COPD (Chronic Obstructive Pulmonary Disease)
- A heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnoea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction
Signs and symptoms
- Dyspnoea (on exertion)
- Chronic cough with or without sputum production +/- haemoptysis
- History of recurrent chest infections, intermittent wheezing and risk factors (smoking, environmental exposures)
- May present with chest pain, weight loss, fatigue, chest pain
- Signs: barrel chest, hyperinflation of the lungs, prolonged expiration + wheezing
- May present with peripheral oedema, hepatomegaly, raised JVP (right-sided heart failure)
Modified MRC Dyspnoea scale| Grade | Degree of Breathlessness Related to Activities |
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| 1 | Not troubled by breathlessness except on strenuous exercise |
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| 2 | Short of breath when hurrying or walking up a slight hill |
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| 3 | Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace |
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| 4 | Stops for breath after walking about 100 m for after a few minutes on level ground |
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| 5 | Too breathless to leave the house, or breathless when dressing or undressing |
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Jones et al. also proposed symptom grading by means of the CAT assessment (no symptom = 0, most severe = 40)
Investigation
- All patients with suspected COPD based on clinical signs and symptoms: spirometry with pre and post-bronchodilator measurements
- Diagnostic criterion = post-bronchodilator FEV1/FVC < 0.7
- Assessment of the degree/severity of airflow obstruction (GOLD grading)
GOLD grading| GOLD 1 | Mild | FEV1 ≥ 80% predicted |
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| GOLD 2 | Moderate | 50% ≤ FEV1 < 80% predicted |
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| GOLD 3 | Severe | 30% ≤ FEV1 < 50% predicted |
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| GOLD 4 | Very Severe | FEV1 < 30% predicted |
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- NB: diagnosis is based on the ‘absolute’ FEV1/FVC ratio whilst the severity airflow obstruction is based % of predicted values.
- Assessment of symptoms/risk of exacerbation (GOLD ABE)
- ≥ 2 moderate exacerbations or ≥ 1 leading to hospitalization per year = GOLD E
- 0-1 moderate exacerbation per year (not leading to hospitalization)
- GOLD A = mMRC 0-1 or CAT < 10
- GOLD B = mMRC ≥ 2 or CAT ≥ 10
- Other investigations: CT chest for assessment of lung volume reduction surgery, lung cancer screening and to find differential diagnosis
Management
- Initial management
- GOLD E = LABA + LAMA inhaler (consider LABA + LAMA + ICS if eosinophils ≥ 300 cells/µL
- GOLD A = single bronchodilator (LABA or LAMA)
- GOLD B = LABA + LAMA inhaler
- Still dyspnoeic despite initial management
- single bronchodilator → LABA + LAMA
- Still exacerbations despite initial management
- single bronchodilator → LABA + LAMA + ICS (if eonsinophils ≥ 300 cells/µL)
- LABA + LAMA → LABA + LAMA + ICS (if eonsinophils ≥ 100 cells/µL)
- If already on LABA + LAMA +/- ICS then consider adding azithromycin and/or roflumilast
- Non-pharmacological management
- GOLD A = smoking cessation + vaccinations
- GOLD B or E = smoking cessation + pulmonary rehabilitation + vaccinations
NB: Vaccinations = flu, pneumococcal, pertussis, COVID-19 and Shingles
- Long-term oxygen therapy if
- PaO2 < 55 mmHg or SpO2 < 88% at least twice in three weeks
- 60 > PaO2 > 55 mmHg or SpO2 = 88% + pulmonary hypertension or congestive cardiac failure or polycythaemia
Reference: GOLD Guideline 2023