Approach to chronic obstructive pulmonary disease in primary care

Case description

A 58-year-old female smoker presents complaining of dyspnea associated with chronic cough and sputum production during the winter months. Her general health is good, and she is not taking any medications. She recently took early retirement to spend more time golfing but finds she is too short of breath to play more than 9 holes even though she now has the time. She gets breathless walking up a slight hill. She is 1.64 m tall, weighs 65 kg, and has a body mass index of 24. Results of respiratory and cardiac examinations are normal. Chest radiography shows hyperinflation. Office spirometry reveals moderate airflow obstruction.

Sources of information

PubMed was searched from January 2000 to December 2007 using the key words COPD, practice guidelines, randomized controlled trials, therapy, and health outcomes. The Canadian Thoracic Society’s guideline on management of COPD was reviewed extensively, and some of the references published before 2003 were gathered from this document. The approach we describe was developed based on the clinical experience of the authors and is supported by evidence when referenced. Generally, the recommendations on pharmacologic and nonpharmacologic therapy are based on data from randomized controlled trials (level I evidence).

Screening and diagnosis

Screening can be carried out with simple office spirometry. All smokers and ex-smokers 40 years old and older should be screened. Screening with spirometry is underused in primary care, and health care providers should consider developing a way of identifying smokers and ex-smokers in their practices in order to ensure that these patients are offered screening for COPD. Ways to identify these patients include flagging charts or using computerized reminders, particularly during periodic health visits. A recent prospective observational study that screened 818 smokers older than 40 with no known diagnosis of COPD found a prevalence of COPD of 18.9%.8 More than 40% of those with COPD had moderate to severe impairment in lung function. These results are consistent with those of other studies that have reported a prevalence of COPD of 7.4% to 18% in general practice.9,10 Preliminary results from the multinational Burden of Obstructive Lung Disease (BOLD) study demonstrated a prevalence of COPD of 10.7% based on a forced expiratory volume of air in 1 second (FEV₁) of < 80% and an FEV₁–forced vital capacity ratio of < 0.7.11 Spirometry is inexpensive and is supported financially through most provincial health care programs. Although the cost-effectiveness of office spirometry has not been established,12 the early diagnosis it provides will identify patients who require more aggressive interventions aimed at smoking cessation and allow implementation of pharmacologic and nonpharmacologic therapy.

A diagnosis of COPD requires a postbronchodilator FEV₁–forced vital capacity ratio of < 0.7. If this parameter normalizes over time, then the diagnosis must be withdrawn and an alternative diagnosis considered.1

Classification of severity and prognosis

Once the diagnosis is confirmed, patients should be carefully evaluated to identify factors contributing to the disease, the effect of COPD on their lives, and prognosis (Table 1). Potential systemic manifestations of the disease must be identified, as they might strongly influence decisions about treatment. These systemic manifestations include pulmonary hypertension and cor pulmonale, coronary artery disease, hypercapnia, osteopenia or osteoporosis, peripheral muscle dysfunction and low body mass index, depression and anxiety, and concomitant eosinophilic bronchitis.

Traditionally, the severity of COPD has been classified based on the degree of reduction in FEV₁. While FEV₁ is a useful measure, it does not accurately predict capacity for exercise13 or survival as well as other measures, such as formal laboratory-based exercise testing or symptoms of dyspnea.14 Measures other than FEV₁ should be used to establish disease severity in primary care practice. These measures include evaluating the degree of dyspnea using the modified Medical Research Council (MRC) dyspnea scale15 or BODE index.

Dyspnea is a frequent symptom in COPD, and a simple classification scheme modified from the MRC dyspnea scale (Table 215) can assist in identifying the severity of disease.1 The scale can be easily and efficiently applied in an office setting.

Chronic obstructive pulmonary disease is a major cause of morbidity and mortality. The long-term prognosis in most patients indicates progressive deterioration in lung function and increased systemic manifestations. Severity of dyspnea and capacity for exercise are more predictive of mortality than FEV₁ is.14,16 The BODE index17 is a multidimensional tool that has been shown to predict survival based on body mass index (< 21 is associated with greater mortality), FEV₁ (airflow obstruction), degree of dyspnea (MRC grade), and capacity for exercise (6-minute walk distance). The BODE score is useful in establishing prognosis and severity of disease,17,18 is responsive to respiratory rehabilitation,19 predicts risk of hospitalization for COPD patients better than FEV₁ does,20 and is sensitive to change following exacerbations.21 In primary care, the BODE score gives an estimate of prognosis and, therefore, might be helpful in determining which patients should be considered for more aggressive therapy and follow-up. The BODE index is also useful for identifying response to certain interventions. Patients who have high BODE scores (indicating worse prognoses) might benefit from discussions about end-of-life care and referral to palliative care specialists.

A BODE score is easy to calculate and should be determined for each patient with COPD; it requires measurement of body mass index, spirometry, a 6-minute walk test, and evaluation of MRC dyspnea grade (Table 317). A higher score (out of 10) indicates a worse prognosis. The mortality hazard ratio associated with a 1-unit change in score is 1.34.

Approach to management

It is crucial for physicians to be positive and supportive. Disease-specific education is important for all patients with chronic illnesses. If formal education programs are not available, information booklets on COPD are useful and are available through most provincial lung associations.

Nonpharmacologic therapy for COPD includes smoking cessation, yearly influenza vaccine, pneumonia vaccine every 5 to 10 years, and oxygen therapy (if patients have resting daytime hypoxemia). Smoking cessation counseling should be offered to all patients who continue to smoke. Cessation rates are higher when counseling is combined with smoking cessation aids, such as nicotine replacement therapy22 or newer therapies including bupropion or varenicline.23

The benefits of pulmonary rehabilitation are well recognized1,24 and include decreased dyspnea, increased capacity for exercise, and better quality of life. The main limiting factors are patients’ motivation, the availability of rehabilitation programs, and failure to refer. It is now recognized that patients with all levels of disease can be enrolled in pulmonary rehabilitation programs, although those with more severe muscle weakness and exercise intolerance and less ventilatory limitation are likely better candidates.25 The role of education in COPD management has gained greater importance with the recognition that education and self-management programs substantially reduce the number of nonscheduled clinic visits, emergency room visits, and hospital admissions.26 We recommend that all patients with COPD receive counseling on the importance of regular structured physical activity. Patients should be encouraged to increase their physical activity and recognize that dyspnea is not a sign of harm.

There have been several recent advances in pharmacologic therapy for COPD. Chronic obstructive pulmonary disease is not asthma, and the role of bronchodilator therapy and corticosteroid therapy is unique in the treatment of COPD.

Short-acting bronchodilator therapy (salbutamol and ipratropium) should be used to reduce dyspnea and improve exercise performance and lung function. Combination therapy achieves greater bronchodilation although has no additional effect on dyspnea or quality of life. Long-acting bronchodilator agents, including long-acting β-agonists (salmeterol and formoterol) and the long-acting anticholinergic agent tiotropium provide sustained improvements in lung function while also achieving improvements in dyspnea and quality of life. With greater understanding of the mechanisms responsible for dyspnea in COPD, it is now established that long-acting bronchodilator therapy, particularly tiotropium, exerts its beneficial effect by reducing dynamic hyperinflation and the resulting increased labour of breathing.27 This helps to alleviate dyspnea and improve capacity for exercise. A recent randomized controlled trial demonstrated a small but significant 5.7% absolute reduction in exacerbation rates in patients with severe COPD (mean FEV₁ was 36% of predicted) treated with tiotropium compared with those taking placebo.28 The combination of tiotropium and ipratropium might cause excessive drying of the mouth and increased sputum viscosity and should, therefore, be used cautiously, if at all.

Inhaled corticosteroids (ICS) have been recommended for patients with moderate to severe airflow obstruction and frequent exacerbations based on data from randomized controlled trials.29 Recent studies evaluating the effect of ICS on mortality have had conflicting results.30 The TORCH trial, a large (n = 6112), multicentre, randomized controlled trial, failed to show a statistically significant reduction in mortality in any of the treatment arms (fluticasone plus salmeterol, salmeterol alone, fluticasone alone) compared with placebo.31 Use of a combination of an ICS and a long-acting bronchodilator agent, though, has been shown to increase lung function, improve health-related quality of life, and reduce dyspnea compared with use of either agent alone.32

In centres where sputum cell count measurement is available, we recommend measuring total and differential cell counts to evaluate for a concurrent diagnosis of eosinophilic bronchitis, which is present in up to 40% of patients with COPD.33 Identifying these patients is important because they will have a greater response to ICS therapy and might also have a greater reduction in exacerbations while receiving this therapy.33,34

Identifying and managing the systemic manifestations of COPD is extremely important. Patients with pulmonary hypertension secondary to COPD and cor pulmonale require careful fluid and diuretic management while stable and during exacerbations. Patients with chronic hypercapnia are at increased risk of respiratory acidosis and hypercapnic respiratory failure with uncontrolled supplemental oxygen therapy, particularly during exacerbations. Ideally, these patients should be identified while they are stable in order to prevent the complications associated with excessive supplemental oxygen delivery during exacerbations. Patients with low body mass and peripheral muscle dysfunction might benefit more from respiratory rehabilitation than patients whose exercise capacity is limited primarily by their ventilatory function.25 Patients with COPD who have osteopenia or osteoporosis should be identified and treated with calcium, vitamin D, and bisphosphonate therapy, particularly when they have ongoing exposure to corticosteroids. Anxiety or depression can result from symptoms of COPD or arise independently. Anxious or depressed patients require careful evaluation and consideration of reversible causes, including excessive β-agonist use or oral corticosteroid therapy. In some situations, therapy directed at controlling symptoms results in a reduction in dyspnea-related anxiety. We have found it beneficial to involve members of an interdisciplinary health care team, including social workers, psychiatrists, or respiratory therapists, in the care of these patients.

Outpatient management of exacerbations

Recurrent exacerbations are a principal feature of COPD and are defined clinically by increases in dyspnea, sputum volume, or sputum purulence. Exacerbations are associated with a substantial negative effect on quality of life, promote accelerated deterioration in lung function, and are associated with an increased risk of mortality.20 Primary care providers commonly manage outpatient exacerbations of COPD. A chest radiograph should be done if clinically indicated, as it could alter management in up to 20% of cases.35 Corticosteroids have been shown to reduce recurrent exacerbations, decrease length of time in hospital, and improve lung function in patients treated in hospital.36 There is now also strong evidence supporting corticosteroid therapy in outpatient management of exacerbations of COPD, and this therapy should be used routinely unless there are contraindications. Based on evidence from a recent randomized controlled trial,37 we recommend a 7- to 10-day course of prednisone (approximately 30 to 40 mg/d) for patients with exacerbations of COPD not requiring hospitalization. Antibiotics should be given to patients with infective exacerbations of COPD, which are usually characterized by increases in sputum volume and purulence. Patients could also benefit from increased doses of their usual short-acting bronchodilator therapy until the exacerbations resolve, although excessive use of short-acting anticholinergic therapy might cause sputum to become more viscous and make airway clearance more difficult. If an underlying cause is identified (eg, congestive heart failure), then therapy directed toward this cause is warranted. Patients with moderate to severe increases in symptoms or who appear unwell require evaluation in the emergency department and should be considered for hospitalization.

Case resolution

Smoking cessation was discussed, and the woman started taking a long-acting anticholinergic agent (tiotropium) once daily along with a short-acting bronchodilating agent (salbutamol), 2 puffs as needed up to 4 times a day. An exercise program was discussed and recommended. She was seen in follow-up in the fall, and influenza vaccine was provided. The patient reported that she had stopped smoking and had noticed an improvement in her dyspnea and capacity for exercise. She was also very happy to report that she was now able to complete all 18 holes of golf with her friends.