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A changing landscape: diagnosis

and management of COPD


Steve Holmes and Jane Scullion

cessation at all ages (Anthonisen et al, 2005)


and the value of pulmonary rehabilitation
Abstract (Puhan et al, 2009), as well as influenza and
Chronic obstructive pulmonary disease (COPD) is a common and often particularly
pneumococcal immunisation and aggressive
debilitating disease. Progressively worsening breathlessness can limit normal daily
management of disease exacerbations (Nichol
functioning, reduce quality of life (QoL) and increase the risk of premature death.
et al, 1999; Groenwold et al, 2009; Wedzicha
Importantly, early diagnosis, improving symptoms and QoL, along with minimising
and Donaldson, 2012)
exacerbations and hospital admissions, are primary goals of patient care. In recent
years, the assessment of COPD has moved away from equating disease severity
solely with the degree of obstructive lung impairment to include patient symptoms,
Diagnosis of COPD
History-taking is central to the diagnosis of
exacerbation history and comorbidities, as well as smoking status. There are now
COPD, with assessment of aetiological factors
more therapies that reduce symptoms and prevent exacerbations, thereby improving
that may have placed the patient at risk of
QoL. This review explores the diagnosis and management of COPD and positive
COPD, and a review of symptoms suggestive
clinical approaches to managing patients.
of the diagnosis. The diagnosis is confirmed
Key words: COPD ■ Breathlessness ■ Quality of life ■ Assessment ■ Primary care by post-bronchodilator spirometry. The FEV1
■ Management to FVC ratio (FEV1/FVC) represents the
proportion of the lung’s vital capacity that

C
can be forcibly expelled in the first second
hronic obstructive pulmonary (Decramer et al, 2012).The chronic productive of breathing out and allows the distinction
disease (COPD) is a common and cough characteristic of bronchitis reflects between a restricted lung volume and airflow
often particularly debilitating disease abnormal responses in the mucus glands in obstruction to be made. COPD airflow
with breathlessness as the primary the airways that normally operate to keep the obstruction is defined as a post-bronchodilator
disabling symptom (Decramer et al, 2012).The airways moist. The chronic inflammation of FEV1 to FVC ratio (FEV1/FVC) of less
Global Initiative for Chronic Obstructive Lung these small airways causes the development of than 0.7. This value should be reviewed in
Disease (GOLD) guidelines define COPD thickened walls that exude an inflammatory- conjunction with a recent chest X-ray and
as a disease state characterised by airflow affected mucus that blocks the airway (Hogg full blood count, in addition to a compatible
limitation that is not fully reversible, is usually et al, 2013). In emphysema, the tiny air sacs clinical history, to make the diagnosis of
progressive, and is associated with an abnormal (alveoli) in the lungs where gas exchange COPD (NICE, 2010; Broekhuizen at al, 2012).
inflammatory response of the lungs to inhaled takes place are gradually destroyed and it is If airflow limitation is fully or substantially
noxious particles or gases (GOLD, 2014). In their narrowing and reduction in number reversible, shown by a marked increase in
addition, COPD is associated with systemic that lead to the severe airflow obstruction in FEV1 in response to a bronchodilator, the
effects and comorbidities, with systemic COPD (Hogg et al, 2013). These pathogenic alternative diagnosis of asthma should be
inflammation a common factor (Decramer mechanisms that underlie COPD all contribute considered. Clinical symptoms are also useful
et al, 2012). Patients can suffer unpleasant to expiratory flow limitation, which in turn to differentiate between COPD and asthma
symptoms that affect daily functioning and inhibits complete lung emptying during the (Table 1) (NICE, 2010). Both asthma and
quality of life (QoL) (National Institute for breathing cycle, a physiological state called COPD involve narrowing of the airways
Health and Care Excellence (NICE), 2011). ‘dynamic hyperinflation’ (Thomas et al, as a result of inflammation, but asthma
Ultimately, COPD increases the risk of 2013). This increases the work of breathing, attacks are usually short-term and reversible,
premature death (Decramer et al, 2012). while decreasing the efficiency of respiratory whereas COPD is progressive and the damage
COPD patients typically have symptoms of muscles, so increasing breathlessness and permanent, with the airflow obstruction only
chronic bronchitis and emphysema, but broad reducing functional capacity. partly reversible.
variations in clinical phenotype are apparent Developing therapies that address the
underlying inflammatory mechanisms of Assessing disease severity
Steve Holmes, General Practitioner, Park Medical COPD and prevent the inexorable course of the There has been considerable change in recent
Practice, Shepton Mallet, Somerset; Jane Scullion, disease has proven challenging (Barnes, 2013). years in the assessment and management of
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Nurse Consultant, Glenfield Hospital, University Nonetheless, effective treatment strategies are COPD. A move away from equating disease
Hospitals Leicester available that address the symptoms of COPD severity solely with the degree of obstructive
and improve patients’ QoL (NICE, 2011). lung impairment has led to the development of
Accepted for publication: January 2015
Evidence shows the importance of smoking multidimensional indices predictive of health

432 British Journal of Nursing, 2015 Vol 24, No 8


status and prognosis such as DOSE (dyspnoea, Table 1. Clinical symptoms used to differentiate between COPD and asthma
obstruction, smoking, exacerbations) (Jones Symptom COPD Asthma
et al, 2009a) and BODE (body mass index
Smoker or ex-smoker Majority Possibly
(BMI), obstruction, dyspnoea, exercise) (Celli
Symptoms under age 35 Rare Common
et al, 2004).
The guidelines of NICE and the GOLD Chronic productive cough Common Uncommon
initiative—a collaboration between the Breathlessness Persistent and Variable
World Health Organization (WHO), the US progressive
National Institutes of Health (NIH) and the Night-time waking with breathlessness Uncommon Common
US National Heart, Lung, and Blood Institute or wheeze
(NHLBI)—recommend that the assessment of Significant diurnal or day-to-day symptom variability Uncommon Common
COPD include: (NICE, 2010)
■■ Spirometric assessment of the severity of
airflow limitation Table 2. Classes of airflow obstruction severity as post-bronchodilator FEV1% predicted
■■ Symptoms
Stage of severity Post-bronchodilator FEV1% predicted
■■ Exacerbation history
I – Mild ≥80%
■■ Comorbidities. (NICE, 2010; GOLD, 2014)
This reflects a more holistic approach to II – Moderate 50−79%
patient care in current clinical practice than III – Severe 30−49%
just the degree of obstruction. In practice, IV – Very severe <30%
holistic assessment should involve the patients’ (NICE, 2010)
ideas, concerns and expectations and other
issues, including their social and spiritual
Table 3. MRC dyspnoea scale
situation. This approach is valuable, as COPD
Grade Degree of breathlessness related to activities
is a heterogeneous condition and no single
measure gives an adequate assessment of 1 Not troubled by breathlessness except on strenuous exercise
disease severity or prognosis. 2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to
Spirometric assessment of the stop for breath when walking at own pace
severity of airflow limitation 4 Stops for breath after walking about 100 metres or after a few minutes on level ground
Evaluation of the severity of airflow limitation 5 Too breathless to leave the house, or breathless when dressing or undressing
is based on the FEV1 values relative to (NICE, 2010)
those predicted for normal people and given
as a percentage (NICE, 2010). Classes of
airflow obstruction severity are presented reliability (Mahler et al, 2009). The scale COPD treatment strategies
as percentage of post-bronchodilator FEV1 correlates with other dyspnoea scales and The goals of COPD patient care are to improve
predicted (Table 2) (NICE, 2010). lung-function measurements, but there is functional status and QoL and minimise
limited evidence to show that functional exacerbations and hospital admissions. Good-
COPD symptoms assessed using capacity can be measured with dyspnoea quality care plans take into account the
patient-centred questionnaires scales. Recent evidence suggests that dyspnoea patients’ needs and preferences, and allow the
We know that FEV1 often has little correlation scales should not be a substitute for actual opportunity for informed decisions about
with the symptoms experienced by patients functional capacity testing (Boer et al, 2012). care options and treatment (NICE, 2010).
and other markers of disease severity. Patient- The COPD assessment test (CAT) is a Recommended interventions include:
centred questionnaires are valuable to gain useful, self-administered patient questionnaire ■■ Smoking cessation (GOLD, 2014)
an accurate clinical picture of disease status, tool that can be used in the everyday clinical ■■ Vaccination (pneumococcal and annual
symptom severity, activity limitation and QoL setting to assess the impact of COPD (Jones et influenza (NICE, 2010))
(van der Molen et al, 2013), although they are al, 2009b). Comparing consecutive CAT scores ■■ Strong encouragement for physical activity
not widely used. provides valuable information for long-term (Vestbo et al, 2013)
Dyspnoea (breathlessness) is the symptom follow up and can help improve management ■■ Suitable referral to pulmonary rehabilitation
that most affects patients’ daily lives and is (Zhao et al, 2014), although it is only validated (NICE, 2010)
often the reason for seeking medical help, for people who only suffer from COPD and ■■ Dealing with anxiety and depression (NICE,
as in the case study presented. The Medical do not have any other comorbidities. Other 2010)
Research Council (MRC) dyspnoea scale is assessments to estimate disease severity include ■■ Management of other comorbidities
a simple-to-administer assessment that can exercise tolerance (e.g. 6-minute walking test (including coronary heart disease,
be used to grade the effect of dyspnoea on suggested in BODE), an assessment of oxygen osteoporosis, etc)
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daily activities and is recommended by NICE saturation using pulse oximetry, history of ■■ Inhaled medications (GOLD, 2014).
(2010) (Table  3). Although a concern is that exacerbations, BMI and the presence of cor
patients can score differently on different pulmonale (failure of the right side of the Smoking cessation
days, the scale provides acceptable test-retest heart) (NICE, 2010). This should be encouraged at all times, including

434 British Journal of Nursing, 2015 Vol 24, No 8


Box 1. A case history: Graham dyspnoea (MRC Grades 3−5) with functional
limitation (Bolton et al, 2013). However, it is
Graham, a 63 year-old accountant, is an avid golfer, but on a recent golfing holiday in Portugal, he
not suitable for people who cannot walk and
was walking slower than his colleagues and struggled to carry his clubs. He had been diagnosed
with COPD 3 years before after two winter ‘chest infections’, following spirometry, chest X-ray, full those who have suffered recent acute coronary
blood count and clinical assessment. His smoking history of 32 pack years and spirometry (FEV1/ syndrome (ACS) or recent major surgery. In
FVC ratio=0.62; FEV1% predicted=57%) confirmed the diagnosis of COPD. Graham was given the case of Graham (Box 2), who has started
separate salbutamol and ipratropium inhalers and, with smoking-cessation support, finally stopped to smoke again and has ongoing anxiety,
smoking. At his last visit, his four-time daily use of ipratropium had been changed to a long-acting pulmonary rehabilitation appears particularly
muscarinic antagonist. Since then, he has begun smoking again, is anxious about his symptoms, and suitable. Pulmonary rehabilitation has been
is increasingly breathless shown to have a number of benefits, which
have been assessed and graded in terms
Box 2. A case history: Graham (continued) of strength of evidence within the BTS
guidelines (Table 4) (Bolton et al, 2013).
In his review, Graham scores 4 on the MRC dyspnoea scale. Spirometry shows his FEV1 has fallen
Outstanding questions include whether or
a little since his previous reading and his CAT score has increased to 26. The nurse is concerned
about Graham’s smoking and high anxiety levels. She does not consider that the deterioration
not the benefits of pulmonary rehabilitation
in FEV1 and symptoms are linked to other medical causes of increased breathlessness. She decrease over time in the disease course of
checks his inhaler technique; ensures he is happy with his inhaler devices and can use them; COPD. Recent evidence suggests that they do
books an influenza vaccination; and arranges the pneumococcal vaccination that he has not had not. Van Ranst et al (2014) have shown that
previously. He is referred for a pulmonary rehabilitation course; breathing techniques to cope with those severely impaired by COPD with high
breathlessness are also discussed. Stepping up Graham’s medication from a single long-acting exacerbation rates can experience reductions
bronchodilator to either a combination inhaler or an additional inhaler is discussed too in both exacerbation and hospitalisation
frequency after participation in comprehensive
Table 4. Benefits of pulmonary rehabilitation and strength of evidence
pulmonary rehabilitation.
Strength of Degree of breathlessness related to activities
evidence
Anxiety and depression
Depression and anxiety are significant and
A Improves exercise capacity
common comorbidities in people with
Reduces the perceived intensity of breathlessness
COPD, but can be difficult to identify and
Improves health status
Reduces number of hospitalisations and days treat because their symptoms often overlap
Reduces anxiety and depression associated with COPD with those of the disease and often remain
B Upper-arm strength/endurance training improves arm function
unrecognised and under-treated (Yohannes
Benefits persist beyond training period and Alexopoulos, 2014). Recent evidence
Improves survival points to a biological link, suggesting that
Improves recovery after hospitalisation for exacerbation low-grade chronic inflammation mediates in
Enhances the effect of long-acting bronchodilators part the association of depressive symptoms
C Respiratory muscle training can be beneficial (dyspnoea, health status, exercise and pulmonary function (Yohannes and
capacity), especially when combined with general exercise training Alexopoulos, 2014).
(Bolton et al, 2013) Once recognised, treatment of depression
is important. Several approaches are used and
in Graham’s case (Box 1). Smoking cessation is seen as a failure on the part of the clinician or have shown promising results. These include
the most important intervention and the one patient (GOLD, 2014). smoking cessation, pulmonary rehabilitation,
with the greatest capacity to influence the Calculating the value of interventions, psychological therapy, and pharmacotherapy
natural history of COPD in those sufferers IMPRESS (the joint initiative between the with antidepressants. It is important to consider
who smoke (GOLD, 2014). Even in severe British Thoracic Society (BTS) and the an integrated approach to tackling depression
COPD, smoking cessation slows progression Primary Care Respiratory Society UK) that involves patients, care givers and the
of the disease and improves survival (Qureshi, formed a ‘value pyramid’ that shows that even necessary health professionals in order to
2014). Intensive smoking cessation programmes with the costs of pharmacotherapy, intense optimise the treatment approach to anxiety and
with pharmacotherapy are warranted. Brief efforts for smoking cessation are more cost- depression (Yohannes and Alexopoulos, 2014).
intervention counselling should be a routine effective and are ‘good value’ compared with
part of all clinicians’ skills, and signposting other interventions (IMPRESS, 2012). Inhaled medications
patients to appropriate services can help them Inhaled therapies are the main pharmacological
to stop smoking. Pharmacotherapies such Pulmonary rehabilitation treatments for COPD, with bronchodilation the
as nicotine-replacement products and other The benefit of pulmonary rehabilitation primary goal. Bronchodilators help symptoms
products including varenicline, bupropion and compared with usual care is strongly by addressing the pathophysiological features
nortriptyline have been shown to be of benefit. supported by clinical evidence for those of dyspnoea, reversing dynamic hyperinflation
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Counselling by physicians and other health patients functionally limited by dyspnoea of the lungs, and emptying the trapped
professionals is also effective. However, ultimately, (Bolton et al, 2013). The BTS guidelines air through dilatation of the distal airways
tobacco dependence can be considered a chronic give a ‘Grade A’ recommendation to offer (Thomas et al, 2013).
disease and relapse is common; it should not be pulmonary rehabilitation to patients with For patients with mild airflow obstruction

436 British Journal of Nursing, 2015 Vol 24, No 8


CLINICAL FOCUS

and symptoms, short-acting ß2-agonists Box 3. A case history: Graham (continued)


(SABAs) and/or short-acting muscarinic
Graham is reassured about his breathlessness and coping mechanisms are discussed. After
antagonists (SAMAs) are the recommended
discussion of the inhaler options (either an ICS/LABA combination inhaler, or both a LAMA and
initial bronchodilator treatment, on an ‘as LABA), Graham decides he would prefer to avoid using steroids and is prescribed a once-daily
required’ basis for relief of breathlessness or LABA to be taken with his once-daily LAMA. Graham feels much happier to attend the pulmonary
exercise limitation (NICE, 2010). Commonly rehabilitation programme and is hopeful that his breathlessness will ease
prescribed short-acting bronchodilators
include salbutamol (a SABA) and ipratropium of the merits of different combinations of mechanisms of action are just becoming
bromide (a SAMA). For those with more inhaled medications in the management of available for prescribing (Bateman et al,
significant symptoms, treatments include stable COPD. 2014). Targeting two different mechanisms of
long-acting ß2-agonists (LABAs) and long- bronchodilation by combining a muscarinic
acting muscarinic antagonists (LAMAs); Optimising the choice of antagonist and a ß2-agonist has the potential to
and for recurrent exacerbations, inhaled intervention maximise bronchodilation without increasing
corticosteroids (ICSs) co-prescribed with a ICS/LABA combinations reduce the rate the dose of the individual bronchodilator,
LABA. In patients with mild-to-moderate of exacerbations and improve lung function while minimising the variability in response
COPD (FEV1≥50% predicted) who remain in COPD (Calverley et al, 2007). Summary to individual agents (Tashkin and Ferguson,
symptomatic or experience exacerbations, a evidence of the effect of ICS on COPD 2013). Recently, Ultibro® (formerly QVA149),
LABA (e.g. salmeterol or formoterol twice- exacerbations is provided by recent Cochrane a new fixed-dose combination of indacaterol
daily or indacaterol once-daily) or a LAMA meta-analyses (Yang et al, 2012; Nannini et al, (LABA) and glycopyrronium (LAMA) as
(e.g. tiotropium or glycopyrronium once- 2013). In an analysis of patients (n=5601) with a once-daily dual bronchodilator delivered
daily or aclidinium twice-daily) are treatment predominantly poorly reversible severe COPD, through a single device was approved.
options (NICE, 2010). exacerbation rates with ICS/LABA twice-daily More recently, a second LABA/LAMA single
combinations were significantly reduced (rate inhaler of umeclidinium and vilanterol was
COPD treatment in moderate to ratio 0.87, 95% CI 0.80–0.94) compared with approved, also indicated for the long-term,
severe disease ICS alone (Nannini et al, 2013). once-daily maintenance treatment of airflow
Combining inhaled medications A clear issue with ICS/LABA is concern obstruction in patients with COPD. Data from
The traditional treatment approach for over adverse side effects, in particular an large phase-III clinical trials showed that LABA/
moderate to severe COPD recommended by increased risk of pneumonia with higher doses LAMA combinations improve lung function
NICE is to start maintenance therapy either of inhaled corticosteroid. Moderate-quality more than the individual LABA and LAMA
with the LAMA tiotropium (once-daily and evidence from the Cochrane analysis shows an components, and were superior to tiotropium
until recently the only LAMA available), increased risk of pneumonia with ICS/LABA in patients with moderate to severe COPD,
or less frequently a LABA (e.g. salmeterol combinations (Nannini et al, 2013). This improving FEV1 and dyspnoea (Decramer et
or formoterol twice-daily or more recently supports the view that patients and clinicians al, 2014; Rodrigo and Plaza, 2014). Indacaterol/
indacaterol once-daily), then to escalate together should carefully assess the benefit/risk glycopyrronium combination was also shown to
treatment with the addition of a combination of ICS/LABA prescribing in severe COPD, be superior to twice-daily salmeterol/fluticasone
inhaler comprising an ICS plus a LABA. given the high level of prescribing of these propionate, improving trough FEV1, dyspnoea
This standard approach of therapy escalation combinations, often outside the guidelines. and use of rescue medication (Vogelmeier et al,
is now being challenged, with a consensus NICE recommends considering a LAMA in 2013). These new combination inhalers with
view from GOLD (2014) recommending addition to LABA where ICS is declined or once-daily administration may also increase
that clinicians rethink this algorithm and not tolerated (as in Graham’s case, Box 3). patient compliance.
consider a broader range of treatment More than 12% of patients with COPD in the
options (Han et al, 2013). The principle UK are prescribed ‘triple’ therapy (NICE, 2011), Managing COPD towards
of the GOLD consensus is based on a a particularly costly intervention. The ‘value the end of life
combined assessment of air flow obstruction, pyramid’ (IMPRESS, 2012) shows the relative Long-term oxygen therapy (LTOT)
symptoms and exacerbation risk on three position of interventions in terms of cost per There is strong evidence for the long-term
axes, stratifying patients into four categories quality-adjusted life years (QALY) and shows administration of oxygen (>15 hours per day)
(A, B, C and D). These include LAMA/ the very high cost of triple therapy (£35 000– to COPD patients with respiratory failure
LABA dual therapy, which is recommended 187  000/QALY) (IMPRESS, 2012). Value resulting in increased survival in patients with
as a treatment alternative for group B patients is an important consideration in optimising severe resting hypoxemia (GOLD 2014;Turner
(high symptoms/low risk), group C patients treatment and management of COPD. For et al, 2014). NICE guidelines recommend that
(low symptoms/high risk) and group D clinicians, the value paradigm is fundamental in LTOT be targeted at patients who have a PaO2
patients (high symptom/high risk). Although achieving high value for patients. These costings (blood gas tension) of less than 7.3 kilopascals
the GOLD view on these categories is highlight the need to focus on appropriate (kPa) when stable or a PaO2 greater than
somewhat controversial, with an inherent prescribing of inhaled medications to reduce 7.3 kPA and less than 8 kPa when stable, and
conflict between how to interpret FEV1 overuse (IMPRESS, 2012). one of: secondary polycythaemia, nocturnal
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and exacerbations and how to interpret hypoxaemia, peripheral oedema or pulmonary


symptoms when CAT and the MRC score New options in bronchodilation hypertension (NICE, 2010). Oxygen is often
(or adapted ‘mMRC’ score) do not correlate, Currently, a number of new treatments that prescribed inappropriately for intermittent
they do point to a broader consideration combine bronchodilators with different use with the intention of preventing hospital

British Journal of Nursing, 2015, Vol 24, No 8 437


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