Signs & Symptoms Of COPD
- COPD should be suspected in any patient who has chronic cough, sputum production or dyspnea w/ or w/o history of risk factors for the disease
A diagnosis of COPD should be considered in patients over 40 yr of age who have a suggestive medical history (ie presence of risk factors) & who present w/ any of the following:
- Chronic cough (present intermittently or daily) & sputum production of at least 3 mth in each of 2 consecutive yr
- Does not reflect the major impact of airflow limitation on the morbidity & mortality in patients w/ COPD
- Cough may be unproductive
- Exertional breathlessness, wheezing, pursed-lip breathing, dyspnea w/ or w/o wheezing
- Rhonchi, prolonged expiratory phase of respiration, chest hyperinflation, use of accessory muscles for respiration, decreased breath sounds
- Signs of cor pulmonale: Neck vein distention, increased pulmonic component of 2nd heart sound, lower extremity edema, hepatomegaly
- The absence of wheezing or chest tightness does not rule out a diagnosis of COPD
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Diagnosis
Spirometry
- Recommended measurement of airflow limitation that confirms the diagnosis of COPD
- A useful tool in the assessment of the severity of the pathological changes in COPD
- Also recommended for patients at risk of COPD, especially smokers >45 yrs old w/ cough, sputum or dyspnea & for regular follow-up of patients w/ documented COPD
- Measures forced vital capacity (FVC) & forced expiratory vol in 1 sec (FEV1)
- A decreased FEV1/FVC ratio is typically seen in patients w/ COPD
- A post-bronchodilator FEV1/FVC <70% confirms the presence of airflow limitation
- Spirometry services should be supported by quality control processes
- Lung volumes are affected by process of aging & FEV1/FVC ratio depends on age, height & sex
- The use of fixed ratio may lead to underdiagnosis in patients <45 yr esp of mild disease & overdiagnosis in patients >50 yr
- There’s a proposal that diagnosis of obstructive pulmonary disease should be based on an FEV1/FVC ratio below the lower limit of normal
- If there is no access to spirometry, COPD diagnosis may be suspected based on history, symptoms & physical signs
- Peak flow measurements may be used to rule out asthma, but not to diagnose COPD
- Has good sensitivity rate but weak specificity
- A forced expiratory time (FET) is the time for a patient to forcefully exhale through open mouth from total lung capacity until air flow is inaudible [≥6 sec is abnormally prolonged & >6 sec is an acceptable guide to presence of FEV1/FVC <50% (obstructive disease)]
- Modified Medical Research Council (mMRC) Dyspnea Scale is useful for classification, which can be used to assist in the evaluation of disease severity & functional disability
MEDICAL RESEARCH COUNCIL DYSPNEA SCALE* |
Grade |
Description |
0 |
Only experience breathlessness w/ strenuous exercise |
1 |
There’s shortness of breath when walking up a slight hill or hurrying on the level |
2 |
Walks slower than people of the same age on the level because of breathlessness or has to stop to catch a breath when walking at own pace on the level |
3 |
Stops to catch a breath after walking about 100 meters or after a few min on the level |
4 |
Too breathless to leave the house or breathless when dressing or undressing |
*Adapted from Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2015.
- COPD Assessment Test (CAT) is a short questionnaire used in routine clinical practice to gauge the health status of COPD patients
- Measures patients’ disease severity using 8 symptoms, w/ scores ranging from 0-40:
- Frequency of cough
- Chest tightness
- Limitations w/ home activities
- Presence of sleep disturbance
- Degree of presence of phlegm
- Breathlessness when climbing stairs/walking uphill
- Confidence w/ outdoor activities even if w/ COPD
- Level of energy
Other Lab Tests
Bronchodilator Reversibility Testing
- Usually performed only once at the time of diagnosis
- May help rule out asthma, establish best attainable lung function, evaluate prognosis & guide treatment decisions
- However, it may not reliably predict response to long-term bronchodilator therapy
Chest X-ray
- Useful mainly in ruling out alternative diagnoses
- May show signs of lung hyperinflation (eg flattened diaphragm), lungs hyperlucency & rapid tapering of the vascular markings
Computed Tomography (CT)
- Not routinely used but may help in excluding other possible diagnosis
- Recommended if surgical management is being contemplated
Pulse Oximetry & Arterial Blood Gas (ABG) Measurement
- Pulse oximetry should be performed in stable patients w/ FEV1 <35% predicted or w/ signs of resp failure or right heart failure
- ABG should be assessed when the peripheral saturation is <92%; should be obtained by arterial puncture
Alpha-1 Antitrypsin Deficiency Screening
- May be useful in young patients (<45 yr) who develop COPD
- Positive results may lead to family screening & counseling
- Alpha-1 antitrypsin serum concentration of <15-20% of the normal value is highly suggestive of homozygous alpha-1 antitrypsin deficiency
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Assessment Of Severity
Severity of COPD is classified based on patient’s symptoms, spirometry results, presence of complications & future risk of exacerbations
CLASSIFICATION OF AIRFLOW LIMITATION1* |
Stage |
Characteristics |
I: Mild COPD |
FEV1 ≥80% predicted
|
II: Moderate COPD |
50% ≤ FEV1 <80% predicted
|
III: Severe COPD |
30% ≤ FEV1 <50% predicted
|
IV: Very Severe COPD |
FEV1 <30% predicted
|
1Classification is based on post-bronchodilator FEV1 in patients w/ FEV1/FVC <0.7
The use of fixed ratio may lead to underdiagnosis in patients <45 yr esp of mild disease & overdiagnosis in patients >50 yr
SYMPTOM/RISK EVALUATION OF COPD* |
Patient Category |
Airflow Limitation Classification |
Characteristics |
A |
I-II |
- mMRC 0-1
- Low risk, less symptoms
|
- CAT (COPD Assessment Test) <10
- ≤1 exacerbations/yr
(w/o hospitalization)
|
B |
I-II |
- mMRC ≥2
- Low risk, more symptoms
|
- CAT ≥10
- ≤1 exacerbations/yr
(w/o hospitalization)
|
C |
III-IV |
- mMRC 0-1
- High risk, less symptoms
|
- CAT <10
- ≥2 exacerbations/yr
(w/ hospitalization)
|
D |
III-IV |
- mMRC ≥2
- High risk, more symptoms
|
- CAT ≥10
- ≥2 exacerbations/yr
(w/ hospitalization)
|
*Adapted from Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2015
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Site Of Care
- Patients belonging to category A or B may be managed on an outpatient basis during exacerbations
- Patients belonging to category C or D may require hospitalization & more aggressive management during exacerbations
Indications for Hospital Treatment for COPD Exacerbations:
- Significant increase in symptoms (eg sudden development of resting dyspnea)
- Severe underlying COPD
- Onset of new symptoms (eg cyanosis, peripheral edema)
- Absence of response to initial medical treatment
- Significant comorbidities (eg heart failure or newly occurring arrhythmias)
- Frequent exacerbations
- Older age
- Lack of home support
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Assessment Of Severity For COPD In Acute Exacerbation
The following are used to assess the severity of a COPD exacerbation:
- History, symptoms
- Physical exam
- Lab tests
Lab Tests
ABG Measurement
- PaO2 <60 mmHg &/or SaO2 <90% w/ or w/o PaCO2 >50 mmHg on room air are indicative of resp failure
- If there are no facilities to measure blood gases, SaO2 should be measured
Chest X-ray
- Helpful in patients w/ suspected pneumonia
- May be useful in identifying alternative diagnoses that can mimic symptoms of exacerbation
Electrocardiogram (ECG)
- Helpful in diagnosing right ventricular hypertrophy, arrhythmias & ischemic episodes
- Aids in the diagnosis of pulmonary embolism from COPD exacerbation, as right ventricular hypertrophy & large pulmonary arteries may lead to confusing radiographic & ECG findings
Complete Blood Count (CBC)
- May show polycythemia (hematocrit >55%) or bleeding
- White blood cells (WBC) may be elevated in patients w/ resp infection
Biochemical Tests
- May be helpful in determining the cause of exacerbation & in diagnosing other comorbid conditions (eg electrolyte imbalances, diabetic crisis, poor nutrition, acid-base disorders)
Sputum Culture
- Presence of purulent sputum during an exacerbation is sufficient basis for starting antibiotics
- Culture & sensitivity testing of sputum must be done if the patient does not respond to initial antibiotic therapy
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Assess Suitability For Discharge
Prior to discharge from the hospital, check the patient based on the following criteria:
- Able to use long-acting either beta2-agonists &/or anticholinergics w/ or w/o inhaled corticosteroids
- Inhaled beta2-agonist is needed every 4 hr or less frequently
- Able to walk across the room (if previously ambulatory)
- Able to eat & sleep w/o frequent interruptions due to breathing difficulty
- Clinically stable for 12-24 hr
- ABG stable for 12-24 hr
- Patient & caregiver adequately understand correct medication use
- Home care arrangements (eg O2 delivery) are in place
- Patient, family & physician are confident that patient can manage well
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