Early detection and diagnosis
Early detection: spirometry for all smokers over 40 and patients with acute bronchitis.
- Spirometric tests should be carried out on all patients with suspected COPD to provide a firm diagnosis of COPD. COPD shows minimal reversibility of FEV1.
- Reversibility testing is important in determining the diagnosis and the optimum treatment. ( Bronchodilator reversibility testing should be done in all patients
- Corticosteroid reversibility testing should be done in patients with moderate to severe disease or those with mild disease who use a bronchodilator more than once a day to detect those who would benefit from regular inhaled corticosteroids.
- Reversibility is present if FEV1 rises by 200ml and 15% after either nebulised bronchodilators, 2 weeks of prednisolone 30mg or 6 weeks of inhaled beclomethasone 500mcg bd or equivalent.
- A high degree of reversibility indicates a large component of asthma in the disease and also a much better prognosis than does a low degree of reversibility.
- Consider a diagnosis of COPD in patients aged over 35 years who have a risk factor (generally smoking) and present with exertional breathlessness, chronic cough, regular sputum production, frequent winter "bronchitis" or wheeze.
- Measure post-bronchodilator spirometry to confirm the diagnosis of COPD.
- Consider alternative diagnoses or investigations in:
- Older people without typical symptoms of COPD where the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7
- Younger people with symptoms of COPD where the FEV1/FVC ratio is 0.7.
- Assess the severity of airflow obstruction according to the reduction in FEV1
- Disability related to COPD can be poorly reflected in the FEV1. A more comprehensive assessment of severity includes the degree of airflow obstruction and disability, the frequency of exacerbations, and the following known prognostic factors: breathlessness (Medical Research Council dyspnoea scale)
Classification of severity of airflow obstruction (when post-bronchodilator ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7)
*Symptoms should be present to diagnose COPD in people with mild airflow obstruction.
Or when FEV1 <50% is accompanied by respiratory failure.
- Stopping smoking is one of the most important components of COPD management and is the only proved way of slowing the progression of the disease
- The drug treatments supported by the best evidence are inhaled anticholinergics and inhaled beta2 agonists
- A combination of these drugs is better at improving the forced expiratory volume in one second (FEV1) than either treatment alone
- Long term domiciliary oxygen therapy may improve survival in patients with moderate to severe hypoxaemia
- Mucolytic drugs can reduce the duration and frequency of exacerbations in people with chronic bronchitis
- Offer pulmonary rehabilitation to all patients who consider themselves functionally disabled by COPD (usually Medical Research Council grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina, or had a recent myocardial infarction.
The COPD escalator
|Classification of treatments for patients with COPD|
|Likely to be beneficial|
|Trade off between benefits and harms|
|Unlikely to be beneficial|
- Step steroids up to 100mcg/day then step down.
- Ipratropium up to 80mcg 4 times a day.
- Nutrition: BMI
- Vaccination: flu and pneumococcal
- FEV1 or QoL as measure of improvement
- Long term domiciliary O2: if FEV1 < 1.5 and O2 sat < 90-92% consider arterial blood gas measurement. Domiciliary O2 if PaO2 < 8.0kPa.
Cardiac failure and COPD
Four easily assessable clinical items (history of ischaemic disease, laterally displaced apex beat, high body mass index, and raised heart rate) provide independent diagnostic information about the presence or absence of concomitant heart failure in the individual primary care patient with COPD
The addition of natriuretic peptide measurements and electrocardiography further increases the accuracy of the diagnosis