Chronic obstructive pulmonary disease (COPD) is a common disabling condition with a high mortality. The most effective treatment is smoking cessation. Oxygen therapy has been shown to prolong life in the later stages of the disease and has also been shown to have a beneficial impact on exercise capacity and mental state. Some patients respond to inhaled steroids. Many patients respond symptomatically to inhaled beta agonists and anti-cholinergics. Pulmonary rehabilitation has been shown to produce an improvement in quality of life.
The majority of patients with COPD are managed by general practitioners and members of the primary healthcare team with onward referral to secondary care when required. This measure is one of five Chronic Obstructive Pulmonary Disease (COPD) measures. The Chronic Obstructive Pulmonary Disease (COPD) set focuses on the diagnosis and management of patients with symptomatic COPD.
COPD is diagnosed if:
- The patient has a forced expiratory volume in one second (FEV1) of less than 80% of predicted normal
- And has an FEV1/FVC ratio less than 70%
- And the patient has symptoms consistent with COPD
Spirometry should be performed after the administration of an adequate dose of an inhaled bronchodilator (e.g., 400 mcg salbutamol).
Prior to performing post-bronchodilator spirometry, patients do not need to stop any therapy, such as long acting bronchodilators or inhaled steroids.
All of these elements are required to make the diagnosis of COPD. Routine reversibility testing is not recommended in NICE, and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines require post bronchodilator spirometry for diagnosis and grading. Failure to use post bronchodilator readings overestimated the prevalence of COPD by 25% (Johannessesn et al. Thorax 2005; 60(10): 842-847). This change will reduce workload in primary care and removes the conflict with evidence based guidelines.
Where doubt occurs as to whether the diagnosis is asthma or COPD, reversibility testing may add additional information to post bronchodilator readings alone and peak flow charts are useful. It is acknowledged that COPD and asthma can co-exist and that many patients with asthma who smoke will eventually develop irreversible airways obstruction. However, where asthma is present, these patients should be managed as asthma patients as well as COPD patients. This will be evidenced by a greater than 400mls response to a reversibility test and a post bronchodilator FeV1 of less than 80% of predicted normal as well as an appropriate medical history.
Patients with reversible airways obstruction should be included on the asthma register. Patients with coexisting asthma and COPD should be included on the register for both conditions.
