Dr David Bellamy compares the two main COPD guidelines available, and relates their major recommendations to everyday general practice
Chronic obstructive pulmonary disease (COPD) is a common disease that affects 1–2% of the population.1 It causes persistent and worsening symptoms, impairs quality of life, and leads to 30 000 deaths each year in the UK.2 A recent major study from Copenhagen has shown that in previously fit continuous smokers, more than 25% will develop COPD over 25 years – a much higher figure than previously thought.3
COPD is significantly under-diagnosed. In a recent UK survey of 8215 smokers aged over 35 years, it was found that only 19% of those with spirometrically defined COPD reported having been diagnosed with a respiratory disease of any kind.4 Even more worrying was that for more severe spirometric COPD, only 47% had a diagnosis of lung disease, of which 63% were diagnosed with asthma.4
Now the evidence-based rationale for best management has been set out and widely publicized in UK and international guidelines on COPD.5,6 A further positive step was the inclusion of COPD in the quality and outcomes framework.7
The most widely used guideline in the UK is from NICE, which was published in 2004, with full endorsement from the British Thoracic Society.5 Increasingly, the international guideline from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) is used and is available on its website (www.goldcopd.com)6
The two sets of guidance are similar in most respects, but differ significantly in the way they define the severity of COPD with respect to spirometry (Tables 1 and 2).
|Table 1: NICE classification of COPD severity|
|Level of severity||FEV1% predicted|
|FEV1= forced expiratory volume|
|Table 2: GOLD classification of COPD severity by spirometry|
0: At risk
Cough and sputum production often precede airflow limitation by many years. Encouraging smoking cessation in patients at risk is the most important way to reduce the burden of COPD
1: Mild COPD
FEV1?80% predicted With or without chronic symptoms (cough, sputum production)
At this stage, the patient may not be aware that their lung function is abnormal
II: Moderate COPD
50% ?FEV1<80% predicted
With or without chronic symptoms (cough, sputum production)
Symptoms usually progress at this stage, with shortness of breath typically developing on exertion
III: Severe COPD
30% ?FEV1<50% predicted
With or without chronic symptoms (cough, sputum production)
Shortness of breath typically worsens at this stage and often limits patients' daily activities.
Exacerbations begin to be seen at this stage
IV:Very severe COPD
FEV1<30% predicted, or
FEV1<50% predicted plus chronic respiratory failure
At this stage, quality of life is appreciably impaired and exacerbations may be life-threatening
|*NOTE: all lung function measurements are post-bronchodilator|
Adapted from the Global Chronic Obstructive Lung Disease website: www.goldcopd.com
Goals of management
The main goals when managing COPD are:6
- preventing disease progression
- relieving symptoms
- improving exercise tolerance
- improving health status
- preventing and treating complications of COPD
- preventing and treating exacerbations
- preventing and minimizing side-effects of treatment
- reducing mortality.
Making the correct diagnosis
Diagnosing COPD relies on a GP's clinical judgement, based on a combination of the patient's history, age, physical examination, and confirmation of the presence of airflow obstruction using spirometry.5,6
It is crucial that GPs initially consider COPD as a possible cause of breathlessness or cough in any smoker or ex-smoker aged over 35 years.5,6
The key symptoms of COPD are:5
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter bronchitis
Spirometry is the gold standard for demonstrating airflow obstruction, which confirms the diagnosis of COPD.6
It should be performed at the time of diagnosis; opportunistically, not more than once per year; or to reconsider the diagnosis if patients show an exceptionally good response to treatment.5
Spirometry must be accurately performed and the doctor or nurse performing the test requires training in both the technique and interpretation of results.5,6 Equipment must be regularly calibrated and maintained to the manufacturer's standards.6
The accepted criteria for confirmation of airflow obstruction are:5,6
- forced expiratory volume (FEV)1 <80% of predicted value
- FEV1:forced vital capacity (FVC) ratio below 0.7 or 70%.
It is, therefore, strange that the corresponding figure in QOF2 is a FEV1 below 70% of the predicted value.8
Many patients with mild COPD could thus be excluded from the benefits of management, particularly relating to smoking, and yet it is this group who are likely to gain most from quitting.
There is again a slight difference in emphasis between NICE and GOLD guidance regarding reversibility testing. The NICE guideline states that there is no need to perform reversibility testing to make a diagnosis in all cases – a classic history confirmed by spirometry ought to be adequate.5 However, GOLD promotes reversibility testing to be performed as standard practice.6
QOF2 retains reversibility testing as an obligatory criterion of diagnosis.8
The main reason for performing such a test is to differentiate COPD from asthma, but this can usually be done on clinical grounds and, where necessary, by careful assessment of response to treatment. The following may be beneficial in identifying asthma:5
- FEV1 and FEV1:FVC ratio return to normal
- a very large (>400 ml) response in FEV1 to either bronchodilator or prednisolone 30 mg oral daily for 2 weeks
- serial peak flow readings showing significant (>20%) diurnal or day-to-day variability.
Classification and assessment of disease severity
Traditionally, the severity of COPD has largely been equated with the FEV1% predicted value. However, COPD is a systemic disease that may affect parts of the body other than the lungs, and so causes disability; its effect on exercise, the activities of daily living, quality of life, and mood all have a significant effect on the patient. Mild airflow obstruction can be associated with significant disability. A true assessment of severity should, therefore, not only include spirometry, but also other measurements such as:5,6
- breathlessness (using the MRC dyspnoea scale)9
- enquiry about how COPD is affecting general daily living (see Box 1)
- frequency of exacerbations
- weight loss (body mass index)
- oxygen saturation using pulse oximeter
- the presence of cor pulmonale.
|Box 1: Five simple questions to ask patients with COPD|
Since you have been on your current treatment:
Key treatment for stable disease
Smoking cessation remains a key part of COPD management as it is the only measure to affect the rate of decline of lung function.10 Patients should be asked at each clinic visit if they would like to stop smoking.5,6 If there is a positive response then help should be offered via Smokestop clinics and prescription of nicotine replacement products, or buproprion, as required.5,6 There is, however, no benefit of trying to coerce patients to quit if they are not ready to do so.
Short-acting bronchodilators, both beta2-agonists and anticholinergics, are the initial treatment for the relief of breathlessness and exercise limitation.5,6 The effectiveness of such therapies should not be assessed by lung function alone, but should include a variety of other measurements such as improvement in symptoms, activities of daily living, and exercise capacity.5,6
Patients who remain symptomatic should have their inhaled treatment intensified to include long-acting bronchodilators (both beta2-agonists and anticholinergics), or should be started on combined therapy using a short-acting beta2-agonist and a short-acting anticholinergic.5
Long-acting bronchodilators have a greater effect on symptom control, resulting in a significant improvement in quality of life scores, and having the ability to reduce the frequency of acute exacerbations.5,6
Inhaled corticosteroids should be prescribed for patients who have a FEV1 <50% of the predicted value,and who have had two or more exacerbations in the past year.5 The GOLD guideline says they should be prescribed where FEV1 <50% and the patient has experienced repeated exacerbations (three in the past 3 years).6 The aim of this treatment is to reduce exacerbations and slow the rate of decline in health status, and not to slow the rate of decline in lung function.5,6
Combining therapies from different drug classes is recommended to increase clinical benefit. This includes combinations of various bronchodilators and long-acting beta2-agonists with corticosteroids.5,6
Pulmonary rehabilitation can result in major improvements in exercise capacity and quality of life. The results can be better than with any drug therapy.6 Sadly this service is still unavailable to a large percentage of COPD patients. There are several reasons for this including: the cost, the fact that several hospitals have not set up the service, and that some needy patients are not being referred due to a lack of knowledge.
A typical programme incorporates physical training, disease education, and nutritional, psychological and behavioural intervention.6 Rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually those who are MRC grade 3 and above).5,6
Treatment of acute exacerbations
Exacerbations cause worsening of both symptoms and quality of life, and it can take as long as 2 months for symptoms to return to baseline. Once exacerbations start to occur, they tend to continue. Most patients with severe COPD have 2–3 exacerbations per year. Exacerbations requiring hospital admission are often a bad prognostic factor.6
An exacerbation is defined as a sustained worsening of the patient's symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Common symptoms are worsening breathlessness, cough, increased sputum production, and change in sputum colour.5 In primary care, pulse oximetry is encouraged to assess the clinical severity of an exacerbation.5
Primary care management of an exacerbation consists of:
- an increase in bronchodilators – consider administering via a nebulizer5
- antibiotics if sputum is purulent5,6
- prednisolone 30 mg daily for 7–14 days.5
Patients should be reviewed after 4–6 weeks, and their management optimized as appropriate.
Prevention of exacerbations
The following may help to reduce the frequency of exacerbations:5,6
- vaccinations – influenza and pneumococcal
- long-acting bronchodilators
- inhaled corticosteroids
- combined long-acting beta2-agonists and inhaled corticosteroids
- mucolytic agents
- pulmonary rehabilitation.
Self-management action plans
The main aim is to provide patients who are at risk of exacerbations with a self-management action plan that encourages them to respond promptly to symptoms of an exacerbation.5 Plans should state that a patient must:
- start oral steroids if breathlessness increases and interferes with activities of daily living
- start antibiotics if sputum becomes purulent
- adjust bronchodilator therapy to control symptoms.
Suitable patients, such as those who have had an exacerbation, should be prescribed a supply of antibiotics and corticosteroids to keep at home for use as part of a self-management strategy. Early and appropriate use of treatment may help to reduce the duration and severity of exacerbations and perhaps prevent a hospital admission. Patients should be advised to contact a healthcare professional if symptoms do not improve.5
It is important that patients with end-stage COPD and their family and carers have access to the full range of services offered by multidisciplinary palliative care teams, including admission to hospices.5
COPD is common but under-diagnosed and under-treated. Much can be done to improve symptoms, prevent exacerbations and treat exacerbations earlier and more effectively. COPD is a multisystem disease and GPs should enquire about associated psychological and social problems as standard. A positive approach can reap greater rewards for the patient and help them to lead a more fulfilling life.
- Soriano J, Maier W, Egger P et al. Recent trends in physician diagnosed COPD in women and men in the UK. Thorax 2000; 55 (9) : 789–794.fgfg
- Respiratory Alliance. Bridging the Gap – Commissioning and Delivering High Quality Integrated Respiratory Healthcare. Cookham: Direct Publishing Solutions, 2003.
- Lokke A, Lange P, Scharling H et al. Developing COPD: a 25 year follow up study of the general population. Thorax 2006; 61 (11): 935–939.
- Shabab L, Jarvis M, Britton J et al. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006; 61 (12): 1043–1047.
- National Institute for Clinical Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in primary and secondary care. Clinical Guideline 12. London: NICE, 2004.
- Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. www.goldcopd.com, 2006.
- British Medical Association. The GMS Contract. Delivering Investment in General Practice. London: BMA, 2004.
- British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
- Fletcher C, Elmes P, Fairburn M et al. The significance of symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 2 (5147): 257–266.
- Fletcher C, Peto R.The natural history of chronic airflow obstruction. Br Med J 1977; 1 (6077): 1645–1648.