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Diagnosis and management of COPD
Research Fellow and General Practitioner, University of Southampton and Christchurch, UK
E-mail: lynchajjr{at}aol.com
Chronic obstructive pulmonary disease (COPD) is characterized by an airflow obstruction and is caused by a mixture of small airways disease and emphysema. Emphysema is the breakdown of alveoli and results in a reduced area for oxygen transfer. ‘Small airways disease’ is the narrowing of the small airways due to chronic or repeated inflammation, scarring and blocking by mucous secretions. The contribution of emphysema and small airways disease to COPD varies between patients but the clinical significance of this is not yet known.
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Aetiology |
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Ninety-five percent of COPD is caused by smoking, with 10–20% of smokers developing COPD. Other causes are environmental and occupational factors such as dusts, chemicals or air pollution. Alpha-1 antitrypsin deficiency is a cause of COPD at a young age (Box 1).
| Box 1. Alpha-1 antitrypsin deficiency Alpha-1 antitrypsin (
The
Consider screening those with COPD under the age of 40 and screen first-degree relatives of those affected for
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1-AT) deficiency is an autosomal recessive condition. About 75 different alleles have been identified. The most defective is the ZZ genotype, present in 1 : 1600 of the population in Denmark and probably about 1 : 5000 in the UK. This increases the risk of developing COPD under the age of 40 in non-smokers. The SS genotype commonly found in Spain, Italy and Latin America increases the risk of COPD in smokers. |
Mortality |
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One in five people in the UK die from respiratory disease and COPD is the third largest cause of respiratory deaths, accounting for around 30 000 deaths per year in the UK. It is estimated that 99 000 working years are lost due to early respiratory death. Slightly more men than women die from COPD. There is also a wide variation in death rate according to social class: men aged 20–64 in unskilled manual occupations are 14 times more likely to die from COPD than men of the same age in professional roles. Overall, deaths from respiratory disease in the UK are higher than the European Union average, especially in women.
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Morbidity and costs |
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Respiratory disease as a whole results in 24 million GP consultations per year costing £501 million. It makes up 7% of all hospital admissions, 13% of all emergency admissions and 10% of all hospital bed days—a fifth of this is due to COPD which accounts for more than 1 million hospital bed days per year. Respiratory disease accounts for 7% of all prescribed drugs. In addition, 25 million days are lost from work each year, excluding self-certified sick leave, costing an estimated £1728.5 million.
| The GP curriculum and COPD General practice is the initial point of contact for most patients and it is important that GPs are aware of the prevalence of COPD and are able to identify high-risk groups. However, other causes of breathlessness must always be considered, in particular indications for urgent referral of suspected lung cancer. Once diagnosed, most mild and moderate COPD can be managed in primary care, co-ordinating care with other health professionals with the aid of disease registers and data recording. Cessation of smoking is a key issue and this needs to be communicated to the patient by identifying their health beliefs and using these to bring about change. Patients should be fully involved in their care management and empowered to self-manage their condition where possible while having access to up-to-date evidence-based treatment information and advice when needed. Regular, systematic reviews of patients help to identify the stage of the disease and prepare patients in advance for increased treatment needs such as nebulizers and oxygen therapy. Doctors need to be aware and sensitive to the social and psychological impact COPD can have on the patient, family, friends and employers and these aspects should be addressed on a regular basis. GPs in training are required to be able to do the following key practical skills:
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Diagnosis of COPD |
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Diagnosis of COPD is based on the history and evidence of irreversible airflow limitation on spirometry. It should be considered in all smokers over the age of 35 who present with at least one of the symptoms listed in Table 1. Studies have shown that 27% of smokers or ex-smokers over the age of 35 who present with chronic cough will have COPD. Opportunistic case finding of these patients in primary care is likely to be cost-effective if those with COPD are then targeted with an intensive smoking cessation programme. The respiratory differential diagnosis of COPD includes asthma, lung cancer, infection and bronchiectasis, but also consider cardiovascular and other non-respiratory causes of respiratory symptoms (Table 2).
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Red flag symptoms
Red flag symptoms include the following:
- acute shortness of breath
- haemoptysis
- chest pain
- rapid weight loss and/or
- hoarseness
Patients should be referred to be seen within 2 weeks by a specialist respiratory team if they have
- Persistent haemoptysis and are smokers or ex-smokers aged 40 years or over
- Chest X-ray suggestive of lung cancer, including pleural effusion and slowly resolving consolidation
- Normal chest X-ray where there is high suspicion of lung cancer
- History of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious lung pathology
Patients should be referred for an urgent chest X-ray if they have
- Haemoptysis
- Any of the following if unexplained or present for more than 3 weeks:
- Cough
- Chest and/or shoulder pain
- Dyspnoea
- Weight loss
- Chest signs
- Hoarseness (refer urgently to be seen by an ENT surgeon if the chest X-ray is normal)
- Finger clubbing
- Cervical or supraclavicular lymphadenopathy
- Features suggestive of metastases from a lung cancer, for example secondaries in the brain, bone, liver or skin
- Cough
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Testing |
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There is not one definitive test to confirm COPD; however, a combination of history, spirometry and exclusion of other causes can lead to a confident diagnosis.
Spirometry
Spirometry can be used for diagnosis of COPD, assessing severity and predicting prognosis but is not good at predicting the quality of life. It cannot be used alone to differentiate COPD from asthma. Spirometry can often be carried out in the practice by an appropriately trained practice nurse. The measurements are repeated three times to ensure that they are reproducible and the following parameters should be obtained:
- FEV1: volume of air the patient can exhale in the first second of forced expiration
- FVC: total volume of air the patient can forcibly exhale in one breath
- FEV1/FVC: ratio of FEV1 to FVC expressed as a percentage.
At least two of the readings should be within 100 ml or 5% of each other and these can then be compared to a table of normal values (Table 3). A diagnosis of airflow obstruction can be made if:
- FEV1/FVC is less than 0.7 (70%) and
- FEV1 is less than 80% of predicted. Note that patients should not be classified as having COPD for the purposes of the Quality and Outcomes Framework (QOF) if FEV1 is more than 70% of that predicted.
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If the spirometer used produces a flow–volume curve, a diagnosis of airways obstruction is supported by a characteristic shape of that curve (Fig. 2).
Reversibility testing can help to distinguish asthma from COPD. The patient is given a bronchodilator or a 2-week course of prednisolone (30 mg daily). Clinically significant COPD is not present if FEV1 and FEV1/FVC return to normal after reversibility testing or there is a greater than 400 ml increase in FEV1. Other features which can be used to differentiate asthma and COPD are shown in Table 4.
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Peak expiratory flow rate
Peak flow rate cannot be used to diagnose COPD but may be helpful in distinguishing COPD from asthma and for monitoring progress. There is little diurnal or day-to-day variation of peak expiratory flow rate (PEFR) in patients with COPD compared to those with asthma; so serial home measurements can help distinguish between the two conditions. However, normal PEFR values do not exclude airflow obstruction.
Chest X-ray
Chest X-rays should be carried out on all patients with suspected COPD on first presentation to exclude other diagnoses such as lung cancer. X-rays may show hyperinflation of the chest (Fig. 3). Repeat X-ray should also be carried out if the patient presents at a later date with red flag symptoms (see above), rapid deterioration with no apparent cause or fails to respond to treatment.
Blood tests
Symptoms of COPD can be exacerbated by anaemia or result in secondary polycytheamia and therefore it is worth checking a full blood count. Salbutamol can result in hypokalaemia and potassium levels should be monitored in patients who are using large amounts of salbutamol or salbutamol in combination with other hypokaleamic medications. Other blood tests such as thyroid function tests should only be carried out if there are other clinical indications.
Body mass index
Both overweight and underweight patients can be compromised and therefore weight needs to be monitored and the patient treated as necessary. Obesity will reduce exercise tolerance and amplify symptoms while cachexia is a sign of severe disease and nutritional supplements may be needed.
Other investigations
Other investigations to be considered, if indicated, include testing for alpha-1 antitrypsin if there is early onset or a family history, ECG and/or echocardiography if cor pulmonale is suspected, and sputum culture if the patient has persistent purulent sputum.
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Management |
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The aims of management are to minimize symptoms and impact on lifestyle, reduce progression and to prevent or limit exacerbations. Most management can be carried out in a GP clinic by a GP, or practice nurse with specialist training. The current QOF includes points for the management of COPD in primary care including a register of patients with COPD, diagnosis by spirometry with reversibility testing, recording of smoking status and smoking cessation advice in last 15 months, influenza vaccination during previous winter, records of FEV1 and inhaler technique checked in last 27 months (Table 5).
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Frequency and content of reviews will depend on the patient, but all patients should be reviewed at least annually with six monthly reviews for those with more severe symptoms (Table 6). A suggested plan of a review is shown in Fig. 4 and this includes all monitoring needed for the current QOF points; however, reviews should be adapted to suit individual patient needs. At each review:
- Check the patient's symptoms since last seen. Use objective measures where possible so that progression can be monitored (Table 7).
- Record smoking status of patients with COPD—advice smokers to stop
- Record any exacerbations or change in symptoms since last seen
- Record body mass index
- Check medication—use of medication, concordance (prescription count), inhaler technique, problems and/or side effects
- Annual influenza vaccination should be offered to all patients with COPD, and pneumococcal vaccination if not previously vaccinated
- Review objective measures of lung function such as spirometry and oxygen saturation, if available. Compare with previous values and values at diagnosis.
- Review mood—depression is common in patients with severe COPD
- Review the need for referral for specialist care
- Address any problems or queries and educate the patient about COPD
- Check all benefits the patient and/or carer is eligible for have been applied for and that the patient and carer are coping at home. Consider referral for occupational therapy and/or social services assessment if appropriate.
- Agree management goals and a date for further review.
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Self-management |
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Self-management education
A patient with COPD spends on average 3 hours a year with a health professional—the other 8757 hours, the patient manages his or her own condition. Helping patients with chronic disease understand and take responsibility for their condition is imperative. Brief, simple education linked to patient goals is most likely to be successful. Include information about the nature of COPD, nature of the treatment and how to use it, self-assessment, recognition of acute exacerbations and the patient's own goals of treatment. The British Lung Foundation (Tel: 08458 50 50 20; website: www.lunguk.org) provides a great deal of well-prepared information for patients. User-led self-management education programmes can be helpful and are becoming increasingly available through the expert patient scheme (accessed through website: www.expertpatients.co.uk).
Written action plan
Management of any chronic disease should be viewed as a partnership between the health professional and patient. Management will only be effective if the medical knowledge and experience of the doctor can be integrated with the patient's own views, beliefs, attitudes and experience to form a common plan of action (Fig. 5).
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Focus on individual needs. Include information about features which indicate when COPD is worsening and what to do under those circumstances. Action plans help patients recognize exacerbations and start medication sooner. However, it is not clear whether this translates into reduced morbidity, mortality or health costs.
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Non-drug therapy |
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Smoking
Stopping smoking is the most important way to improve outcome and should be encouraged at every opportunity (Fig. 6). Bupropion, varenicline or nicotine replacement therapy (if not contraindicated) can be used with a support programme. If it is not successful, then the patient should be reassessed at six monthly intervals.
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Vaccination
Influenza and pneumococcal vaccinations are recommended for all patients with COPD.
Pulmonary rehabilitation
Pulmonary rehabilitation can increase exercise capacity and physical endurance, and it can reduce breathlessness and improve self-esteem and independence. It also benefits the NHS by reducing GP home visits and the number of days spent in hospital. Provision is variable around the country but, if a service is available, refer motivated patients who consider themselves functionally disabled (usually MRC dyspnoea scale 3 and above). Patients with milder symptoms should be encouraged to exercise either through exercise on prescription schemes or by increasing normal activity.
Nutrition
Survival is correlated with maintaining body weight and muscle mass and in severe disease nutritional supplements may be necessary to maintain weight. Consider referral to a dietician for advice if this cannot be managed in primary care. Obese patients should be encouraged to loose weight to reduce respiratory effort.
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Drug therapy for stable COPD |
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Patients with mild COPD may only need to stop smoking to improve symptoms. For all other patients, use a stepwise approach (Fig. 7). Stop therapy if it is ineffective.
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Delivery device
Use a metred dose inhaler if possible and consider adding a spacer if the patient finds activation difficult. Before altering treatment, ensure patients are using the correct inhaler technique.
Consider nebulizers for patients who continue to have distressing or disabling symptoms despite maximal usage of inhalers. Trial initially for 2–3 weeks and only continue if there is an improvement in symptoms, activities of daily living, exercise capacity or lung function. Nebulizers are not available on the NHS in England or Wales but are free of Value Added Tax (VAT). Some are available in Scotland on form GP10A. Anticholinergics need to be delivered via a mouthpiece but otherwise let the patient choose whether to use a face mask or mouthpiece. Provide clear instructions on the use of the nebulizer, monitoring and when to seek help.
Frequent exacerbations
If the patient has two or more exacerbations over a year, and an FEV1 of 50% or less, add inhaled corticosteroids and a long-acting beta-2 agonist. The aim of this is to decrease the frequency of exacerbations. It is worth giving these patients a course of antibiotics and steroids to keep at home and to use at first signs of an exacerbation.
Mucolytic therapy
Consider a trial of mucolytic therapy if the patient has a chronic productive cough but only continue if there is evidence of benefit.
Oxygen
Oxygen should only be prescribed after evaluation by a respiratory physician. Long-term oxygen therapy (LTOT) is indicated in patients with an arterial partial pressure of oxygen of less than 7.3 kPa when stable. Refer patients for consideration of LTOT if they have
- severe airflow obstruction
- an FEV1 of less than 30% (consider referral if FEV1 is 30–49%)
- cyanosis
- polycythaemia
- peripheral oedema
- raised jugular venous pressure or
- an oxygen saturation (SaO2) of less than 92% when breathing air.
Supply of home oxygen varies across the UK. In England and Wales, it must be prescribed on a home oxygen order form and faxed to the supplier. A list of suppliers is available in the British National Formulary. Choice of supplier depends on geographical area. Specify the amount of oxygen required (in hours per day) and the flow rate. Specify any special needs or preferences. For patients with home oxygen concentrators, request backup cylinders in case of power cuts or breakdown. Obtain the patient's consent to pass the details on the form to the supplier and the local fire brigade. The supplier contacts patients to make arrangements for delivery, installation and maintenance of the equipment and trains patients to use it.
In Scotland, refer patients for assessment by a respiratory consultant. If the need for a concentrator is confirmed, the consultant will arrange for the provision of a concentrator through the Common Services Agency. Prescriptions for oxygen cylinders and accessories are dispensed by pharmacists contracted to provide domiciliary oxygen services. In Northern Ireland, oxygen concentrators and cylinders should be prescribed on form HS21. Oxygen concentrators are supplied by a local contractor; oxygen cylinders and accessories are dispensed by pharmacists contracted to provide domiciliary oxygen services.
Anxiety and depression
Anxiety and depression are common in COPD patients and screening should be part of the review process. Offer support and treatment as appropriate; this can include medications and/or talking therapies.
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Treatment of exacerbations |
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Exacerbations can be associated with increased breathlessness, increased sputum volume and sputum purulence. Initial management should include increased frequency of bronchodilator, by a nebulizer if necessary. Add oral antibiotics if there is purulent sputum, and prednisolone (30 mg daily) for 7–14 days if there is a significant increase in breathlessness. Features that should prompt consideration of hospital admission are listed in Table 8. If managed at home monitor with pulse oximetry if available, establish optimum therapy, and arrange appropriate reviews. Hospital-at-home provision may be appropriate for some patients who would otherwise be admitted to hospital.
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Secondary care referrals for COPD patients |
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 TOPAetiologyMortalityMorbidity and costsDiagnosis of COPDTestingManagementSelf-managementNon-drug therapyDrug therapy for stable...Treatment of exacerbations Secondary care referrals for... References |
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Generally, urgency of referral depends on clinical state. Urgent referrals should always be made for patients with haemoptysis who are aged over 40 and are smokers or ex-smokers. Other patients who may need to be referred urgently are those with a rapid decline in FEV1, uncertain diagnosis or severe COPD.
Specialist care should also be sought for patients with cor pulmonale, those with frequent infections, patients aged under 40 or those with suspected alpha-1 antitrypsin deficiency. In addition, secondary care referral may be necessary to access treatment options. For example, secondary care assessment is essential prior to prescription of LTOT and advisable before starting long-term oral steroids or long-term nebulizer therapy. Specialist respiratory referral may also be required to access pulmonary rehabilitation services depending on local arrangements.
Key points
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References |
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Alpha-1 UK. UK Alpha-1 Antitrypsin Deficiency Support Group. Available from: www.alpha1.org.uk/ [date last accessed 16.12.2007].
British Thoracic Society. Pulmonary rehabilitation survey. Available from: www.brit-thoracic.org.uk/c2/uploads/PulRehamJUN03.pdf [date last accessed 16.12.2007].
British Thoracic Society Guideline Group. Intermediate care—Hospital-at-home in chronic obstructive pulmonary disease: British Thoracic Society guideline. In: Thorax (2007) 62:200–210. Available from: www.thorax.bmj.com/cgi/content/full/62/3/200 [date last accessed 16.12.2007].
Chapman S, Robinson G, Stradling J. Chronic obstructive pulmonary disease. In: Oxford handbook of respiratory medicine (2005) 1st Edition. Oxford: Oxford University Press. 115–129.
Department of Health. Quality and Outcomes Framework. Available from: www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare/Primarycarecontracting/QOF/DH_4125653 [date last accessed 16.12.2007].
Gupta R, Limb E. Burden of lung disease. (2006) 2nd edition. British Thoracic Society. Available from: www.brit-thoracic.org.uk/Library/BTSPublications/BurdenofLungDiseaseReports/tabid/164/Default.aspx. [date last accessed 16.12.2007].
Lynch J, Simon C. Oxford GP library: respiratory problems (2007) Oxford: Oxford University Press.
Makita H, Nasuhara Y, Nagai K, et al. Characterisation of phenotypes based on severity of emphysema in chronic obstructive pulmonary disease. Thorax (2007) 62:932–937.
National Institute for Clinical Excellence. Chronic obstructive pulmonary disease (2004) Available from: www.nice.org.uk/guidance/index.jsp?action=byID&;o=10938 [date last accessed 16.12.2007].
National Institute for Clinical Excellence. Referral guidelines for suspected cancer (2005) Available from: www.nice.org.uk/guidance/index.jsp?action=byID&;o=10968 [date last accessed 16.12.2007].
Royal College of General Practitioners. RCGP curriculum—respiratory problems. Available from: www.rcgp-curriculum.org.uk/PDF/curr_15_8_Respiratory_problems.pdf [date last accessed 16.12.2007].
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