diagnosis and assessment of chronic obstructive pulmonary ... · iii or iv by the time of diagnosis...
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Diagnosis and assessment of Chronic Obstructive Pulmonary Disease: COPD
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Definition of COPD
COPD = chronic obstructive pulmonary disease
GOLD 2017 (http://www.goldcopd.org/)
▪ COPD is defined by GOLD as:‘a common, preventable and treatable disease that is characterized by persistent
respiratory symptoms and airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure to noxious particles or gases’
▪ Chronic airflow limitation in COPD is caused by a combination of:• Small airways disease (bronchiolitis)
• Parenchymal destruction (emphysema)
• The relative contributions of each vary from person to person
▪ Major risk factors for developing COPD are:• Tobacco smoking
• Exposure to occupational, outdoor and indoor air pollution (e.g. burning wood)
▪ Exacerbations and comorbidities contribute to overall severity in
individual patients
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22%
28%29%
21%
40–49 years
50–59 years
60–69 years
>70 years
COPD does not just affect elderly adults
AARC 20031. Landis SH. Int J Chron Obstruct Pulmon Dis 2014;9:597–611
2. American Lung Association 2013
N=4,343
COPD, chronic obstructive pulmonary disease.
Figure adapted from Confronting COPD in America
▪ 50% of patients with COPD in the USA are <65 years old1
▪ COPD prevalence is increasing in younger age groups,
particularly in women2
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Despite objective measures and diagnosis guidelines, COPD is under-diagnosed globally
GOLD Stage I+
GOLD Stage II+
Doctor-diagnosed COPD
Pe
rce
nt
30
25
20
15
10
5
0
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
Buist S et al. Lancet 2007;370:741–50
▪ BOLD study showed that fewer patients are diagnosed with COPD than actually have COPD
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COPD is not usually diagnosed until it is clinically apparent and moderately advanced
ADL = activities of daily living; COPD = chronic obstructive pulmonary disease; HRQoL = health-related quality of life
1. Celli BR et al. Eur Respir J 2004;23:932–46
2. Jones RCM, et al. Lancet Respir Med 2014
3. Lundbäck et al. Eur Respir J 2003;21(Suppl. 40):3s–9s
4. Decramer M et al. Respir Med. 2011;105:1576–87
▪ COPD is usually not diagnosed until it is clinically apparent
and moderately advanced1,2
▪ By the time COPD is diagnosed, often ≥50% of lung function
has been lost and need for healthcare utilization is high2,3
▪ Although airway obstruction may be very mild in early COPD,
patients often have significant impairment of HRQoL and
reduced ADL4
• Many individuals consider breathlessness and low exercise tolerance
as features of ageing
• Smoker’s cough may be regarded as normal
• Affected individuals often do not request medical attention
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One third of patients have progressed to GOLD Stage III or IV by the time of diagnosis
COPD severity at initial spirometry-confirmed diagnosis1
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
1. Jones RCM, et al. Lancet Respir Med 2014
2. Mapel DW, et al. Int J Chron Obstruct Pulmon Dis 2011
13%
45%25%
17%
GOLD 1
GOLD 2
GOLD 3
GOLD 4
▪ UK retrospective, cohort
study1
• 22,821 patients >40 years
• Data collected during
1990–2009
• Coded diagnosis of COPD in
primary care records
▪ 42% GOLD Stage 3 or 4 by
time of diagnosis
▪ Similar effect was noted in
study of US Lovelace
Patient Database2
• 31% of patients had GOLD
Stage 3 or 4 at diagnosis
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COPD and asthma are distinct conditions that can be differentiated from each other
COPD = chronic obstructive pulmonary disease
GOLD 2017 (http://www.goldcopd.org/)
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Diagnosis of COPD
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity
GOLD 2017 (http://www.goldcopd.org/)
▪ Diagnosis of COPD should be considered in patients aged >40 with
dyspnea, chronic cough or sputum production and/or a history of
exposure to risk factors
▪ Spirometry is required to make the diagnosis of COPD
• The presence of post-bronchodilator FEV1/FVC <0.70 confirms the presence of
persistent airflow limitation, and therefore confirms COPD in patients with
appropriate symptoms and significant exposure to noxious stimuli
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Symptoms, a history of risk factors, and spirometry all contribute to the diagnosis of COPD
SPIROMETRY: required to
establish diagnosis
Symptoms
Dyspnea
Chronic cough
Chronic sputum
Risk-factor history
Host factors
Tobacco
Occupation
Indoor/outdoor pollution
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity
GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017 (http://www.goldcopd.org/)
▪ Consider COPD if symptoms and/or a history of risk factors are present
▪ Confirm the diagnosis with spirometry (post-bronchodilator FEV1/FVC <0.70)
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Spirometry is the gold standard for the diagnosisand assessment of COPD
▪ Patients with COPD typically show a decrease in FVC and FEV1
The presence of a postbronchodilator FEV1/FVC <0.70 and
FEV1 <80% predicted confirms the presence of airflow limitation
that is not fully reversible
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity;
GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017 (http://www.goldcopd.org/)
FEV1 FVC FEV1/FVC
Normal 4 L 5 L 80%
COPD 1.8 L 3.2 L 56%
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Obstructive lung disease has a characteristically different spirometry loop to ‘normal’
The first landmark reached is the PEFR. The first blast of air exhaled from
the patient reaches this flow rate almost immediately. The flow rate then
quickly slows as more air is exhaled. This landmark is very important in
judging if the patient is giving maximal effort, overall quality of the test,
strength of expiratory muscles, and the condition of the large airways, such
as the trachea and main bronchi.
This illustration shows the variety of flow volume loop shapes that often
relate to particular disease. When looked at in relation to the lung volume
further clinical information can be revealed.
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Flo
w (
Litre
s/s
ec)
6
4
2
0
–2
–4
–6
–8
Volume
(Litres)
Flo
w (
Litre
s/s
ec)
Volume
(Litres)
PEFR
8
6
4
2
0
–2
–4
–6
–8
10
NormalEmphysema
Bronchitis
FEF25
FEF50
FEF75
FIF25FIF50
FIF75
1 2 3 4 5 6
FEV0.5 FEV1 FEV3 FVC
FEV = forced expiratory volume; FVC = forced vital capacity; FIF = forced inspiratory fraction; PEFR = peak expiratory flow rate
http://www.morgansci.com/choose-your-pft-solution/what-is-a-pft-test/static-and-dynamic-spirometry.php
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GOLD 2017: assessing symptoms and exacerbation risk to determine appropriate treatment
CAT = COPD Assessment Test; COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity;
GOLD = Global Initiative for Chronic Obstructive Lung Disease; HRQoL = health-related quality of life; mMRC = modified Medical Research Council
GOLD 2017 (http://www.goldcopd.org/)
▪ Spirometry should be conducted first to determine the severity of airflow limitation (GOLD Grade 1–4)
▪ Either dyspnea or symptoms should be then be assessed, followed by recording of exacerbation history
(including prior hospitalizations), to determine GOLD Group (A–D) and subsequent appropriate
pharmacological treatment
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Conclusions
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity ; GOLD = Global Initiative for Chronic
Obstructive Lung Disease
1. American Lung Association 2013
2. Buist S et al. Lancet 2007;370:741–50
3. Mapel DW et al. Int Journal of COPD 2011;6:573–81
4. Jones RCM et al. Lancet Respir Med 2014;2:267–76
5. GOLD 2017 (http://www.goldcopd.org/)
▪ COPD prevalence is increasing in younger age groups, particularly in
women1
▪ Despite objective measures and diagnosis guidelines, COPD is under-
diagnosed globally2
• One third of patients have GOLD stage III or IV COPD by the time of
diagnosis3,4
▪ Diagnosis of COPD should be considered based on the presence of
symptoms and risk factors5
• Spirometry is the gold-standard for diagnosis of COPD, and is required for the
assessment of airflow limitation severity and prognosis5
• Assessment of symptoms and exacerbation risk as required to determine
GOLD Group and for the selection of appropriate pharmacological treatment5