COPD diagnosis, management and prevention—2020 strategy
By Global Initiative for Chronic Obstructive Lung Disease2019-12-30T09:28:00+00:00
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Global strategy for diagnosis, management, and prevention of COPD
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Answers provided by Dr Steve Holmes, GP, Park Medical Practice, Shepton Mallet. Funded by an educational grant from Teva UK Limited.
COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, a history of recurrent lower respiratory tract infections and/or a history of exposure to risk factors for the disease
Key indicators for considering a diagnosis of COPD
Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Spirometry is required to establish a diagnosis of COPD:
Dyspnoea that is:
progressive over time
characteristically worse with exercise
Chronic cough:
may be intermittent and may be unproductive
recurrent wheeze
Chronic sputum production:
any pattern of chronic sputum production may indicate COPD
Recurrent lower respiratory tract infections
History of risk factors:
host factors (such as genetic factors, congenital/developmental abnormalities, etc)
tobacco smoke (including popular local preparations)
smoke from home cooking and heating fuels
occupational dusts, vapours, fumes, gases, and other chemicals
Family history of COPD and/or childhood factors:
for example, low birthweight, childhood respiratory infection, etc
Classification of airflow limitation severity in COPD (based on post-bronchodilator FEV1)
In patients with FEV1/FVC < 0.70:
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
Revised combined COPD assessment
Figure 1: The refined ABCD assessment tool
In the revised assessment scheme (see Figure 1), patients should undergo spirometry to determine the severity of airflow limitation (i.e., spirometric grade). They should also undergo assessment of either dyspnoea using modified Medical Research Council (mMRC), or symptoms using COPD assessment test (CAT™). Finally, their history of exacerbations (including prior hospitalisations) should be recorded
The number provides information regarding severity of airflow limitation (spirometric grade 1 to 4) while the letter (groups A to D) provides information regarding symptom burden and risk of exacerbation which can be used to guide therapy
Example: Consider two patients—both patients with FEV1 <30% of predicted, CAT™ scores of 18 and one with no exacerbations in the past year and the other with three exacerbations in the past year. Both would have been labelled GOLD D in the prior classification scheme. However, with the new proposed scheme, the subject with three exacerbations in the past year would be labelled GOLD grade 4, group D
Refer to Table 1 for a list of differential diagnosis
Table 1: Differential diagnosis of COPD
Suggestive features
These features tend to be characteristic of the respective diseases, but are not mandatory. For example, a person who has never smoked may develop COPD (especially in the developing world where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even in elderly patients.
Onset in mid-life
Symptoms slowly progressive
History of tobacco smoking or exposure to other types of smoke
Onset early in life (often childhood)
Symptoms vary widely from day to day
Symptoms worse at night/early morning
Allergy, rhinitis, and/or eczema also present
Family history of asthma
Obesity coexistence
Chest X-ray shows dilated heart, pulmonary oedema.
Pulmonary function tests indicate volume restriction, not airflow limitation
Large volumes of purulent sputum
Commonly associated with bacterial infection
Chest X-ray/CT shows bronchial dilation, bronchial wall thickening.
Onset all ages
Chest X-ray shows lung infiltrate
Microbiological confirmation
High local prevalence of tuberculosis
Obliterative bronchiolitis
Onset at younger age, non-smokers
May have history of rheumatoid arthritis or acute fume exposure
Seen after lung or bone marrow transplantation
CT on expiration shows hypodense areas
Diffuse panbronchiolitis
Predominantly seen in patients of Asian descent
Most patients are male and non-smokers
Almost all have chronic sinusitis
Chest X-ray and high-resolution computed tomography show diffuse small centrilobular nodular opacities and hyperinflation
Management of stable COPD
The management strategy for stable COPD should be predominantly based on the individualised assessment of symptoms and future risk of exacerbations
All individuals who smoke should be strongly encouraged and supported to quit
The main treatment goals are reduction of symptoms and future risk of exacerbations
Management strategies include pharmacological and non-pharmacological interventions
A. Pharmacological treatment
1. Initial treatment
See Figure 2 for an overview of initial pharmacological treatment
Rescue short-acting bronchodilators should be prescribed to all patients for immediate symptom relief
Figure 2: Initial pharmacological treatment
Group A:
all Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator
this should be continued if benefit is documented
Group B:
initial therapy should consist of a long-acting bronchodilator
for patients with severe breathlessness initial therapy with two bronchodilators may be considered
Group C:
initial therapy should consist of a LAMA
Group D:
in general, therapy can be started with a LAMA as it has effects on both breathlessness and exacerbations
for patients with more severe symptoms (order of magnitude of CAT™ ≥20), especially driven by greater dyspnoea and/or exercise limitation, LAMA/LABA may be chosen as initial treatment
in some patients, initial therapy with LABA/ICS may be the first choice; this treatment has the greatest likelihood of reducing exacerbations in patients with blood eosinophil counts ≥300 cells/µl. LABA/ICS may also be first choice in COPD patients with a history of asthma
ICS may cause side-effects such as pneumonia, so should be used as initial therapy only after the possible clinical benefits versus risks have been considered
2. Management cycle
Following implementation of therapy, patients should be reassessed for attainment of treatment goals and identification of any barriers for successful treatment (see Figure 3). Following review of the patient response to treatment initiation, adjustments in pharmacological treatment may be needed
Figure 3: GOLD COPD management cycle
3. Follow-up pharmacological management
The follow-up pharmacological treatment algorithm (see Figure 4) can be applied to any patient who is already taking maintenance treatment(s) irrespective of the GOLD group allocated at treatment initiation. The need to treat primarily dyspnoea/exercise limitation or prevent exacerbations further should be evaluated. If a change in treatment is considered necessary then select the corresponding algorithm for dyspnoea or exacerbations; the exacerbation algorithm should also be used for patients who require a change in treatment for both dyspnoea and exacerbations. Identify which box corresponds to the patient's the current treatment
Figure 4: Follow-up pharmacological treatment
For patients with persistent breathlessness or exercise limitation on long-acting bronchodilator monotherapy, the use of two bronchodilators is recommended:
if the addition of a second long acting bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to monotherapy. Switching inhaler device or molecules can also be considered
For patients with persistent breathlessness or exercise limitation on LABA/ICS treatment, LAMA can be added to escalate to triple therapy:
alternatively, switching from LABA/ICS to LABA/LAMA should be considered if the original indication for ICS was inappropriate (e.g. an ICS was used to treat symptoms in the absence of a history of exacerbations), or there has been a lack of response to ICS treatment, or if ICS side-effects warrant discontinuation
At all stages, dyspnoea due to other causes (not COPD) should be investigated and treated appropriately. Inhaler technique and adherence should be considered as causes of inadequate treatment response
Exacerbations
For patients with persistent exacerbations on long-acting bronchodilator monotherapy, escalation to either LABA/LAMA or LABA/ICS is recommended. LABA/ICS may be preferred for patients with a history or findings suggestive of asthma. Blood eosinophil counts may identify patients with a greater likelihood of a beneficial response to ICS. For patients with one exacerbation per year, a peripheral blood level ≥300 eosinophils/μl identifies patients more likely to respond to LABA/ICS treatment
For patients with ≥2 moderate exacerbations per year or at least one severe exacerbation requiring hospitalisation in the prior year, LABA/ICS treatment can be considered at blood eosinophil counts ≥100 cells/μl, as ICS effects are more pronounced in patients with greater exacerbation frequency and/or severity
In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways:
escalation to LABA/LAMA/ICS. A beneficial response after the addition of ICS may be observed at blood eosinophil counts ≥100 cells/μl, with a greater magnitude of response more likely with higher eosinophil counts
add roflumilast or azithromycin (see below) if blood eosinophils <100 cells/μl
In patients who develop further exacerbations on LABA/ICS therapy, we recommend escalation to triple therapy by adding a LAMA. Alternatively, treatment can be switched to LABA/LAMA if there has been a lack of response to ICS treatment, or if ICS side effects warrant discontinuation
In patients treated with LABA/LAMA/ICS who still have exacerbations the following options may be considered:
add roflumilast. This may be considered in patients with an FEV1 <50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalisation for an exacerbation in the previous year
add a macrolide. The best available evidence exists for the use of azithromycin, especially in those who are not current smokers. Consideration to the development of resistant organisms should be factored into decision-making.
stopping ICS. This can be considered if there are adverse effects (such as pneumonia) or a reported lack of efficacy. However, a blood eosinophil count ≥300 cells/μl identifies patients with the greatest likelihood of experiencing more exacerbations after ICS withdrawal and who subsequently should be followed closely for relapse of exacerbations
Blood eosinophil count
The threshold of a blood eosinophil count ≥300 cells/μl identifies the top of the continuous relationship between eosinophils and ICS, and can be used to identify patients with the greatest likelihood of treatment benefit with ICS
The use of blood eosinophil counts to predict ICS effects should always be combined with clinical assessment of exacerbation risk (as indicated by the previous history of exacerbations)
B. Non-pharmacological treatment
Non-pharmacological treatment is complementary to pharmacological treatment and should form part of the comprehensive management of COPD
Some relevant non-pharmacological measures based on the GOLD group AT DIAGNOSIS are summarised in Table 2
Table 2: Non-pharmacological management of COPD[A]
Depending on local guidelines
Smoking cessation (can include pharmacological treatment)
B, C and D
[A] Can include pharmacological treatment
Education, self-management and pulmonary rehabilitation
Education is needed to change patients' knowledge but there is no evidence that used alone it will change patient behaviour
Education self-management with the support of a case manager with or without the use of a written action plan is recommended for the prevention of exacerbation complications such as hospital admissions
Rehabilitation is indicated in all patients with relevant symptoms and/or a high risk for exacerbation
Physical activity is a strong predictor of mortality. Patients should be encouraged to increase the level of physical activity although we still don't know how to best ensure the likelihood of success
Influenza vaccination is recommended for all patients with COPD
Pneumococcal vaccinations PCV13 and PPSV23 are recommended for all patients >65 years of age. The PPSV23 is also recommended in younger patients with significant comorbid conditions including chronic heart or lung disease
Nutritional supplementation should be considered in malnourished patients with COPD
All clinicians managing patients with COPD should be aware of the effectiveness of palliative approaches to symptom control and use these in their practice
End of life care should include discussions with patients and their families about their views on resuscitation, advance directives and place of death preferences
Treatment of hypoxemia
In patients with severe resting hypoxemia long-term oxygen therapy is indicated
In patients with stable COPD and resting or exercise-induced moderate desaturation, long term oxygen treatment should not be routinely prescribed. However, individual patient factors may be considered when evaluating the patient's needs for supplemental oxygen
Resting oxygenation at sea level does not exclude the development of severe hypoxemia when travelling by air
Treatment of hypercapnia
In patients with severe chronic hypercapnia and a history of hospitalisation for acute respiratory failure, long term noninvasive ventilation may be considered
Interventional bronchoscopy and surgery
Please refer to the full GOLD strategy for recommendations on interventional therapy
Management of exacerbations
An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy
As the symptoms are not specific to COPD relevant differential diagnoses should be considered
Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections
The goal for treatment of COPD exacerbations is to minimise the negative impact of the current exacerbation and to prevent subsequent events
Short-acting inhaled beta2 -agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation
Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge
Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalisation duration. Duration of therapy should not be more than 5–7 days
Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalisation duration. Duration of therapy should be 5–7 days
Methylxanthines are not recommended due to increased side-effect profiles
Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalisation duration and improves survival
Following an exacerbation, appropriate measures for exacerbation prevention should be initiated
COPD and comorbidities
COPD often coexists with other diseases (comorbidities) that may have a significant impact on disease course
In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated per usual standards regardless of the presence of COPD
Lung cancer is frequently seen in patients with COPD and is a main cause of death
Cardiovascular diseases are common and important comorbidities in COPD
Osteoporosis and depression/anxiety are frequent, important comorbidities in COPD, are often under diagnosed, and are associated with poor health status and prognosis
Gastroesophageal reflux is associated with an increased risk of exacerbations and poorer health status
When COPD is part of a multimorbidity care plan, attention should be directed to ensure simplicity of treatment and to minimise polypharmacy
[1] Recommendations by the GOLD Committees for use of any medication are based on the best evidence available from the published literature and not on labeling directives from government regulators. The Committee does not make recommendations for therapies that have not been approved by at least one major regulatory agency.
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease—2020 report. November 2019.
www.goldcopd.org
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