This tool is designed to support family physicians and primary care nurse practitioners in identifying and managing COPD in adult patients (≥ 18 years).
Chronic obstructive pulmonary disease (COPD)
Screening and diagnosis
Early screening for COPD in the general population using questionnaires and risk assessment has been useful in identifying persons at risk for COPD. However, screening asymptomatic patients for COPD is not recommended. If patients have symptoms including cough, sputum production, difficulty breathing, or wheezing, then screening can be used for early detection.
Screen adult patients presenting with symptoms for COPD using questionnaires and risk assessment to support early detection.
Patients must have at least 1 respiratory symptom and 1 risk factor to be qualified for the diagnosis of COPD.
Respiratory symptoms
Risk factors
- Exertional breathlessness
- Chronic cough
- Regular sputum production
- Frequent winter ‘bronchitis’/recurrent lower respiratory tract infections
- Chronic wheeze
- Chest tightness
Symptoms of COPD are similar to those of asthma. However, COPD is unlikely in patients younger than 40 and diagnosis is dependent on history of exposure to risk factors.
- Current or past tobacco smoking
- Exposure to secondhand 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
Comorbidities
Rule out the following comorbidities before confirming diagnosis of COPD:
- Asthma
- Anxiety and/or depression
- Cardiovascular disease
- Diabetes
- GERD
- Musculoskeletal disorders
- Malignancies
- Osteoporosis
- Pulmonary embolism
Spirometry
Use forced spirometry to establish a diagnosis of COPD in patients who screen positive for symptoms and risk factors.
Spirometry measures forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). To diagnose COPD, use spirometry by measuring air flow before and after the administration of an inhaled bronchodilator. A post-bronchodilator FEV1/FVC ratio ≤ 0.7 confirms the diagnosis of COPD. Although spirometry should be done within 3 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.
Interpretation of spirometry results
GOLD Grades and severity of airflow obstruction
GOLD 1: mild
FEV1 ≥80% predicted
GOLD 2: moderate
50% ≤ FEV1 < 80% predicted
GOLD 3: severe
30% ≤ FEV1 < 50% predicted
GOLD 4: very severe
FEV1 < 30% predicted
Assessment
Once COPD has been diagnosed, evaluate the severity and magnitude of disease by assessing degree of disability, past medical history, and previous history of moderate and severe exacerbation.
Degree of disability (UM)
Degree of COPD related disability depends on symptom severity, and can be measured using:
- Clinical frailty scale (CFS)
- COPD assessment test (CAT)
- Medical Research Council (MRC) Dyspnea Scale
Past Medical History
Assess a patient’s medical history by assessing:
- Patients’ exposure to risk factors (smoking, environmental exposures)
- Past medical history including early life experiences
- Asthma, allergy, sinusitis, nasal polyps, HIV, tuberculosis
- Family history of COPD
- Frequency and history of exacerbation or previous hospitalizations for respiratory disorder
- Presence of comorbidities
Exacerbation
Exacerbation are associated with increased rates of hospitalization, 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 a hospital admission or ED visit
Pharmacological management
Selecting Therapy
Chose medications based on availability, 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 comorbidities, and managing breathlessness.
Bronchodilators (GOLD)
Inhaled bronchodilators are the mainstay of drug therapy for symptom management and often given regularly to prevent or reduce COPD symptoms. Inhaled bronchodilators are often given as a metered dose, soft mist, or dry powder inhaler.
Beta-2 agonists
Antimuscarinic drugs
There are short acting beta-2 agonists (SABA) and long-acting beta-2 agonists (LABA).
- Give SABAs as needed relief of episodic dyspnea and initial treatment of exacerbation. SABAs effects wear off within 4-6 hours, but regular and as-needed use improve FEV1 and symptoms.
- LABAs show a duration of action of 12 or more hours, and do not provide any additional benefit from as-needed SABA therapy.
There are short acting anti-muscarinic (SAMAs) and long acting anti-muscarinic (LAMAs).
- Short-acting muscarinic antagonists (SAMAs) should not be given as short-acting relief in those also prescribed long-acting muscarinic therapy due to the cumulative anticholinergic side effects.
- Long-acting muscarinic antagonists (LAMA) improve symptoms, and the effectiveness of pulmonary rehabilitation while also reducing exacerbation and hospitalizations.
Choosing initial therapy
Choose initial medication based on past exacerbations and severity of disease.
0-1 moderate to severe exacerbation in the past year
0-1 moderate to severe exacerbation in the past year
>2 moderate to severe exacerbation with at least 1 hospital admission in the past year
CAT <10, mMRC 0-1
CAT ≥ 10, mMRC ≥2
CAT ≥ 10, mMRC ≥ 2
Initiate treatment with a long-acting bronchodilator (LABA or LAMA)
Initiate treatment with either a LABA or LAMA
Initiate treatment with LABA + LAMA
Long-acting is preferred, however; if patient experiences very occasional breathlessness, short-acting can be used.
Combination therapy is superior to monotherapy, however; combination therapy is not always appropriate.
Consider adding inhaled corticosteroid (ICS) to LAMA + LABA if patient has had 2 moderate exacerbation within a year, with one requiring hospitalization.
All patients with COPD should be provided with short acting bronchodilator PRN
Note: Combining bronchodilators that have different mechanisms and durations of action can increase bronchodilation with a lower side effect risk. LAMA and LABAs significantly improve lung function, dyspnea, health status, and reduce exacerbation rates in comparison to monotherapy. There are numerous combinations of LABA and LAMA in a single inhaler available. (GOLD)
Click to view inhaled medication options for COPD.
Maintenance therapy New
Assess patients COPD based on symptoms and history of exacerbations. The main treatment goals during maintenance of COPD are reduction of symptoms and future exacerbations.
Note:
- step down from combination therapy is not recommended, especially if the individual is at high risk of exacerbation
- assessment of inhaler technique and adherence should happen at every visit.
Oral medications (GOLD)
Consider oral medications only if patient has maximized use of inhaler therapies:
Macrolide antibiotics
In patients experiencing increased exacerbation in one year with high symptom burden, give azithromycin or erythromycin to reduce the risk of future exacerbation.
Give Azithromycin 250mg/day or 500mg three times per week, or Erythromycin 250mg two times a day for 1 year in patients prone to exacerbation.
Mucolytic agents (NICE)
Consider mucolytic agents for patients with chronic cough productive of sputum and continue if there is symptomatic improvement. Regular treatment with mucolytics such as Carbocysteine and N-acetylcysteine reduce exacerbation and modestly improve health status.
Roflumilast
Consider Roflumilast if patient has FEV1 <50%, especially if they have experienced at least 1 hospitalization for an exacerbation in the past year.
Systemic glucocorticoids
Although systemic glucocorticoids should be given to patients experiencing COPD exacerbation, it is not recommended as long-term therapy.
Exacerbation management
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
Ruling out
Rule out confounders or contributors in patients with suspected COPD exacerbation:
- Pneumonia
- Pulmonary embolism
- Heart failure
- Less commonly: pneumothorax, myocardial infarction
Treatment
When treating COPD exacerbation, the goal of treatment is to minimize the negative impact of the current exacerbation and prevent subsequent events.
- Give an increased dose of SABA as the initial bronchodilator to treat the exacerbation. Initiate maintenance therapy with LABA when the patient becomes stable.
- Consider inhaled corticosteroid in patients with frequent exacerbation.
- In patients with severe exacerbation, systemic corticosteroids should be given to reduce treatment failure, and improve lung function and breathlessness. Limit duration to be no more than 5 days.
- Consider antibiotics when there are signs of bacterial infection. Do not use antibiotics as prophylaxis for COPD exacerbation. However, it may be considered if patient is experiencing high symptom burden with triple inhaled therapy.
Follow up after an exacerbation
Follow-up within 2-4 weeks after hospital discharge should be completed when possible. Additional follow-up at 3 months is recommended to ensure the patient is stable and to re-evaluate lung function with spirometry.
At every follow up, assess the following:
- The ability of the patient to cope with their usual environment
- Review the patient’s ability to understand their treatment regimen
- Reassess inhaler technique
- Current symptom burden via CAT or mMRC
At the 3-month follow-up:
- Measure spirometry – a decline in FEV1 can be easily tracked by spirometry when performed at regular intervals (most commonly to do yearly) to identify patients who are declining
Therapy Considerations
AECOPD contributes to a decline in lung function, poor health status, and increased susceptibility to repeated exacerbations which results in increased morbidity and mortality with COPD. Smoking cessation, immunization, and pulmonary rehabilitation have been shown to improve lung function and reduce exacerbations.
The long-term administration of oxygen increases survival and decreases hospitalization in patients with severe chronic resting hypoxemia. Administer long-term oxygen therapy for stable patients who:
- Have an oxygen saturation ≤88% with or without hypercapnia confirmed twice over a 3-week period; or
- Have an oxygen saturation of 88% if there is evidence of pulmonary hypertension or peripheral edema.
Once placed on oxygen therapy, re-evaluate patients every 60-90 days (about 3 months) with repeat arterial blood gas and oxygen saturation measurements.
Adherence to therapy is a challenging issue in COPD. Inhaled therapy adherence is a multifaceted issue affected by several factors including social, environmental, cognitive ability, manual dexterity, and coordination skills. Non-adherence leads to inadequate symptom control, heightened exacerbation risk, increased healthcare usage and costs, and reduced quality of life. To address this, collaborate with pharmacists, nurses, and other physicians to enhance inhalation technique and adherence through patient interventions. Consider minimizing the variety and number of inhalers to mitigate non-adherence challenges.
Treatment given through inhalation requires education on proper inhalation techniques and training on the inhaler device which is crucial for optimal outcomes. Inhaled medications come in many devices that differ in size and portability, preparation steps, actuation force, drug delivery time, and maintenance requirements. The choice of drug delivery system significantly impacts treatment benefits and adherence. It is imperative to collaboratively select the most suitable drug delivery system for the patient while considering device characteristics and the patients’ abilities, goals, and preferences. If the patient is already proficient in using a specific inhaled therapy device, prescribe new therapy using the same device when possible.
Although inhaled therapy is the keystone of management for patients, the propellants in metered-dose inhalers (MDIs) are powerful 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 inhalers like dry powder inhalers (DPIs) and soft mist inhalers (SMIs) that are kinder to the environment and have a lower carbon footprint due to their lack of these greenhouse gases. Not all patients can use DPIs or SMIs, so ensuring they have proper use of their MDIs not only benefits the patient but also the environment.
Non-pharmacological management
Patient education
Patient education is important for patients to understand the nature of their disease, risk factors for progression, and is crucial to achieving optimal management and health outcomes. This includes teaching patients how to use their inhalers properly and use oxygen devices correctly. The general aim of patient education is to help cope with COPD as best as possible.
Non-pharmacological management
COPD patients often exhibit decreased physical activity, starting a detrimental cycle of inactivity that puts them at risk of higher hospitalization rates, decreased quality of life, and mortality. It is imperative to promote exercise training since it enhances physical activity levels of COPD patients.
- Smoking cessation is the single most important intervention to slow the rate of functional decline in COPD.
- Cigarette smoking is a key environmental risk-factor for COPD, as it is associated with a higher prevalence of respiratory symptoms, lung function abnormalities, and a greater rate in decline in FEV1 and mortality.
- Advise smokers to quit and assist them in doing so. At every opportunity, advise and encourage each patient with COPD who is smoking to stop, and offer help to do so.
In COPD, low BMI and diminished fat-free mass are associated with worse outcomes. Those with COPD who are malnourished may gain substantial benefits from nutritional supplementation including weight gain which can enhance respiratory muscle strength and overall improvement in quality of life. Recommending antioxidant supplementation with Vitamin C, Vitamin E, zinc, and selenium have been shown to improve antioxidant deficits, quadriceps strength, and serum total protein. Nutritional supplementation has shown significant improvements in respiratory strength, walk tests, and health status for malnourished patients. Consider referral to a dietician.
Recommend the following vaccinations to all patients with COPD:
- Influenza vaccine: killed or live inactivated vaccines are more effective in elderly patients.
- SARS-CoV-2: The CDC recommends that COVID vaccination should be given to people with COPD.
- Pneumococcal vaccine: Give one dose of the 20-valent pneumococcal conjugate vaccine, or one dose of the 15-valent pneumococcal conjugate vaccine followed by 23-valent pneumococcal vaccine for COPD patients.
- Tdap: It is now recommended that all patients with COPD are protected against pertussis (whooping cough), tetanus and diphtheria.
- Shingles: Routine vaccination is recommended.
- RSV: Give COPD patients ≥60 years old vaccination to reduce exacerbation of COPD.
Encourage patients with high symptom burden and risk of exacerbation to partake in a formal, rehabilitation program. Pulmonary rehabilitation includes exercise training, combined with disease-specific education improves exercise capacity, symptoms, and quality of life among all grades of COPD severity. It should be considered as part of integral patient management as it has been shown to be the most effective therapeutic strategy to improve shortness of breath, health status, and exercise tolerance.
It is important to educate all patients on avoiding irritants and knowing how to deal with exposure, including:
Outdoor air pollution: advise patients to wear a mask whenever possible, especially when exposed to chemical agents, fumes, and greenhouse gases.
Secondhand smoke: encouraging patients to avoid any passive smoke and avoiding areas populated by smokers.
Indoor air pollution: advising patients to avoid chemicals, being mindful of ventilation, dust, wood-burning sources of heat, etc.
Follow-up
Routine follow up with COPD patients is essential in identifying and monitoring lung function. At each follow up, symptoms, exacerbation, and measures of airflow should be monitored to determine when to modify management. Management should have a continuous cycle of review, assessing, and adjusting medications, as necessary. This may involve increasing therapy, decreasing therapy, or switching inhaler device or medications. A decline in FEV1 can be easily tracked by spirometry when performed at regular intervals (most commonly to do yearly) to identify patients who are declining.