to the unifying work developed and continually updated by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) [3] in enabling clinicians and researchers to figuratively speak the same language. Some readers may recall an epoch when COPD was confusingly construed as overlapping conditions of chronic bronchitis, emphysema, and asthma within the confines of chronic airflow limitation. In appreciation of GOLD, standard definitions of COPD have been refined and gained widespread acceptance, thus fostering mutual understanding and expedient communication within the medical community.

Nonetheless, such universality in evaluating COPD tends to mask the particularity of COPD as it presents in various contexts. The term COPD confers varying connotations among diverse individuals and people groups. For instance, diagnosis of COPD will likely evoke more unease among people where the disease is less common than in populations with shared predisposing factors leading to a high prevalence of the disease. Contrariwise, detecting COPD in younger patients and non-smoking women may prove challenging for a disease oft erroneously thought to be confined to older smoking men. A diagnosis of COPD made a decade or two ago does not conjure up the same notions compared to one recently established, as the rapid rate of advancement in medical knowledge may have a consequent impact on the minds of both the patient and the clinician. Two score and more years ago, diagnosis of the disease was often met with nihilism, as physicians had little to offer and diagnoses were delayed with scant attention paid to the early stages of COPD. Not much was known about the natural progression of the disease, save for a greater rate of decline in lung function among susceptible smokers compared to healthy adults. Currently, we know that that simplistic paradigm requires a reformation to accommodate multifactorial disease progression, with myriad contributory factors that may be present earlier in life, some even in childhood or in utero [4]. This paradigm shift goes some way toward answering the age-old question of why some smokers develop COPD but not others. With such advancement in knowledge, the stigma of COPD as a self-afflicted smoker’s disease should also be done away with. In today’s context, a diagnosis of COPD should no longer convey a sense of shame for the patient nor an attitude of sanctimony among others.

3. Confronting COPD within different contexts

The age of nihilism should also give way to a future of hope. Historical phenomena such as the stigmatization of smokers who develop COPD and denial of treatment options for those with the severe disease remain significant only as they are related to the responsibility of the present and the promises of the future. An appreciation of different contexts in the clinical presentation of COPD calls for earlier means of diagnosing COPD in an individual patient’s lifetime, or at least the ability to predict which individuals are susceptible to COPD. From the newer theoretical understanding of the development of COPD also emanates anticipation of better preventive strategies in the future [4, 5].

In treating COPD, contextualization is crucial. Global guidelines formulated using evidence derived from restricted clinical trial formats are unlikely to be fully relevant to every clinical context in the real world. Clinicians in low-resource countries may be quite adept at managing COPD without the standard spirometry and other tests to rule out differential diagnoses as recommended by global practice guidelines. Recent developments in genomics, phenotyping, endotyping, and identifying treatable traits for the telos of personalized medicine may be impracticable in certain settings. Here again is where the universality of COPD, in that it is such a prevalent disease, must be balanced with the particularity of managing COPD within different contexts. Precision medicine does not always entail the use of proteomics and biomarkers, important as they are for the understanding and treatment of the disease, to guide therapeutic decisions. Neither does personalizing medicine mean forsaking the norm or whatever works for the whole, in favor of the quixotic or specific. More empirically, individualizing treatment requires reasoning and adaptation. When confronting COPD in extensive contexts, the clinician must be willing to apply powers of observation and reasoning: deduction (what works for the whole or in principle, should work for the individual), induction (observe what works for an individual to form a general conclusion), as well as abduction (to infer based on observation and assumption). Additionally, the clinician must be willing to adapt to different or changing contexts when confronting COPD. This is an especially essential trait in an era of scientific progress vitiated by disruptions brought about by the current pandemic. The rapid espousal and widespread use of telehealth and remote monitoring to overcome the physical restrictions due to the pandemic are positive demonstrations of adaptive contextualization of therapeutics in COPD.

In sum, contextualization is important for both evaluating and managing the nuances of this common and complex disorder. Patient and physician education, acceptance and usage of evidence-based guidelines, and therapeutic evolution all require careful contextualization for salubrious practical implementation.