chronic%20obstructive%20pulmonary%20disease
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Treatment Guideline Chart

Chronic obstructive pulmonary disease (COPD) is an inflammatory respiratory disease characterized by reversible airflow limitation.

The patient usually has chronic cough, sputum production or dyspnea with or without history of risk factors for the disease.

The chronic airflow limitation is caused by a combination of small airways disease and parenchymal destruction.

It is a preventable and treatable disease.

Chronic%20obstructive%20pulmonary%20disease Diagnosis

Spirometry

  • Recommended measurement of airflow limitation that confirms the diagnosis of COPD
    • A useful tool in the assessment of the severity of the pathological changes in COPD
  • Also recommended for patients at risk of COPD, especially smokers >45 years old with cough, sputum or dyspnea and for regular follow-up of patients with documented COPD
    • Use must be restricted to patients needing essential or urgent test to diagnose COPD or to assess lung function status in patients for surgery or interventional procedures during increased COVID-19 prevalence in the community
  • Measures forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1)
    • A decreased FEV1/FVC ratio is typically seen in patients with COPD
    • A post-bronchodilator FEV1/FVC <70% confirms the presence of persistent of airflow limitation
  • Spirometry services should be supported by quality control processes
  • Lung volumes are affected by process of aging and FEV1/FVC ratio depends on age, height, sex and race
    • The use of fixed ratio may lead to underdiagnosis in patients <45 years especially of mild disease and overdiagnosis in patients >50 years
  • If without access to spirometry, COPD diagnosis may be suspected based on history, symptoms and physical signs
    • Peak flow measurements may be used to rule out asthma, but not to diagnose COPD
      • Has good sensitivity rate but weak specificity
  • A forced expiratory time (FET) is the time for a patient to forcefully exhale through open mouth from total lung capacity until air flow is inaudible [≥6 seconds is abnormally prolonged and >6 seconds is an acceptable guide to presence of FEV1/FVC <50% (obstructive disease)]
  • Modified British Medical Research Council (mMRC) Dyspnea Scale is useful for classification, which can be used to assist in the evaluation of disease severity and functional disability

Modified MRC Dyspnea Scale*

Grade

Description

0

Only experience breathlessness with strenuous exercise

1

There’s shortness of breath when walking up a slight hill or hurrying on the level

2

Walks slower than people of the same age on the level because of breathlessness or has to stop to catch a breath when walking at own pace on the level

3

Stops to catch a breath after walking about 100 meters or after a few minutes on the level

4

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

*Adapted from: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2021 report.

  • COPD Assessment Test (CAT) is a short questionnaire used in routine clinical practice to gauge the health status of COPD patients [please refer to Jones et al. Eur Respi J.2009;34(3):648-657 or Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guidelines figure 2.3]
    • Measures patients’ disease severity using 8 symptoms, with scores ranging from 0-40:
  • Frequency of cough
  • Chest tightness
  • Limitations with home activities
  • Presence of sleep disturbance
  • Degree of presence of phlegm
  • Breathlessness when climbing stairs/walking uphill
  • Confidence with outdoor activities even if with COPD
  • Level of energy

Laboratory Tests

COPD - Long-term Management

Bronchodilator Reversibility Testing

  • Usually performed only once at the time of diagnosis
  • May help rule out asthma, establish best attainable lung function, evaluate prognosis and guide treatment decisions
  • However, it may not reliably predict response to long-term bronchodilator therapy

Pulse Oximetry and Arterial Blood Gas (ABG) Measurement

  • Pulse oximetry should be performed in stable patients especially those with FEV1 <35% predicted or with signs of respiratory failure or right heart failure
  • ABG should be assessed when the peripheral saturation is <92%

Alpha-1 Antitrypsin Deficiency (AATD) Screening

  • Recommended procedure by the World Health Organization (WHO) and the European Respiratory Society (ERS) for all patients diagnosed with COPD especially in AATD-prevalent areas
  • May be useful in young patients (<45 years) who develop COPD
  • Positive results may lead to family screening and counseling
  • Alpha-1 antitrypsin serum concentration of <15-20% of the normal value is highly suggestive of homozygous AATD

SARS-CoV-2 Polymerase Chain Reaction Assay

  • Recommended for COPD patients with new or worsening respiratory symptoms, fever and other symptoms which could be COVID-19 related
  • Reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 is also recommended prior to performing spirometry or bronchoscopy

COPD - Acute Exacerbation

ABG Measurement

  • PaO2 <8 kPa, <60 mmHg and/or SaO2 <90% with or without PaCO2 >50 mmHg on room air are indicative of respiratory failure
  • If there are no facilities to measure blood gases, SaO2 should be measured

Electrocardiogram (ECG)

  • Helpful in diagnosing right ventricular hypertrophy, arrhythmias and ischemic episodes
  • Aids in the diagnosis of pulmonary embolism from COPD exacerbation, as right ventricular hypertrophy and large pulmonary arteries may lead to confusing radiographic and ECG findings

Complete Blood Count (CBC)

  • May show polycythemia (hematocrit >55%) or bleeding
  • White blood cells (WBC) may be elevated in patients with respiratory infection

Biochemical Tests

  • May be helpful in determining the cause of exacerbation and in diagnosing other comorbid conditions (eg electrolyte imbalances, diabetic crisis, poor nutrition, acid-base disorders)

Sputum Culture

  • Presence of purulent sputum during an exacerbation is sufficient basis for starting antibiotics
  • Culture and sensitivity testing of sputum must be done if the patient does not respond to initial antibiotic therapy

COPD Exacerbation

Definition of COPD Exacerbation

  • An acute event wherein the patient’s symptoms worsen beyond normal daily variations that leads to change in medication
  • Viral and bacterial respiratory tract infections are the common causes
    • Exacerbations caused by bacterial etiology in 50% of patients
  • Other causes: Air pollution, interruption of maintenance medications, other comorbidities (GERD)

Signs and Symptoms of COPD Exacerbation

  • Increased breathlessness, wheezing, chest tightness
  • Increased cough and sputum, change in color and/or tenacity of sputum
  • Fever, malaise, fatigue, depression, confusion, sleep disturbances, decreased exercise tolerance
  • Respiratory rate >25 breaths/minute, heart rate >110 beats/minute, use of accessory muscles for breathing and/or dyspnea at rest may indicate severe acute exacerbation
  • Can be difficult to differentiate from COVID-19 infection which can present with cough and breathlessness but accompanied by fever, diarrhea, nausea, vomiting, fatigue, confusion, muscle pains, anosmia, dysgeusia and headache

Imaging

COPD - Long-term Management

Chest X-ray

  • Useful mainly in ruling out alternative diagnoses
  • May show signs of lung hyperinflation (eg flattened diaphragm), lung hyperlucency and rapid tapering of the vascular markings
  • May be considered in COPD patients with moderate to severe symptoms of COVID-19 or worsening respiratory status

Computed Tomography (CT)

  • Not routinely used but may help in excluding other possible diagnosis
  • Recommended if surgical management is being contemplated
  • Recommended in COPD and non-COPD patients to diagnose and assess severity of COVID-19
  • CT Angiography may be considered if pulmonary embolism is suspected in patients with COVID-19

COPD - Acute Exacerbation

Chest X-ray

  • Helpful in patients with suspected pneumonia
  • May be useful in identifying alternative diagnoses that can mimic symptoms of exacerbation

Assessment

Severity of COPD is classified based on patient’s symptoms, spirometry results, presence of complications and future risk of exacerbations

Classification of airflow limitation1*

Stage

Characteristics

I: Mild COPD

  • FEV1 ≥80% predicted

II: Moderate COPD

  • 50% ≤ FEV1 <80% predicted

III: Severe COPD

  • 30% ≤ FEV1 <50% predicted

IV: Very Severe COPD

  • FEV1 <30% predicted
*Adapted from: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2021 report.
1Classification is based on post-bronchodilator FEV1 in patients with FEV1/FVC <0.7
The use of fixed ratio may lead to underdiagnosis in patients <45 years especially of mild disease and overdiagnosis in patients >50 years

SYMPTOM/RISK EVALUATION OF COPD*

Patient Category

Airflow Limitation Classification

Characteristics

A

I-II

  • mMRC 0-1
  • Low risk, less symptoms
  • CAT (COPD Assessment Test) <10
  • ≤1 exacerbations/year (without hospitalization)

B

I-II

  • mMRC ≥2
  • Low risk, more symptoms
  • CAT ≥10
  • ≤1 exacerbations/year (without hospitalization)

C

III-IV

  • mMRC 0-1
  • High risk, less symptoms
  • CAT <10
  • ≥2 exacerbations/year or with ≥1 hospitalization

D

III-IV

  • mMRC ≥2
  • High risk, more symptoms
  • CAT ≥10
  • ≥2 exacerbations/year or with ≥1 hospitalization
*Adapted from: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2021 report.

The following are used to assess the severity of a COPD exacerbation:
  • History, symptoms
  • Physical exam
  • Lab tests
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