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Systemic Effects of COPD: Just the Tip of the Iceberg

The Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease defines COPD as “a preventable and treatable disease with some significant extra-pulmonary effects that may contribute to the severity in individual patients” (1). It is interesting to note that this definition highlights the systemic effects of COPD even before mentioning that COPD is “also” characterized by poorly reversible airflow limitation (1). This is not to diminish the central role of chronic airflow obstruction in patients with COPD, but to underlie the clinical relevance that many of the extra-pulmonary manifestations of the disease can have in some patients (2). Yet, this paradigm has permeated clinical practice very slowly. The ATS/ERS guidelines were the first to include it in their recommendations, and this was just four years ago (3)! In contrast, as early as in 1966, Burrows et al. had already described two distinct COPD phenotypes, the “blue bloater” and the “pink puffer,” the latter being characterized by marked weight loss and skeletal muscle atrophy (cachexia) (4). It was not, however, until 1993 when Schols et al. identified weight loss in COPD as a prognostic factor that, importantly, was independent of the degree of airflow limitation (5). Since this seminal observation, many different investigators have contributed to identify the presence of chronic low-level systemic inflammation (in combination with other factors such as a sedentary life style, tissue hypoxia and malnutrition, among others) as a key mechanism in the pathogenesis of many (if not all) the systemic effects of COPD (6, 7). In this issue of the Journal of COPD, Decramer and colleagues (8) summarizes the presentations and discussions of a round-table meeting of experts held in Miami