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COPD:

Diagnosis and Assessment

Barry Make, MD

Co-Director, COPD Program

Director, Pulmonary Rehabilitation; Respiratory Care

National Jewish Health

Professor of Medicine

University of Colorado Denver School of Medicine

COPD Diagnosis and Assessment

Objectives:

• Improve patient assessment in your office setting

• Improve diagnosis in your office

COPD Challenges

What are your challenges in caring for patients with COPD?

COPD Challenges

What are your challenges in caring for COPD? A. Recognizing patients who might have COPD B. Making a diagnosis of COPD C. Assessing COPD severity D. Reducing shortness of breath E. Taking medications regularly F. Preventing hospital admissions G. Improving survival H. Improving activities I. Improving quality of life

Learning Objectives

• Make an appropriate diagnosis of COPD

– Record smoking history in all patients

– Assess respiratory symptoms in all patients

with a history of cigarette smoking

– Perform spirometry in all patients with

respiratory symptoms and a history of

cigarette smoking

– Correctly interpret spirometry

Let’s Discuss . . .

• What is COPD

COPD: Definition

• Common, preventable and treatable

• Persistent airflow limitation

• Airflow limitation usually progressive

• Enhanced inflammatory response to noxious

particles or gases

• Exacerbations and co-morbidities contribute to

overall severity in individual patients

Global Initiative for Chronic Obstructive Lung Disease. Global strategy of the

diagnosis, management, and prevention of COPD. http://www.goldcopd.org

Updated 2011.

http://www.goldcopd.org


COPD: What Are The Diagnostic

Criteria?

• Common, preventable and treatable

• Persistent airflow limitation

• Airflow limitation usually progressive

• Enhanced inflammatory response to noxious

particles or gases

• Exacerbations and co-morbidities contribute to

overall severity in individual patients

Global Initiative for Chronic Obstructive Lung Disease. Global strategy of the

diagnosis, management, and prevention of COPD. http://www.goldcopd.org

Updated 2011.



COPD Diagnostic Criteria

Two major criteria and one minor criterion

Major criteria:

1) Airflow limitation “post-bronchodilator”

2) Exposure to noxious particles or gases

(primarily cigarette smoking)

Minor criteria:

Exclusion of other conditions

Celli BR et al. Eur Respir J. 2004;23:931-946

GOLD Guidelines 2011. www.goldcopd.com Barry Make, MD

Chronic

Bronchitis Emphysema

Asthma Airflow

Obstruction ATS. AJRCCM. 1995;152:S77-121.

Chronic Bronchitis:

American Thoracic Society. AJRCCM. 1995.

Chronic productive

cough

for 3 months in each of

2 successive years

in a patient in whom

other causes of

chronic cough have

been excluded

Clinical Definition

Emphysema: Pathologic Definition

Abnormal permanent

enlargement of the

airspaces

distal to the terminal

bronchioles,

accompanied by

destruction of their

walls without

obvious fibrosis

American Thoracic Society. AJRCCM. 1995.

COPD Symptoms ? What is the most common

complaint that you hear from your

patients with COPD?

A. Chest tightness

B. Cough (productive or non-productive)

C. Dyspnea (with or without exertion)

D. Wheezing

E. Other

Can History & Physical Examination

Make a Diagnosis of COPD?

A. Yes

B. No

?

COPD Diagnosis:

History and physical exam :

• Relatively normal in early disease

• Not helpful when negative to exclude mild

disease

• Only positive in the presence of severe disease

(severe airflow limitation)

Are History and Physical Sufficient?

Suspected COPD Patients: Insight from the Basic History & Physical Exam

COPD Diagnosis:

Most patients present initially with:

1. cough and/or sputum,

2. dyspnea - but only with increased activity, or

3. a hospitalization for worsening dyspnea, with

or without increased cough, sputum

(acute exacerbation of COPD)

Insights from Medical History

Suspected COPD Patients:

Is your patient:

• A current or former smoker?

• Having a morning cough with or without sputum?

• Restricted in physical activity?

• Complaining about activity intolerance?

• Experiencing a decline in activities of daily living?

Not going grocery shopping

Using a golf cart instead of walking

No longer shopping in the mall

Reduced job performance

Insight from the Basic History & Physical Exam

Ferguson GT et al. Chest. 2000;117:1146-1161.

COPD Diagnosis:

Physical examination:

• Increased forced expiratory time (>5 seconds)

• In severe disease:

• Unable to speak complete sentences without

stopping to take a breath

• Decreased breath sounds

• Hyper-resonant percussion note

• Use of accessory respiratory muscles

Are History and Physical Sufficient?

COPD Diagnosis:

“Persistent airflow limitation” can only be

diagnosed with certainty by post-bronchodilator

spirometry

• More sensitive and accurate than peak flow

Persistent Airflow Limitation?

How can you improve assessment

for possible presence of COPD?

How should you use spirometry?

Qaseem A et al. Ann Intern Med. 2007;147:633-638.

Who Should Have Spirometry?

A) Case-finding in patients at risk – screening

B) Make a diagnosis in patients with symptoms

1) National Lung Health Education Program: www.nlhep.org.

2) Global Initiative for Chronic Obstructive Lung Disease. www.goldcopd.com.

3) ATS/ERS Task Force. Eur Respir J. 2004;23:932-946.

4) U.S. Preventive Services Task Force. Ann Intern Med. 2008;148:529-534.

5) Qaseem A et al. Ann Intern Med. 2007;147:633-638.

Use of Screening Spirometry: Summary of Recommendations

In Favor of Screening Against Screening

National Lung Health

Education Program 1

U.S Preventive Services Task

Force 4

Global Initiative for Chronic

Obstructive Pulmonary

Disease (GOLD) 2

American College of

Physicians 5

American Thoracic Society 3

European Respiratory Society 3

http://www.goldcopd.com

1. Make a diagnosis in patients with symptoms

Mandatory

2. Case-finding in patients at risk:

• Not uniformly recommended

• Lack of studies to assess whether early

diagnosis improves outcomes or smoking

cessation efforts

• Most patients with COPD do not present with

symptoms until FEV1 is < 50% of predicted

Qaseem A et al. Ann Intern Med. 2007;147:633-638.

Who Should Have Spirometry?

How can you improve your efficiency

in assessing the possible presence

of COPD?

How can you improve your efficiency

in assessing the possible presence

of COPD?

Can you use a Questionnaire?

COPD Population Screener

www.copd.org

COPD Population Screener™ (COPD-PS)

• 5 items completed by the patient – Shortness of breath (past 4 weeks)

– Productive cough

– Activity limitations (past year)

– Smoking history (entire life)

• Add up score: 0 - 10 – Score 6 to 10, breathing problems likely to be caused

by COPD

— Perform spirometry

– Score 0-5, breathing problems (if present) may have other cause, discuss with health care provider

COPD Population Screener

COPD Questionnaires

• There is currently no perfect questionnaire

• Efforts are under way to develop a better questionnaire for use with peak flow meter

– NHLBI COPD Case-Finding Grant

• ? What is the target population in need of diagnosis

• ? Can a questionnaire and peak flow identify those at high risk and indicate need for spirometry


• Spirometry

– Spirometry in your office

Spirometry in Your Office?

• Barriers to routine office spirometry use:

• Cost – equipment, personnel, time

• Complexity – equipment, personnel time, personnel training, incorporation into office and patient flow

• Knowledge deficit – spirometry role, performance, and importance

BARRIERS CAN BE OVERCOME!

Perceived Barriers

Spirometry - Perceived Barriers

Cost – equipment costs $1,000 - $2,000

• Mouthpiece & nose clip - < $2 per test

• Spirometers: www.nlhep.org

Billing for Spirometry

• Billing codes and reimbursement for simple

spirometry vary by region

Reimbursement - about $25

• Use spirometry code 94010 in conjunction with an

ICD-9-CM code representing symptoms or suspected

diagnosis

Spirometry code 94060 for before and after

bronchodilator testing

National Lung Health Education Program: www.nlhep.org

Billing for Spirometry

Diagnostic codes for use with spirometry:

• Cough (786.2)

• Simple chronic bronchitis (491.0)

• Muco-purulent chronic bronchitis (491.1)

• Acute bronchitis (466.0)

• COPD (496.0)

• Shortness of breath (786.05)

• Restrictive lung disease (515)

• Asthma (493.91)

National Lung Health Education Program: www.nlhep.org

Spirometry Procedure

• Maximal, forced exhalation after a maximal

inhalation into a spirometer

• Need two reproducible efforts to assure

maximum values are obtained

• Patient may be seated (preferred) or standing,

but use the same position on subsequent tests

• Nose clip is preferred

• Coaching is essential

AAFP and ATS statements on spirometry

http://www.aafp.org/afp/20040301/1107.htm (Accessed 01/03/2009)

http://www.thoracic.org/sections/publications/statements/pages/pfet/pft2.html (Accessed 01/03/2009)

http://www.aafp.org/afp/20040301/1107.htm

http://www.thoracic.org/sections/publications/statements/pages/pfet/pft2.html

Spirometry Measures

• FVC (FEV6) – Forced Vital Capacity

Total volume of air exhaled with a maximally

forced effort from a full inspiration

• FEV1 - Forced Expiratory Volume in One Second

Maximal volume of air exhaled in the first second

of a forced expiration from full inspiration

• FEV1 /FVC – Ratio of FEV1 divided by FVC (FEV6)

©Copyright 2011 National Jewish

Health

Spirometry in Normal & Airflow Limitation

Normal

0 1 2 3 4 5 6

Time (seconds)

Vo

lum

e (

lite

rs)

1

2

3

4

5

6


Normal

FEV1

0 1 2 3 4 5 6

FVC

Time (seconds)

Vo

lum

e (l

iter

s)

1

2

3

4

5

6


Airflow Limitation

FEV1

0 1 2 3 4 5 6

1

2

3

4

5

6

7 8

FVC

Time (seconds)

Normal

FEV1

0 1 2 3 4 5 6

FVC

Time (seconds)

Vo

lum

e (l

iter

s)

1

2

3

4

5

6

COPD SPIROMETRY - PATTERN RECOGNITION

Normal

FEV1 / FVC > 70%

FEV1 > 80%

pred

FVC

> 80%

pred


Normal Airflow

Limitation

FEV1 / FVC > 70% < 70%

FEV1 > 80%

pred

< 80%

pred

FVC

> 80%

pred

usually

> 80%

pred


Normal Airflow

Limitation

Restrictive

Defect

FEV1 / FVC > 70% < 70% > 70%

FEV1 > 80%

pred

< 80%

pred

< 80%

pred

FVC

> 80%

pred

usually

> 80%

pred

< 80%

pred

Importance of FEV1

• Single best predictor of survival

• Used in composite indices predicting survival

• Generally correlates with symptoms (dyspnea,

health-related quality of life and exercise)

• Marker for exacerbations (FEV1 < 50%

predicted)

• Marker for hypoxia (FEV1 < 30% predicted)

• Guide to therapy (GOLD and ATS/ERS

guidelines)

Stratification of Severity in COPD by FEV1%

Celli BR et al. Eur Respir J. 2004;23:932-946. Global Initiative for Chronic Obstructive Lung Disease. Executive Summary Updated 2004. Available at: http://www.goldcopd.com/workshop/ toc.html. Accessed February 21, 2005.

I* (Mild)

IV (Very Severe)

III (Severe)

II (Moderate)

100%

80%

30%

50%

0%

ATS/ERS and GOLD Guidelines FE

V1%

*COPD is defined as FEV1/FVC <70%.

COPD Diagnosis:

• Spirometry is necessary to diagnose COPD,

particularly early in the course of the disease

• Also useful to determine severity (stage) and assess

prognosis

• Barriers to increased spirometry use:

Cost - equipment

Complexity - personnel time required

Knowledge deficit - role, performance, importance

BARRIERS CAN BE OVERCOME!

Importance of Spirometry

How Can We Implement

COPD Diagnosis?

Goal: Make patients with COPD better Method: Integrate all office personnel in the management of patients with COPD

It Takes A Village . . .

• How can your office effectively and efficiently operate to:

– Determine which patients might have COPD (COPD screening questionnaire?)

– Perform spirometry

What Are the Roles of Your

Office Health Care Team?

It takes a village . . .

A. Greeter B. Medical Assistant C. Physician D. Nurse practitioner E. Physician assistant F. Nurse G. Patient health advocate

What Happens To A Patient

With COPD When They Are In Your Office?

1. Enter through the front door 2. 3. 4. 5. Go into room to be seen by prescribing

health-care provider 6. 7. 8.

Assessment of Dyspnea

MMRC Questionnaire Dyspnea Score

0. SOB with strenuous exercise

1. SOB hurrying on level or walking up slight hill

2. Stop when walking on level, or slower than people of the same age

3. Stop after walking ~100 m, or after a few minutes on level

4. Too short of breath to leave the house or while dressing / undressing

Global Initiative for Chronic Obstructive Lung Disease. Global strategy of the diagnosis, management, and prevention of

COPD. http://www.goldcopd.org/Guidelines/guidelines-global-strategy-for-diagnosis-management.html. Published

December 2011. Accessed September 19, 2012.

Assessment of Symptoms

COPD Assessment Test

(CAT)

– 8 item measure of

health status

– Score 0 - 5

– Impact

< 10 – low

11 - 20 – medium

21 - 30 – high

31 - 40 – very high

0 Cough 5

0 Phlegm 5

0 Chest tightness 5

0 Short of breath on hill

or flight of stairs

5

0 Limitation in

home activities

5

0 Confidence

leaving home

5

0 Sleep 5

0 Energy 5

None All the

time

Jones PW, et al. Eur Respir J. 2009;34(3):648-654.

COPD Assessment Test. (CAT). http://www.catestonline.org/. Accessed September 25, 2012.

• COPD exacerbation: acute increase in respiratory

symptoms beyond the usual day-to-day variation,

leading to a medication change

• Exacerbations increase decline in lung function,

health status, and the risk of death

• Greatest risk factor for future exacerbations is a

history of previous exacerbations

– ≥ 2 exacerbations per year is considered

high risk

Assessment of Exacerbation Risk




Combined COPD Assessment R

ISK

GO

LD

Sta

ge o

f A

irfl

ow

Lim

itati

on

RIS

K

Exa

ce

rbati

on

his

tory

≥ 2

0 - 1

C D

A B

MMRC 0 - 1

CAT < 10

4

3

2

1

MMRC ≥ 2

CAT ≥ 10

Risk

Symptoms


COPD. http://www.goldcopd.org Update 2011. Accessed September 19, 2012.

Additional Assessment of COPD

• Current smoking

• Oxygenation

– Pulse oximetry at rest

• Comorbidities

– Treat comorbidities as medically indicated




COPD: Personalize Goals of Management

• Relieve symptoms (SOB)

• Improve exercise tolerance

• Improve health status

• Prevent disease progression

• Prevent and treat exacerbations

• Reduce mortality

Reduce

symptoms

OR

Reduce

risk




COPD: Pharmacologic Therapy

FIRST CHOICE

Ex

ac

erb

ati

on

s p

er

ye

ar

≥ 2

1

0

MMRC 0-1

CAT < 10

GOLD 4

MMRC ≥ 2

CAT ≥ 10

GOLD 3

GOLD 2

GOLD 1

SAMA prn

or

SABA prn

LABA

or

LAMA

ICS + LABA

or

LAMA

A B

D C

ICS + LABA

or

LAMA

Global Initiative for Chronic Obstructive Lung Disease. Global strategy of the diagnosis, management, and prevention

of COPD. http://www.goldcopd.org/Guidelines/guidelines-global-strategy-for-diagnosis-management.html. Published


ICS= inhaled corticosteroid

LAMA=long-acting antimuscarinic antagonist

SAMA=short-acting antimuscarinic antagonist

SABA=short-acting beta2 agonist

MMRC 0-1

CAT < 10

GOLD 4

GOLD 3

GOLD 2

GOLD 1

LAMA or

LABA or

SABA and

SAMA

LAMA and

LABA

ICS and LAMA or ICS + LABA and

LAMA or ICS + LABA and

PDE4-inh or LAMA and LABA or LAMA and PDE4-inh

LAMA and LABA


SECOND CHOICE

A

D

C

B

Exacerb

ati

on

s p

er

year

≥ 2

1

0

MMRC ≥ 2

CAT ≥ 10




PDE4-inh=phosphodiesterase-4 inhibitor

≥ 2

1

0

MMRC 0-1

CAT < 10

GOLD 4

MMRC ≥ 2

CAT ≥ 10

GOLD 3

GOLD 2

GOLD 1

Theophylline

PDE4-inh.

SABA and/or SAMA

Theophylline

Carbocysteine SABA and/or

SAMA Theophylline

SABA and/or SAMA

Theophylline


ALTERNATIVE CHOICES

A

D C

B

Ex

ac

erb

ati

on

s p

er

ye

ar




Other Therapies for COPD

• Smoking cessation

• Oxygen

– Resting SpO2 ≤ 88%

• Pulmonary rehabilitation

– For all patients

• Lung volume reduction surgery

– FEV1 < 45% predicted and emphysema




Smoking Cessation Slows Lung Function Decline in Mild COPD

Adapted from: Anthonisen NR, et al. Am J Respir Crit Care Med. 2002;166(5):675-679.

Anthonisen NR, et al. Ann Intern Med. 2005;142(4):233-239.

Calverley P, et al. Lancet. 2003;361(9356):449-456.

Sustained

Quitters

Intermittent

Quitters

Continuous

Smokers

HR mortality in usual care vs special

Intervention: 1.18 (95% CI:1.02-1.37)

FE

V1 (

L)

Year

Smoking Cessation and Mortality

0

4

8

12

16

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Follow-up (years)

% P

ati

en

ts D

yin

g

Smoking Cessation

Usual Care

-15%

Anthonisen NR, et al. Ann Int Med. 2005:142(4):233-239.

Smoking Cessation Therapies

Varenicline 2 mg/day

Bupropion SR

NRT nasal spray

NRT patch

NRT gum

NRT patch + bupropion SR

NRT patch + spray

33.2%

24.2%

26.7%

23.4%

19.0%

28.9%

25.8%

Medication Cessation Rates

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice

Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service; 2008.

NRT=nicotine replacement therapy

Ries AL, et al. Chest. 2007;131(5 Suppl):4S-42S.

Evidence-Based Pulmonary Rehabilitation Guidelines

• Pulmonary rehabilitation:

– Improves the symptom of dyspnea - 1A

– Improves health-related quality of life - 1A

– Lower extremity exercise training at high

intensity produces greater physiologic

benefits than lower intensity training - 1B

Pulmonary Rehab Improves Dyspnea

Adapted from Salman GF, et al. J Gen Intern Med. 2003;18(3):213-221.

Effect Size With 95% CI

-1 0 1 2

Guyatt et al, 19922

Simpson et al, 1992

Bauldoff et al, 1996

Bendstrup et al, 1997

Wijkatra et al, 1995

Goldstein et al, 1994

Overall-mild/moderate

Overall-severe

Cambach et al, 1997

Griffiths et al, 2000

Wedzicha et al, 1998

Troosters et al, 2000

Wedzicha et al, 1998

Guell et al, 2000

Pulmonary Rehabilitation Improves Exercise And Health Status At One Year

Griffiths TL, et al. Lancet. 2000;355(9201):362-368.

P = 0.002

Dis

tan

ce W

alk

ed

(m

ete

rs)

1 year

100

175

212

137

6 weeks Before

P = 0.000

Exercise

Rehab

Control

Quality of Life

Qu

ality

of

Lif

e (

SG

RQ

)

1 year 6 weeks Before

50

62

69

56 P <0.000

P = 0.010

Rehab

Control

Oxygen Improves Survival in COPD

Flenley DC. Chest. 1985;87(1):99-103.

NOTT Group. Ann Intern Med. 1980;93(3):391-398.

Medical Research Council Working Party. Lancet 1981;1(8222):681-686.

Nocturnal Oxygen Therapy Trial (NOTT) study: COT – Continuous oxygen (17.7 hr) NOT – Nocturnal oxygen MRC trial: O2 – “nocturnal” oxygen (15hr) Controls – no oxygen


• Smoking cessation

Communication Strategies to Improve Adherence

1. Build a relationship

2. Focus on listening

3. Collaborate on the treatment plan

4. Manage time

5. Follow up

Bender BG. Pediatric Allergy: Principles and Practice. D. Leung, H. Sampson, R. Geha, and S. Szefler (eds.). New York: Elsevier; 455-462..

Tobacco Use: 2005 Prevalence

USA Colorado Rural Colorado

Current

Smokers 20.9% 17.3% 19.8%

http://www.cdphe.state.co.us/cohid/tabsdata.html

Deadly and linked with medical co-morbidities

Associated with lost work productivity and high costs

Associated with negative perceptions in social situations

Discouraged by many state governments and discouraged, limited, or barred in the workplace

And yet, about 20% of adults in Colorado

continue to smoke

Almost Everybody Seems to Know

That Smoking Is . . .

Jarvis MJ. BMJ. 2004;328(7434):277-279.

Dani JA, De Biasi M. Pharmacol Biochem Behav. 2001;70:439-446.

Addiction is Why People Continue

to Smoke

People smoke because they are addicted to nicotine

Smoking is a stronger addiction than heroin

addiction

There is a clear link between smoking, nicotine

receptors, and addiction

Challenges for Providers in the “Real World”

• Time (“I have too many other things to do”)

• Clinician Doubt (“Nothing helps people quit”)

• Provider “burn out” (“I’ve tried everything”)

• Remember: It’s a marathon, not a sprint

Physician Intervention

When physicians advise patients to quit

smoking, smoking cessation rates increase by

30%

Even very brief interventions by physicians can

be very effective

"Advising Smokers to Quit" is a measure of

physician performance in the US.

Physician Approach to Smoking

Cessation: 2 As and an R

1. ASK about tobacco use at each visit

2. ADVISE to quit at each visit

3. REFER for appropriate smoking cessation

help

Ask About Smoking

Ask all patients about smoking at each visit.

• The “fifth vital sign” or the “first vital sign”

Document smoking status routinely

Incorporate tobacco use as a vital sign assessed at

every visit to all health care providers

Increases smoking cessation interventions and may

increase quit rate

Advise

Strongly urge every patient to quit at every

visit.

• Use a clear, strong approach

• A < 3-minute message is sufficient

• Personalize the message for each

individual

Refer

• Refer to appropriate smoking cessation therapy

• Refer to support services

• QuitLine

• Other community services

• Provide pharmacotherapy options

QuitLine Fax Referral

Goals of Management in COPD

www.goldcopd.org

• Relieve symptoms

• Prevent disease progression

• Improve exercise tolerance

• Improve health status

• Prevent and treat complications

• Prevent and treat exacerbations

• Reduce mortality

COPD MANAGEMENT GOALS

Diagnose

Reduce Risk

Smoking cessation Immunize Reduce other exposures

Reduce Symptoms

Reduce Complications

Bronchodilators Consider inhaled steroids Pulmonary rehabilitation

Consider oxygen Treat exacerbations

Spirometry

Patient

Education

Patient

Education

Patient

Education

Patient

Education

www.goldcopd.org

COPD Stages

www.goldcopd.org

Stage FEV1 Rationale

I Mild FEV1 ≥ 80% Early detection

II Moderate 80% > FEV1

> 50% Early presentation

III Severe

50% > FEV1

> 30%

Symptoms, increased mortality, exacerbations, hospitalizations

IV Very Severe

FEV1 < 30% Need for oxygen, surgery

National Jewish Health COPD Toolkit

• Tools for the Healthcare Provider and Patient

– COPD Toolkit Provider Training

– Provider Manual

– Spirometer

– Patient COPD Toolkit Workbook

– Follow-up office visits

NJH COPD

Tools for Managing COPD

Why COPD Toolkit?

To improve care of COPD patients through:

– Evidence based education on diagnosis and management

• Achieved through one-day workshop followed by two in-the-clinic review and practice

– Patient education to increase effective self-management and medication adherence

• Achieved by helping providers to educate and support patients through multidisciplinary trainings and patient materials

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