Chronic obstructive pulmonary disease (COPD)

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This tool is designed to support family physicians and primary care nurse practitioners in identifying and managing COPD in adult patients.

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Initial assessments and diagnosis

Case finding1-4

Case finding for COPD in the general population has been helpful in identifying persons to screen for COPD. Screen adult patients presenting with symptoms of COPD to support early detection.

Patients are clinically suspected of having COPD if they have at least 1 respiratory symptom and 1 risk factor.
Respiratory symptoms
  • Exertional breathlessness  
  • Chronic cough  
  • Regular sputum production 
  • Frequent winter ‘bronchitis’/recurrent lower respiratory tract infections  
  • Chronic wheeze 
  • Chest tightness  
Risk factors
  • Current or past tobacco smoking  
  • Exposure to second-hand smoke
  • Exposure to cannabis smoke   
  • Smoke from home cooking and heating fuels
  • Occupational dusts, vapors, fumes, gases, and other chemicals  
  • Host factors (genetic, developmental abnormalities, low birthweight, prematurity, childhood respiratory infections)

Symptoms of COPD are similar to those of asthma. However, COPD is unlikely in patients younger than 40 and diagnosis is dependent on a history of exposure to risk factors.

Diagnosis1-4

Spirometry

In patients who screen positive for symptoms and risk factors, use forced spirometry to establish a diagnosis of COPD.

  • Spirometry measures forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before and after administering an inhaled bronchodilator. 
  • A post-bronchodilator FEV1/FVC ratio ≤ 0.7 confirms the diagnosis of COPD. 

Although spirometry should be done within three months of developing symptoms, if access to spirometry is a barrier and there is a high degree of suspicion of COPD in a patient, therapy may be started on speculation.

Differential diagnosis

Rule out the following conditions before confirming a diagnosis of COPD: 

  • Anemia 
  • Asthma* 
  • Bronchiectasis 
  • Cardiovascular disease 
  • Interstitial lung disease   
  • Neuromuscular disease   
  • Obesity  
  • Tuberculosis 

*Differentiating asthma from COPD in adults may be clinically difficult but is important as they differ in first-line therapies and chronic management. Asthma can present as wheezing and chest tightness that is common at night, whereas COPD can present as morning cough that produces phlegm. Additionally, patients with asthma are more likely to have allergic or atopic dermatitis (eczema).

Evaluate severity of disease1-4

Once COPD has been diagnosed, evaluate the severity and magnitude of the disease by assessing the degree of disability, past medical history, and previous history of moderate and severe exacerbation.

Degree of disability

The degree of COPD related disability depends on symptom severity, and can be measured using:

COPD assessment test (CAT)
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COPD assessment test (CAT)

CAT

CAT score interpretation:

>30: very high
>20: high
10-20: medium
<10: low

Modified medical research council (mMRC) dyspnea scale
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Modified medical research council (mMRC) dyspnea scale

mMRC

Severity of airflow obstruction
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The severity of airflow obstruction is measured using:

CAT

    Medical history
  • Exposure to risk factors (smoking, environmental exposures).
  • Past medical history including early life experiences (e.g. asthma, allergy, sinusitis, nasal polyps, HIV, tuberculosis).  
  • Family history of COPD.
  • Assess and manage the following comorbidities:
    • Anemia   
    • Anxiety/depression   
    • Cancer   
    • Diabetes   
    • Heart failure/ischemic heart disease  
    • Hypertension  
    • Malnutrition  
    • Metabolic syndrome   
    • Osteopenia   
    • Osteoporosis   
    • Peripheral muscular dysfunction   
    • Sleep apnea 
Physical examination
  • Auscultation   
  • Signs of lung hyperinflation, accessory muscle use   
  • Signs of generalized muscle wasting   
  • Ankle swelling (heart failure)   
  • Cachexia, malnutrition 
Previous history of moderate and severe exacerbation

Exacerbation is associated with increased rates of hospitalization and disease progression and can vary greatly between patients. Identifying patients with frequent past exacerbation will help to identify the severity of disease and those susceptible to exacerbation.  

Classification of severity
  • Mild exacerbation: new or worsening respiratory symptoms without a change in any medications 
  • Moderate exacerbation: sustained worsening of respiratory status that requires systemic corticosteroids and/or antibiotics  
  • Severe exacerbation: rapid deterioration of respiratory status that requires a hospital admission or ED visit 
Risk of acute exacerbation

The best way of identifying the severity of disease and patients susceptible to exacerbation is through exacerbation history: 

  • Low risk of exacerbation:  ≤1 moderate exacerbation in the past year and did not require ER visit or hospitalization  
  • High risk of exacerbation:  ≥ 2 moderate or ≥1 severe exacerbation in the last year, requiring hospital admission or ED visit
Physical examination
  • Auscultation   
  • Signs of lung hyperinflation, accessory muscle use   
  • Signs of generalized muscle wasting   
  • Ankle swelling (heart failure)   
  • Cachexia, malnutrition 

Pharmacological management

Selecting therapy

Choose medications based on cost and clinical response balanced with side effects. Individualize the treatment regimen as the relationship between symptom severity, airflow obstruction, and exacerbation severity differs with each patient. Initial management should address reducing exposure to risk factors, managing comorbidity, alleviating dyspnea (mMRC), improving health status (CAT), reducing the risk of acute exacerbation and mortality.

Choosing initial therapy4

Choose initial medication based on past exacerbation and severity of disease. 

* Low AECOPD risk = ≤1 moderate AECOPD in the last year (moderate AECOPD is an event with prescribed antibiotic and/or oral corticosteroids) and did not require hospital admission/ED visit
** High AECOPD risk = ≥2 moderate AECOPD or ≥1 severe exacerbation in the last year
† A single inhaler containing a combination of medications is preferred; however, separate inhalers may be used based on patient preference. LAMA+LABA is generally preferred over ICS+LABA (except in patients with concomitant asthma) because of additional improvements in lung function and the lower rates of adverse events such as pneumonia.
‡ Oral agents include prophylactic macrolide/PDE-4 inhibitor/mucolytic agents.
§ Consider stepping down to LAMA + LABA if LAMA + LABA + ICS did not result in improved symptoms or health status or because of adverse effects of significant importance.
†† Short-acting bronchodilators include SABAs (short-acting beta-2 agonists) and SAMAs (short-acting antimuscarinics), and are used for as needed relief of episodic dyspnea. SAMAs should not be given as short-acting relief in those also prescribed long-acting muscarinic therapy due to the cumulative anticholinergic side effects.
LAMA = long-acting antimuscarinic agent
LABA = long-acting beta-2 agonist 
ICS = inhaled corticosteroid 

Combining bronchodilators that have different mechanisms and durations of action can increase bronchodilation with a lower side effect risk. The combination of LAMA + LABA significantly improves lung function, dyspnea, health status, and reduces exacerbation rates in comparison to monotherapy with a LAMA or LABA. There are numerous combinations of LABA and LAMA in a single inhaler, which is preferable to using two separate inhalers.2

Additional considerations affecting inhaler selection

Poor adherence could lead to: 

  • Inadequate symptom control  
  • Heightened exacerbation risk,   
  • Increased healthcare usage and costs  
  • Reduced quality of life  
  • Increased risk of adding inappropriate therapy

To improve adherence:

  • Consider minimizing the number and variety of inhalers (e.g., using combination inhalers)  
  • Check whether cognitive ability, dexterity, or inspiratory flow may be limiting a patient’s ability to use an inhaler  
  • Consider using pharmacists, nurses and/or certified respiratory educators (CRE) to counsel the patient 
  • Select a drug delivery device that is appropriate for the patient’s cognitive ability, hand and lung strength, and preferences 
  • If a patient already knows how to use a particular device and requires additional therapy, consider prescribing a therapy that is delivered in the same type of device. 
  • Helpful questions to ask when considering delivery device: 
    • Can the patient perform a quick, deep voluntary inhalation?  
      • If ‘no’ – all except DPI are re viable options  
      • If ‘yes’ – all devices are options 
    • Can sufficient inspiratory flow be achieved?  
      • If ‘no’ – MDIs favoured over DPIs (may need spacer)
      • If ‘yes’ – all devices are options  
    • Does the patient have sufficient hand-lung coordination?  
      • If ‘no’ – DPIs favoured over MDIs and SMIs   
      • If also ‘no’ to above 2 questions – may need to use a spacer compatible device (MDI or SMI)
      • If ‘yes’ – all devices are options
  • The propellants in metered-dose inhalers (MDIs) are potent greenhouse gases and have a large carbon footprint contributing to climate change
  • HFC-134a and HFC-227ea propellants are replacing CFCs in MDIs and are found to be powerful greenhouse gases 
  • Choose dry powder inhalers (DPIs) and soft mist inhalers (SMIs) that are kinder to the environment and have a lower carbon footprint if appropriate for a patient 
  • If choosing MDIs, consider recommending the use of a spacer to make the MDI device more effective by allowing medicine to get directly to the lungs and reduce environmental exposure

Maintenance therapy1,4

Review the patient’s risk of exacerbation, symptom burden, and comorbidities at least annually. 

Goals of treatment for stable COPD

Reduce symptoms* 

  • Relieve symptoms (mMRC) 
  • Improve health status (CAT) 
  • Improve exercise tolerance 

Reduce risk* 

  • Prevent disease progression 
  • Prevent and treat exacerbation
  • Reduce mortality 

* For patients at low risk of exacerbation, the primary focus is on reducing symptoms and improving health status. For patients at high risk of exacerbation, the focus is on reducing symptoms and risk.

If patient is not achieving goals of therapy:

  • Check inhaler technique and adherence 
  • Optimize non-pharmacological measures 
  • Optimize pharmacological therapy (consider increasing dose, switching inhalation device, or stepping up therapy – see Choosing Initial Therapy) 

Oral medications1,2,4

Oral medications may be considered (in consultation with a specialists) if a patient has maximized use of inhaler therapies (additional use details below). 

Macrolide antibiotics (azithromycin)

  • Use: consider in appropriate* patients who continue to experience exacerbation despite treatment with LAMA + LABA + ICS (triple therapy)
  • Note: conduct regular ECG monitoring before and during use to monitor for QTc interval prolongation-related clinical events (stop or do not start azithromycin if QTc >450 in males or >470 in females) 

*Appropriate patients have normal QT interval, no significant drug interactions with concomitant medications, and no evidence of active or indolent infection with atypical mycobacteria 

Mucolytic agents (n-acetylcysteine)

  • Use: consider for patients with chronic cough productive of sputum and continue if there is symptomatic improvement

PDE-4 inhibitor (roflumilast) 

  • Use: consider for patients treated with LAMA + LABA + ICS (triple therapy) who have FEV1 <50%, especially if they have experienced at least 1 hospitalization for an exacerbation in the past year
  • Note: monitor patients for weight loss, and neuropsychiatric effects including suicidality. Assess the potential of drug interactions as well

Systemic glucocorticoids (prednisone) 

  • Use: should be given to patients experiencing a COPD exacerbation
  • Note: not recommended as long-term therapy

Exacerbation management

Acute exacerbation of COPD (AECOPD) are defined as increased dyspnea and/or cough and sputum that worsen in less than 14 days and is often associated with increased inflammation and may be accompanied by tachycardia and/or tachypnea.1,4,8

Prevent

Preventing AECOPD is important because they contribute to a decline in lung function, poor health status, and increased susceptibility to repeated exacerbation which results in increased morbidity and mortality. 

To reduce AECOPD risk:

  • Encourage smoking cessation  
  • Encourage measures to prevent respiratory infections, such as vaccination, handwashing, and mask wearing 
  • Refer for pulmonary rehabilitation (for patients with a high symptom burden and AECOPD risk) 
  • Optimize pharmacological therapy

Assess

Watch for the warning signs of a COPD flare up including: 

  • Unusual increase in shortness of breath  
  • Increased cough  
  • Increase in the amount, thickness, or stickiness of phlegm (may also be a change in colour) 
  • Extreme fatigue

Rule out

In patients with suspected COPD exacerbation, rule out confounders or contributors:

  • Pneumonia  
  • Pulmonary embolism 
  • Heart failure  
  • COVID-19
  • Less commonly: pneumothorax, myocardial infarction, cardiac arrhythmias 

Treat early

  • Provide patients with a COPD action plan with self-management education so they can recognize signs of an AECOPD and seek treatment early (ideally within 48 hours), which reduces hospitalization.  
  • Advise patients to call or visit a doctor if symptoms persist or worsen after 48 hours in spite of patient-initiated treatment.    

Choose an appropriate treatment when managing AECOPD: 

  • Continue the patient’s existing COPD therapy (which may include long-acting bronchodilators with or without ICS) 
  • Increase dosage of SABD (SABA preferred; add SAMA if not improving promptly on SABA) 
  • Consider a course of systemic corticosteroids*. 
  • Add antibiotics* if the patient has increased sputum purulence with increased sputum volume and/or increased dyspnea. The choice of antibiotic should be based on local resistance patterns, comorbidities, sputum volume and purulence, and history of antibiotic use in the past 3 months. 

*Oral, or intravenous if unable to take oral medications. Generally, a 5-day course is preferred. 

When can a patient be treated as outpatient versus when is hospital care required?

Potential indications for hospitalization include:

  • Severe symptoms such as dyspnea at rest, high respiratory rate, decreased oxygen saturation, drowsiness and confusion 
  • Acute respiratory failure  
  • The onset of new physical signs (peripheral edema)  
  • Failure to respond to initial medical management  
  • Presence of serious comorbidities (heart failure, new arrhythmias, etc.)  
  • Insufficient home support

Follow-up after an exacerbation

Follow-up within two to four weeks after hospital discharge and again at three-months. Refer to pulmonary rehabilitation as soon as possible after discharge (ideally patients should start the program within one month of discharge).

At every follow-up, assess the following:  

  • Ability to cope with their usual home environment  
  • Ability to understand their treatment regimen  
  • Inhaler technique  
  • Current symptom burden via CAT or mMRC  

At the three-month follow-up: 

  • Measure spirometry – a decline in FEV1 can be easily tracked by spirometry when performed at regular intervals (most commonly yearly) to identify patients who are declining 

Patient self-management and education

Patients and their caregivers should receive verbal and written education to support self-management.1-3,8

Resources
Physical activity
  • Encourage patients to think about which activities they prefer and set goals related to these 
  • Exercise programs may be available through local community, recreation and seniors centres 
  • Additional supports include: The Lung Health Foundation virtual Fitness for Breath classes and exercise videos 
  • Pulmonary rehabilitation should be encouraged for patients with high symptom burden and risk of exacerbation. Pulmonary rehabilitation includes exercise training, which, combined with disease-specific education, improves exercise capacity, symptoms and quality of life among all grades of COPD severity 
Smoking cessation
Vaccinations
  • Influenza vaccine (OHIP covered)
  • SARS-CoV-2 (OHIP covered)
  • Pneumococcal vaccine – consult current recommendations
  • RSV (OHIP covered for high risk individuals 60+ and may be purchased for others 60+)
  • TD (booster) – every 10 years (OHIP covered)
  • Shingles (OHIP covered for those between 65-70 years old)
  • Patients can track their vaccinations using the Vaccination Tracker from the Canadian Lung Association

Advance care planning

  • Having good advance care planning can reduce anxiety for patients and their families and provides an opportunity to offer emotional support.8   
  • Hospitalization may act as a natural trigger to initiate discussions with patients and their families on advance care planning – including advance directives and resuscitation.8
Patient resource
  • Documentation templates, step-by-step conversation guides, and resources for providers related to advance care planning in Ontario: Hospice Palliative Care Ontario
  • Information, tools, and resources for patients and caregivers related to advance care planning in Ontario: Speak up Ontario

Coordination of care

Patients with COPD would benefit from a collaborative approach involving providers across a variety of expertise such as physicians, nurses, pharmacists and dieticians to facilitate the implementation of effective management approaches and support self-care to reduce the risk of re-hospitalization and exacerbation, improve quality of life, and reduce mortality. Routine follow up with patients with COPD is essential in identifying and monitoring lung function.9 

Follow-up with a respirologist may be considered in those with severe disease, supplemental oxygen dependence and frequent severe exacerbation to consider invasive treatment options.9

References

  • [1]

    Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease [Internet]. 2023. Available from: www.goldcopd.org

  • [2]

    Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of chronic obstructive pulmonary disease (version 3.0). 2021.  

  • [3]

    National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2019 Jul 26;1–77.

  • [4]

    Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Beauchesne MF, B. Kermelly S, et al. 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2023 Jul 4;7(4):173–91. 

  • [5]

    Canadian Pharmacists Association. Compendium of pharmaceuticals and specialities.

  • [6]

    Cataldo D, Hanon S, Peché RV, Schuermans DJ, Degryse JM, De Wulf IA, et al. How to choose the right inhaler using a patient-centric approach? Adv Ther. 2022;39(3):1149–63.  

  • [7]

    Panigone S, Sandri F, Ferri R, Volpato A, Nudo E, Nicolini G. Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment. BMJ Open Respiratory Research. 2020 Mar 1;7(1):e000571.

  • [8]

    Ontario Health. Chronic obstructive pulmonary disease: Care in the community for adults [Internet]. 2023. Available from: https://www.hqontario.ca/evidence-to-improve-care/quality-standards/view-all-quality-standards/chronic-obstructive-pulmonary-disease

  • [9]

    Expert opinion.