Diagnosis and management of COPD in a

primary care setting

Botova Svetlana Nikolaevna
Department of endocrinology and internal medicine
Federal State Budgetary Educational Institution of
Higher Education “Privolzhsky Research Medical
University ”
Definition

• COPD, a common preventable and treatable disease,

is characterized by persistent airflow limitation that
is usually progressive and associated with an
enhanced chronic inflammatory response in the
airways and the lung to noxious particles or gases

• Exacerbations and comorbidities contribute to the

overall severity in individual patients.
• That COPD is not just a disease of the lungs, but is a multi-
system disease requiring a multidimensional assessment and
holistic approach to management.

• That pharmacological and non-pharmacological therapy not

only improves current control (symptoms, health status,
activity levels) but also can reduce future risk of
exacerbations, disease progression and mortality (depending
on the intervention).
Risk Factors for COPD

Genes

Infections

Socio-economic
status

Aging Populations
Diagnosis and Assessment: Key Points

A clinical diagnosis of COPD should be considered in

any patient who has
•dyspnea,
•chronic cough or sputum production,
•history of exposure to risk factors for the disease.
Consider a diagnosis of COPD in patients who are:

1. Over 35 years
2. Smokers or ex-smokers
3. Have any of the following symptoms:
o Breathlessness on exertion
o Chronic cough
o Regular sputum production
o Frequent winter “bronchitis” or “chest infections”
o Wheeze
Differential diagnosis

1. Pulmonary
•asthma
•bronchiectasis
•sarcoidosis
•tuberculosis
•(stenosing) bronchial tumour
•Obliterative bronchiolitis
2. Extra pulmonary
•Congestive cardiac failure
 Clinical features differentiating COPD and asthma

COPD Asthma
Smoker or ex-smoker Nearly all Possibly

Symptoms under age 35 Rare Often

Chronic productive common uncommon
cough
Breathlessness Persistent and Variable over
progressive over weeks
weeks
When to refer
Diagnostic uncertainty
•no history of cigarette smoking / noxious gas exposure
•Mismatch between symptoms and objective tests
•Confounding important co-morbidities
•Any restrictive pattern on spirometry
•Severe disease at presentation or rapidly declining symptoms or
lung function
•Occupational history
•Predominant excessive sputum production
•Onset of symptoms under 40 or family history of alpha-1-
antitrypsin deficiency (A1AD)
Primary care clinicians should aim to identify
differential diagnoses, possible extrapulmonary
effects and co-morbidities by asking about the
following:

• weight loss
• effort intolerance
• waking at night
• ankle swelling
• fatigue
• occupational hazards
• chest pain
• haemoptysis
Red Flag Signs/Symptoms

Important alternative diagnoses possible (red flags)

•Haemoptysis
•Weight loss
•Acute breathlessness
•Crushing central chest pain on exertion
•Very low Sp02
•Finger clubbing and abnormality on chest x-ray
On examination, the following signs may be present:

• Hyperinflated chest
• Use of accessory muscles of respiration
• Wheeze or quiet breath sounds
• Peripheral oedema
• Raised JVP
• Cyanosis
• Muscle wasting / cachexia
As part of an initial assessment, in addition to
spirometry, patients should also have:

• Their smoking status recorded

• An estimation of their MRC dyspnea score
• A record of the number of exacerbations (courses of
steroids / lower respiratory antibiotics) in the last year
• A chest X-ray to exclude other pathology
• CBC to exclude anaemia or polycythaemia
• A calculation of their body mass index (BMI)
• Oxygen saturation (Sp02)
 Diagnosis and Assessment: Key Points

• Spirometry is required to make

the diagnosis;
• the presence of a post-
bronchodilator FEV1/FVC < 0.70
confirms the presence of
persistent airflow limitation
and thus of COPD.
Diagnosis and Assessment: Key Points

• The goals of COPD assessment are to determine the

severity of the disease, including the severity of
airflow limitation, the impact on the patient’s health
status, and the risk of future events.
• Comorbidities occur frequently in COPD patients, and
should be actively looked for and treated
appropriately if present.
Diagnosis of COPD

EXPOSURE TO RISK
SYMPTOMS FACTORS
shortness of breath
tobacco
chronic cough occupation
sputum indoor/outdoor pollution

SPIROMETRY:
Required to establish diagnosis
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Assessment of Airflow Limitation:
Spirometry

Spirometry should be performed after the

administration of an adequate dose of a short- acting
inhaled bronchodilator to minimize variability.
A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation.
Where possible, values should be compared to
age-related normal values to avoid overdiagnosis of
COPD in the elderly.
Spirometry: Normal Trace Showing FEV1 and FVC
Spirometry: Obstructive Disease
Assessment of COPD: Goals

• Determine the severity of the disease, its impact on the

patient’s health status and the risk of future events (for
example exacerbations) to guide therapy.

• Consider the following aspects of the disease separately:

 current level of patient’s symptoms
 severity of the spirometric abnormality
 frequency of exacerbations
 presence of comorbidities.
Assessment of COPD

 Assess symptoms
 Assess degree of airflow limitation using spirometry
 Assess risk of exacerbations

 Assess comorbidities
Combined Assessment of COPD

• Combine these assessments for the purpose of

improving management of COPD
Symptoms of COPD
The characteristic symptoms of COPD are
chronic and progressive dyspnea, cough, and
sputum production that can be variable from
day-to-day.

•Dyspnea: Progressive, persistent and

characteristically worse with exercise.
•Chronic cough: May be intermittent and may
be unproductive.
•Chronic sputum production: COPD patients
commonly cough up sputum.
Assess symptoms
COPD assessment test
Modified MRC (mMRC)Questionnaire
Assess degree of airflow limitation
Classification of Severity of Airflow Limitation in
COPD*

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1

Assess Risk of Exacerbations

To assess risk of exacerbations use history of

exacerbations and spirometry:
Two or more exacerbations within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk.
One or more hospitalizations for COPD
exacerbation should be considered high risk.
Assess symptoms first

• If CAT < 10 or mMRC 0-1:

Less Symptoms/breathlessness (A or C)
(С) (D)
• If CAT > 10 or mMRC > 2: More
Symptoms/breathlessness (B or D)

(А) (В)

CAT < 10 CAT ≥ 10

Symptoms
mMRC 0-1 mMRC ≥ 2
Breathlessness
 Assess risk of exacerbations next
4 ≥2
or
(GOLD Classification of

(C) (D) > 1 leading

Airflow Limitation)

to hospital
3 admission
Risk

2 1 (not leading
(A) (B) to hospital
admission)
1 0

CAT < 10 CAT ≥ 10

mMRC 0-1 • If GOLD 3 or 4 or ≥ 2 exacerbations per
mMRC ≥ 2 year or > 1 leading to hospital admission:
High Risk (C or D)

• If GOLD 1 or 2 and only 0 or 1

exacerbations per year (not leading to
hospital admission): Low Risk (A or B)
 Combined Assessment of COPD

When assessing risk, choose the highest risk

according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)

Patient Characteristic Spirometric Exacerbations CAT mMRC

Classification per year
Low Risk
A GOLD 1-2 ≤1 < 10 0-1
Less Symptoms
Low Risk
B GOLD 1-2 ≤1 > 10 >2
More Symptoms
High Risk
C GOLD 3-4 >2 < 10 0-1
Less Symptoms
High Risk >2
D GOLD 3-4 >2 > 10
More Symptoms
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Assess COPD Comorbidities
COPD patients are at increased risk for:
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
• Bronchiectasis
These comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately.
Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude alternative
diagnoses and establish presence of significant comorbidities.
Lung Volumes and Diffusing Capacity: Help to characterize severity,
but not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can be used to
evaluate a patient’s oxygen saturation and need for supplemental
oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD
develops in patients of Caucasian descent under 45 years or with a
strong family history of COPD.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Therapeutic Options: Key Points

 Smoking cessation has the greatest capacity to

influence the natural history of COPD. Health care
providers should encourage all patients who smoke to
quit.
 Pharmacotherapy and nicotine replacement reliably
increase long-term smoking abstinence rates.
 All COPD patients benefit from regular physical activity
and should repeatedly be encouraged to remain active.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

 Therapeutic Options: Key Points

 Appropriate pharmacologic therapy can reduce COPD

symptoms, reduce the frequency and severity of
exacerbations, and improve health status and exercise
tolerance.
 None of the existing medications for COPD has been
shown conclusively to modify the long-term decline in
lung function.
 Influenza and pneumococcal vaccination should be
offered depending on local guidelines.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

А-А-А-А-А algorythm
Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists (SABA)
Long-acting beta2-agonists (LABA)
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Combination long-acting beta2-agonist + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Therapeutic Options: Bronchodilators

 Bronchodilator medications are central to the

symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta2-
agonists, anticholinergics, theophylline or combination
therapy.
The choice of treatment depends on the availability of
medications and each patient’s individual response in terms
of symptom relief and side effects..
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Therapeutic Options: Bronchodilators

 Long-acting inhaled bronchodilators are convenient and

more effective for symptom relief than short-acting
bronchodilators.
 Long-acting inhaled bronchodilators reduce
exacerbations and related hospitalizations and improve
symptoms and health status.
 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.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

 Manage Stable COPD: Key Points
 Identification and reduction of exposure to risk factors
 Individualized assessment of symptoms, airflow limitation,
and future risk of exacerbations
 rehabilitation and maintenance of physical activity.
 Pharmacologic therapy

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Manage Stable COPD: Goals of Therapy

 Relieve symptoms
Reduce
 Improve exercise tolerance symptoms
 Improve health status

 Prevent disease progression

Reduce
 Prevent and treat exacerbations risk
 Reduce mortality

© 2015 Global Initiative for Chronic Obstructive Lung Disease

 Manage Stable COPD: Non-pharmacologic

Patient Essential Recommended Depending on local

Group guidelines

Smoking cessation (can Flu vaccination

A include pharmacologic Physical activity Pneumococcal
treatment) vaccination

Smoking cessation (can

Flu vaccination
include pharmacologic
B, C, D Physical activity Pneumococcal
treatment)
vaccination
Pulmonary rehabilitation
Previous strategy of COPD treatment
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and therefore not
necessarily in order of preference.)

Patient Recommended Alternative choice Other Possible

First choice Treatments
LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + LABA LAMA and LABA or
or LAMA and PDE4-inh. or SABA and/or SAMA
C
LAMA LABA and PDE4-inh. Theophylline

ICS + LABA ICS + LABA and LAMA or Carbocysteine

and/or ICS+LABA and PDE4-inh. or N-acetylcysteine
D
LAMA LAMA and LABA or SABA and/or SAMA
LAMA and PDE4-inh. Theophylline
 Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
RECOMMENDED FIRST CHOICE

C D
GOLD 4
ICS + LABA ICS + LABA 2 or more

Exacerbations per year

or and/or or
LAMA LAMA > 1 leading
GOLD 3 to hospital
admission

A B
GOLD 2 1 (not leading
SAMA prn LABA to hospital
or or admission)
GOLD 1 SABA prn LAMA
0

CAT < 10 CAT > 10

mMRC 0-1 mMRC > 2
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations

An exacerbation of COPD is:

“an acute event characterized by a worsening of the
patient’s respiratory symptoms that is beyond normal
day-to-day variations and leads to a change in
medication.”

© 2015 Global Initiative for Chronic Obstructive Lung Disease

 Manage Exacerbations: Key Points
 The most common causes of COPD exacerbations are viral upper
respiratory tract infections and infection of the
tracheobronchial tree.

 Diagnosis relies exclusively on the clinical presentation of the

patient complaining of an acute change of symptoms that is
beyond normal day-to-day variation.

 The goal of treatment is to minimize the impact of the current

exacerbation and to prevent the development of subsequent
exacerbations.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

 Manage Exacerbations: Key Points

 Short-acting inhaled beta2-agonists with or without short-acting

anticholinergics are usually the preferred bronchodilators for
treatment of an exacerbation.

 Systemic corticosteroids and antibiotics can shorten recovery

time, improve lung function (FEV1) and arterial hypoxemia (PaO2),
and reduce the risk of early relapse, treatment failure, and length
of hospital stay.

 COPD exacerbations can often be prevented.

© 2015 Global Initiative for Chronic Obstructive Lung Disease
 Manage Exacerbations: Assessments

Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa with or
without PaCO2 > 6.7 kPa when breathing room air indicates respiratory
failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
CBC: identify polycythemia, anemia or bleeding.
Purulent sputum during an exacerbation: indication to begin
empirical antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, and poor
nutrition.
Spirometric tests: not recommended during an exacerbation.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations: Treatment Options
Oxygen: titrate to improve the patient’s hypoxemia with a target
saturation of 88-92%.

Bronchodilators: Short-acting inhaled beta2-agonists with or

without short-acting anticholinergics are preferred.

Systemic Corticosteroids: Shorten recovery time, improve lung

function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk
of early relapse, treatment failure, and length of hospital stay. A
dose of 40 mg prednisone per day for 5 days is recommended.
Nebulized magnesium as an adjuvent to salbutamol treatment in
the setting of acute exacerbations of COPD has no effect on FEV1.
 Manage Exacerbations: Treatment Options

Antibiotics should be given to patients with:

1. Three cardinal symptoms:

increased dyspnea,
increased sputum volume,
and increased sputum purulence.
2. Who require mechanical ventilation.
Indications for Hospital Admission

1. Marked increase in intensity of symptoms

2. Severe underlying COPD
3. Onset of new physical signs
4. Failure of an exacerbation to respond to initial medical
management
5. Presence of serious comorbidities
6. Frequent exacerbations
7. Older age
8. Insufficient home support