clinical knowledge summaries cks chronic obstructive pulmonary disease (copd) diagnosis of copd in...

Clinical Knowledge Summaries CKS

Chronic obstructive pulmonary disease (COPD)

Diagnosis of COPD in primary care

Educational slides based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

Key learning points and objectives• To be able to:

o Recognise people who are at risk of COPD.o Describe the diagnostic features of COPD.o Describe the key features that can help distinguish

COPD from asthma.o Describe how to use spirometry to aid in the

diagnosis and management of COPD.

Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

Definition• Chronic obstructive pulmonary disease (COPD)

is:o A treatable and largely preventable lung disease with

symptoms such as cough, sputum, and increasing breathlessness.

• Airflow obstruction is:o Usually progressive, not fully reversible, and does not

change markedly over several months.o Associated with abnormal inflammatory response of

the lungs, mainly to noxious particles, especially cigarette smoke.


How common is it?• Around 3 million people in the UK have COPD.

o An additional 2 million have undiagnosed COPD.• Prevalence increases with age.

o Most people are not diagnosed with COPD until they are 50 years of age or older.

• A GP practice looking after 7000 people will have around 200 people with COPD (many undiagnosed).

• COPD is:o The second largest cause of emergency hospital

admissions (one in eight). o One of the most expensive inpatient conditions treated by

the NHS.


Risk factors• Smoking tobacco is the major risk factor for

developing COPD (90% of cases are caused by cigarette smoking). o Lower morbidity and mortality rates for pipe and cigar

smokers (compared with cigarettes).• Other risk factors include:

o Occupational exposure — dust, chemicals, noxious gases, and particles.

o Air pollution — wood, animal dung, crop residues, and coal.

o Genetics — homozygous alpha1-antitrypsin deficiency (less than 1% of cases).


Prognosis• COPD is progressive. Once developed, it cannot be

cured. However:o Stopping exposure (e.g. smoking) may slow or halt the

progression.• In the UK, about 30,000 people die of COPD each year

(5% of all deaths).o Mortality from COPD increases with age, severity of

disease, and socioeconomic deprivation.• Exacerbations of COPD that need hospital admission

are associated with an inpatient mortality rate of 3–4%.o This increases to 11–24% for people who require

treatment in an intensive care unit.Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

Complications• COPD is associated with:

o Disability and impairment of quality of life. o The person may develop reduced mobility or become

increasingly housebound.o Depression and anxiety.

o Two of the most common and least treated comorbidities of COPD.

o Frequent respiratory infections. o Polycythaemia. o Respiratory failure.


Symptoms of COPD• Typical symptoms of COPD include:

o Exertional breathlessness.o Chronic cough.o Regular sputum production.o Frequent 'winter bronchitis'.o Wheeze.

• Other symptoms include:o Weight loss.o Exercise intolerance.o Ankle swelling.o Fatigue.o Chest pain or haemoptysis (uncommon).


Physical signs of COPD• The following signs may be present:

o Hyperinflated chest.oWheeze or quiet breath sounds.o Pursed lip breathing.o Use of accessory muscles.o Peripheral oedema.o Cyanosis.o Raised jugular venous pressure.o Cachexia.


What else could it be?• Asthma

• Can be difficult to distinguish from COPD and both conditions may coexist (discussed later).

• Bronchiectasis• Congestive cardiac failure.• Lung cancer.• Interstitial lung disease (e.g. asbestosis).• Bronchopulmonary dysplasia.• Anaemia.• Obstructive sleep apnoea.• Tuberculosis.


Making a diagnosis of COPD • There is no single diagnostic test for COPD.• A diagnosis of COPD should be considered in

people:o Over the age of 35 who have a risk factor (generally

smoking) ando Who present with one or more of the following

symptoms: • Exertional breathlessness.• Chronic cough.• Regular sputum production.• Frequent winter bronchitis.• Wheeze.


Making a diagnosis of COPD

• Consider alternative diagnoses.• Arrange a chest X-ray to help exclude other

causes.• Consider the possibility of alpha1-antitrypsin

deficiency if:o The person is younger than 40 years of age or has

a family history of alpha1-antitrypsin deficiency.


Making a diagnosis of COPD • Reconsider the diagnosis of COPD (and

consider the possibility of asthma) if:o The person has a marked response to drug

treatment (e.g. inhaled beta-2 agonist).

• A marked response includes:o A marked improvement in symptoms, oro Return of forced expiratory volume (FEV1) and

FEV1/FVC forced vital capacity ratio to normal.


Distinguishing asthma from COPD• Consider the possibility of asthma if the

person:oHas a family history of asthma.oHas other atopic diseases or nocturnal or

variable symptoms.o Is a non-smoker.o Experiences onset of symptoms at younger than

35 years of age.o To help distinguish asthma from COPD, first

compare the clinical features. Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

Distinguishing clinical featuresClinical features COPD AsthmaSmoker or ex-smoker Nearly all Possibly

Age < 35 years Rare Often

Chronic productive cough Common Uncommon

Breathlessness Persistent and productive

Variable

Night-time waking with breathlessness or wheeze

Uncommon Common

Significant diurnal or day-to-day variation in symptoms

Uncommon Common


Distinguishing asthma from COPD

• If diagnostic doubt still remains, consider:o Doing longitudinal observations of symptoms,

peak flow, and/or spirometry, oro Performing reversibility testing using either

inhaled bronchodilators or oral prednisolone.


Longitudinal observations

• Asthma may be likely if:o Serial domiciliary peak expiratory flow

measurements show a 20% or greater diurnal or day-to-day variability.

o On spirometry, clinically significant COPD is not present if the FEV1/FVC ratio increases to 0.7 or greater at follow up.


Reversibility testing

• The following findings are indicative of asthma:o A large (greater than 400 mL FEV1) response to

inhaled bronchodilators.o A large (greater than 400 mL FEV1) response to

30 mg oral prednisolone given daily for 2 weeks.


Spirometry• To confirm the diagnosis of COPD use

spirometry:o The ratio of FEV1 to FVC should be less than 0.7.

• The slow or relaxed vital capacity (SVC) can be used instead of FVC, if:o The SVC is higher than the FVC, or o The person cannot perform a forced manoeuvre to

full exhalation.• Spirometry should be done 15–20 minutes after

the person has inhaled (via a spacer):o Salbutamol 200 micrograms, or o Terbutaline 500 micrograms.


Spirometry• If the FEV1 is 80% of predicted normal or

greater, a diagnosis of COPD should be made only if there are respiratory symptoms (e.g. breathlessness or cough).o Predicted normal values of FEV1 and FVC:

• Depend on age, height, and sex. • May over diagnose COPD in elderly people and are not

applicable in black and Asian populations.

• Repeat spirometry if:o The person has an exceptionally good response to

treatment. Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

Using spirometry

• Spirometry measurements are used to:oMeasure the severity of airflow obstruction, ando Guide treatment and prognosis.

• However when used alone spirometry can:o Underestimate the impact of the disease, or o Overestimate it.


Using spirometry • Following post-bronchodilator spirometry,

airflow obstruction can be classified as:o Stage 1 (mild) - FEV1 80% of predicted value or

higher (symptoms must be present).o Stage 2 (moderate) - FEV1 50–79% of predicted

value.o Stage 3 (severe) - FEV1 30–49% of predicted value.

o Stage 4 (very severe) - FEV1 less than 30% of predicted value.


Assessing the severity of COPD• NICE state that no single measure can

adequately assess the true severity of COPD.• Assess the severity of COPD according to:

o The reduction of FEV1 on spirometry,o The degree of breathlessness according to the

Medical Research Council (MRC) dyspnoea scale,o The BMI - (BMI of less than 20 kg/m2 is associated

with increased mortality) ando Presence of cor pulmonale.


Grade Level of activity1 Not troubled by breathlessness except during

strenuous exercise2 Short of breath when hurrying or walking up a

slight hill3 Walks slower than contemporaries on the

level because of breathlessness, or has to stop for breath when walking at own pace

4 Stops for breath after walking about 100 m or after a few minutes on the level

5 Too breathless to leave the house, or breathless when dressing or undressing

MRC dyspnoea scale


Summary• Smoking tobacco is the major risk factor for developing COPD

(90%).• COPD cannot be cured but stopping smoking may slow or halt

progression.• Asthma can be difficult to distinguish from COPD (both may

coexist).o Longitudinal observations (e.g. with peak flow meters) and reversibility

testing can help distinguish asthma from COPD.

• There is no single diagnostic test for COPD. Consider a diagnosis if the person is: o Older than 35 years, has a risk factor (e.g. smoking), and has typical

symptoms. • Spirometry is used to measure airflow obstruction and help inform

management.

clinical knowledge summaries cks chronic obstructive pulmonary disease (copd) diagnosis of copd in...

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