Assess and Monitor Disease - COPD

 

Initial Diagnosis

Diagnosing COPD depends on clinical judgement based on a combination of history, physical examination, functional assessment and confirmation of the presence of airflow obstruction using spirometry.

Crucially, diagnosis depends on considering COPD in the first place. Such a diagnosis should be considered in any patient who has dyspnoea, chronic cough or sputum production, and / or a history of exposure to risk factors for the disease, especially cigarette smoking. Algorithm A shows this in greater detail. These symptoms are not diagnostic in themselves although the presence of multiple symptoms increases the likelihood of a diagnosis of COPD. Spirometry is needed to establish the diagnosis.

 

History and Assessment

  • Risk factors especially smoking history
  • Symptoms and pattern of development
  • Past medical history
  • Co-morbidities
  • History of exacerbations or previous hospitalisations for respiratory disease
  • Appropriateness of current medical treatments
  • Problems with current or previous therapies
  • Inhaler techniques
  • Impact of disease on patient's life
  • Social and family support

 

Co-Morbidities

  • Common Pathway - Diseases with common pathophysiology (smoking related diseases)
  • Complicating - e.g pulmonary hypertension
  • Intercurrent Acute illness - Respiratory tract infections
  • Systemic Co-morbidities associated with COPD - Osteoporosis, metabolic syndrome, ischaemic heart disease

 

Assessment of Severity


Assessment of COPD severity is based on :

 


Stages of COPD are based on spirometry

Stage I: Mild COPD:
Individual may not be aware that his/her lung function is abnormal. Sometimes,but not always chronic cough and sputum production.
- (FEV1 ≥ 80% predicted; Mild airflow limitation (FEV1/FVC < 70%)

Stage II: Moderate COPD:
Patients typically seek medical attention at this stage because of chronic respiratory symptoms or an exacerbation of their disease. Will have shortness of breath typically developing on exertion.
- Worsening airflow limitation (FEV1 50% to 80% predicted :FEV1/FVC < 70%), with shortness of breath typically developing on exertion.

Stage III: Severe COPD:
(FEV1 30% to 50% predicted: FEV1/FVC < 70%), Further worsening of airflow limitation with greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on a patient' quality of life.

Stage IV: Very severe COPD:
(FEV1< 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure; FEV1/FVC < 70%;).
- Severe airflow limitation with at this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening

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MRC Dyspnoea Scale

 
Grade 1 Not troubled by breathlessness except on strenuous exercise
Grade 2 Short of breath when hurrying or walking up a slight hill
Grade 3 Walks slowe than contemporaries on level ground because of breathlessless, or has to stop for breath when walking at own pace
Grade 4 Stops for breath after walking about 100m or after a few minutes on level ground
Grade 5 Too breathless to leave the house or breathless when dressing or undressing

 

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BODE Index

BODE index

A number of composite scores have been developed to better characterise severity in patients with COPD. The most accepted is the BODE index.

Variables and Point Values Used for the Computation of the Body- Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity (BODE) Index.

Additional Investigations

Bronchodilator reversibility testing:
To rule out a diagnosis of asthma

Chest X-ray: Seldom diagnostic in COPD but valuable to exclude alternative diagnoses, and identify co morbidities such as cardiac failure

Arterial blood gas measurement: Perform in patients with FEV1< 50% predicted or with clinical sign suggestive of respiratory failure or right heart failure.

Pulse Oximetry

Alpha-1 antitrypsin deficiency screening: Perform when COPD develops in patients under 45 years or with a strong family history of COPD

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