Chronic obstructive pulmonary disease (COPD) is now recognized as a major source of ill health around the world with an important impact on both developed and developing economies. The emphasis in research has shifted from a purely physiological focus that mainly considered how airway smooth muscle tone can be modulated to improve lung emptying. Although long-acting inhaled beta-agonist and antimuscarinic antagonists have improved clinical management for many symptomatic patents, there is increasing attention being paid to the inflammatory component of COPD in the airways and lung parenchyma and to its close association with other diseases, which cannot simply be attributed to their having a common risk factor such as tobacco smoking. This clinical review is intended to identify not only those areas where pharmacological treatment has been successful or has offered particular insights into COPD but also to consider where existing treatment is falling short and new opportunities exist to conduct original investigations. A picture of considerable complexity emerges with a range of clinical patterns leading to several common end points such as exacerbations, exercise impairment and mortality. Defining subsets of patients responsive to more specific interventions is the major challenge for the next decade in this field.
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