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At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease (COPD)

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BASED ON THE GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD) UPDATED 2010

Please refer to the GOLD Report (updated 2010) at www.goldcopd.org

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DIAGNOSING COPD

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A diagnosis of COPD should be considered in any individual who has dyspnea, chronic cough or sputum production, and/ or a history of exposure to risk factors for the disease, especially cigarette smoking.

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Key Indicators for Considering a COPD Diagnosis

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Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Progressive (worsens over time). Usually worse with exercise. Persistent (present every day). Described by the patient as an “increased effort to breathe,” “heaviness,” “air hunger,” or “gasping.”

• Chronic cough:

May be intermittent and may be unproductive.

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• Dyspnea that is:

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• Chronic sputum production: Any pattern of chronic sputum production may indicate COPD.

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• History of exposure to risk factors: Tobacco smoke (including popular local preparations). Occupational dusts and chemicals. Smoke from home cooking and heating fuel. The diagnosis should be confirmed by spirometry.

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Where spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expiratory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but has poor specificity since it can be caused by other lung diseases and by poor performance. In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made to provide access to standardized spirometry.

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ASSESS AND MONITOR COPD RE

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A detailed medical history of a new patient known or thought to have COPD should assess:

Patient’s exposure to risk factors, such as smoking and occupational or environmental exposures

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Past medical history, including asthma, allergy, sinusitis or nasal polyps, respiratory infections, and other respiratory diseases.

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Family history of COPD or other chronic respiratory disease.

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Pattern of symptom development: COPD typically develops in adult life and most patients are concious of increased breathlessness, more frequent ”winter colds,” and some social restriction for a number of years before seeking medical help.

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History of exacerbations or previous hospitalizations for respiratory disorder: Patients may be aware of periodic worsening of symptoms even if these episodes have not been identified as exacerbations of COPD.

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Presence of comorbidities, such as heart disease, malignancies, osteoporosis, and musculoskeletal disorders, which may also contribute to restriction of activity.

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Appropriateness of current medical treatments: For example, beta-blockers commonly prescribe for heart disease are usually contraindicated in COPD

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Impact of disease on patient’s life, including limitation of activity; missed work and economic impact; effect on family routines; and feelings of depression or anxiety.

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Social and family support available to the patient.

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Possibilities for reducing risk factors, especially smoking cessation.

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Physical Examination

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Though an important part of patient care, a physical examination is rarely diagnostic in COPD. Physical signs of airflow limitation are usually not present until significant impairment of lung function has occurred, and their detection has a relatively low sensitivity and specificity. A number of physical signs may be present in COPD, but their absence does not exclude the diagnosis.

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STAGES OF COPD1

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Stage I: Mild COPD – Characterized by mild airflow limitation (FEV1/FVC < 0.70; FEV1 ≥ 80% predicted). Symptoms of chronic cough and sputum production may be present, but not always. At this stage, the individual is usually unaware that his or her lung function is abnormal.

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Stage II: Moderate COPD – Characterized by worsening airflow limitation (FEV1/FVC < 0.70; 50% ≤ FEV1 < 80% predicted), with shortness of breath typically developing on exertion and cough and sputum production sometimes also present. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease.

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Stage III: Severe COPD – Characterized by further worsening of airflow limitation (FEV1/FVC < 0.70; 30% ≤ FEV1 < 50% predicted), greater shortness of breath, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on patients’ quality of life.

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Stage IV: Very Severe COPD – Characterized by severe airflow limitation (FEV1/FVC < 0.70; FEV1 < 30% predicted or FEV1 < 50% predicted plus the presence of chronic respiratory failure). Patients may have Stage IV: Very Severe COPD even if the FEV1 is > 30% predicted, whenever these complications are present. At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening. 1

Values are post bronchodilator.

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Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality Prevent or minimize side effects from treatment.

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GOALS OF COPD MANAGEMENT

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Cessation of cigarette smoking should be included as a goal throughout the management program.

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Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Manage Exacerbations

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An effective COPD management plan includes four components:

PHARMACOLOGIC THERAPY OF STABLE COPD Bronchodilators: These medications are central to symptom management in stable COPD. Inhaled therapy is preferred. The choice between β2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of sympton relief and side effects.

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Bronchodilators are prescribed “as needed” to relieve intermittent or worsening symptoms, and on a regular basis to prevent or reduce persistent symptoms.

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Long-acting inhaled bronchodilators are more effective and convenient.

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Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

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Glucocorticosteroids: Regular treatment with inhaled glucocorticosteroids is only appropriate for symptomatic patients with an FEV1