Clinical Context

According to the World Health Organization, Fact Sheet No. 315, COPD affects 210 million patients throughout the world, and the mortality rate is expected to increase to more than 30% in the next decade. Persons with COPD have airflow obstruction that is not completely reversible; however, COPD might be misdiagnosed because the symptoms overlap with other medical conditions.

This review describes approaches to the diagnosis and management of COPD.

Study Highlights

  • The first step in the diagnosis of COPD is to differentiate this condition from asthma.
  • Typical features that differentiate COPD from asthma include the following:
  • Airway obstruction that is not fully reversible vs obstruction that is almost or fully reversible
  • Age of onset at middle age or older vs childhood or adolescence
  • Constant and generally progressive disease state vs variable with fluctuating symptoms
  • Hyperinflation at rest, reduced elastic recoil, and impaired diffusing capacity vs history of atopy and normal or elevated diffusing capacity
  • Symptoms of chronic and progressive dyspnea, cough, and sputum vs episodic breathlessness, wheezing, cough, and chest tightness
  • Inflammation leading to small airway disease and parenchymal destruction vs airway hyper-responsiveness
  • COPD diagnosis should be considered in all long-term smokers with shortness of breath or cardiovascular disease.
  • Comorbid respiratory tract conditions include bronchiectasis, pulmonary tuberculosis, panbronchiolitis, and bronchiogenic carcinoma.
  • Patients 40 years or older with respiratory tract symptoms or frequent respiratory tract infections should undergo a history and physical examination, along with prebronchodilator and postbronchodilator spirometry testing.
  • History should include age at onset of symptoms, limitation of activities, and exposure to tobacco and other noxious substances at work or at home.
  • Patient questionnaires based on the patient's symptoms have a poor sensitivity and specificity for a COPD diagnosis.
  • Physical examination findings of wheezing, decreased breath sounds, or prolonged expiration are not sensitive or specific for a COPD diagnosis.
  • Spirometry measurement of FEV1, forced vital capacity (FVC), and the ratio of FEV1 to FVC is the most accurate method to diagnose COPD.
  • Airway obstruction is determined by a postbronchodilator ratio of FEV1 to FVC of less than 0.7.
  • The Global Initiative for Chronic Obstructive Lung Disease guidelines define mild COPD as an FEV1 of at least 80%; moderate COPD as an FEV1 of less than 80%; severe COPD as an FEV1 of less than 50%; and very severe COPD as an FEV1 of less than 30% or less than 50%, along with chronic respiratory failure.
  • Postbronchodilator FEV1 rarely returns to normal levels in COPD but usually returns to 80% or greater of predicted levels in asthma.
  • Other diagnostic measures might include chest radiography, computed tomography, pulse oximetry, complete blood count, and an alpha1-antitrypsin deficiency test.
  • Influenza and pneumonia vaccinations should be given as indicated.
  • Management of stable COPD includes health education for patients and families, instruction on inhaler techniques, and pulmonary rehabilitation.
  • Patients should avoid tobacco, occupational dust and chemicals, air pollution, and infections.
  • Inhaler choice should be individualized based on medication need, the patient's ability to use the inhaler correctly, cost, availability of instruction, and patient preference.
  • The most commonly used inhalers are metered-dose inhalers (including pressurized and breath-activated).
  • Dry powder inhalers are easier to use than metered-dose inhalers but are unsuitable for patients with impaired inspiratory flow.
  • Nebulizers have limited role for daily use.
  • Pulmonary rehabilitation includes exercise training, self-management education, and psychosocial and nutritional education and intervention.
  • Pulmonary rehabilitation is recommended for all symptomatic patients at all disease stages.
  • Treatment of exacerbations includes increasing dose of maintenance bronchodilator, adding a second class of bronchodilator, adding oral corticosteroids, and possibly adding inhaled corticosteroids and antibiotics.
  • Referral to a pulmonary specialist is indicated if the diagnosis is not clear; the patient is younger than 40 years; and if there is a poor treatment response, an accelerated decline in lung function, frequent exacerbations despite treatment, or evaluation of the patient before surgery.

Clinical Implications

  • The most accurate method to diagnose COPD is spirometric measurement of the FEV1, FVC, and the ratio of FEV1 to FVC.
  • The main components of management of stable COPD include health education for patients and families, particularly smoking cessation; monitoring of inhaler technique; and pulmonary rehabilitation.
  • ….(Medscape)