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Chronic Obstructive Pulmonary Disease (COPD)

Brief Overview: Per UpToDate, “The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a project initiated by the National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO), defines COPD as a "heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, expectoration, exacerbations) due to abnormalities of the airway (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction". In practice, the diagnosis of COPD requires all of the following:

  • The presence of pulmonary symptoms (dyspnea, cough, or sputum production)
  • The appropriate clinical context (most notably but not exclusively tobacco exposure)
  • Evidence of airflow limitation that persists despite acute bronchodilator treatment.”

Classification based on FEV1 – Per UpToDate, "While the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy recommends COPD diagnosis using symptoms accompanied by a forced expiratory volume in one second (FEV1)/ forced vital capacity (FVC) ratio <0.7, the severity of obstruction is determined by the FEV1 percent predicted. The GOLD severity grading system uses four grades:

  • GOLD 1 (mild disease): FEV1 ≥80 percent predicted

  • GOLD 2 (moderate disease): FEV1 between 50 and 80 percent predicted

  • GOLD 3 (severe disease): FEV1 between 30 and 50 percent predicted

  • GOLD 4 (very severe disease): FEV1 <30 percent predicted"

Prevalence: According to UpToDate, “It is estimated that approximately 10 percent of individuals aged 40 years or older have COPD, although the prevalence varies between countries and increases with age.”

Etiology:

  • Chronic inhalational exposure leading to airway inflammation and lung parenchymal damage.
  • Cigarette smoking is the primary cause.
  • Other contributors include occupational dusts/chemicals, air pollution, and alpha-1 antitrypsin deficiency (genetic).

Risk Factors:

  • Cigarette moking
  • Environmental exposures to toxins, fumes, dust, vapors, smoke, chemicals, etc.
  • Biomass fuel exposure
  • Age
  • Atopy
  • Increased airway responsiveness to allergens or external triggers
  • Asthma
  • Childhood pneumonias
  • TB infection
  • HIV
  • Premature birth, early-life asthma
  • Genetics, family history of COPD or other chronic respiratory illnesses
  • Chronic exposure to air pollution

Commonly Associated Conditions:

  • Lung cancer
  • Bronchiectasis
  • Cardiovascular disease
  • Osteoporosis
  • Metabolic syndrome
  • Anxiety, depression
  • Sleep-related breathing disorders
  • Diabetes
  • Rheumatoid arthritis
  • IBD
  • GERD

Common Medications:

  • Inhaled bronchodilators with or without ICS
  • Short-acting bronchodilators for PRN relief – albuterol and levalbuterol
  • SAMA – ipratropium
  • SABA-SAMA – albuterol with ipratropium
  • Long-acting bronchodilators:
    • LABA = salmeterol, formoterol, arformoterol, indacaterol, vilanterol, olodaterol
    • LAMA = tiotropium, aclidinium, umeclidinium, glycopyrrolate, revefenacin
  • Combination inhalers:
    • LABA/LAMA combinations
    • ICS/LABA combinations (selected patients with frequent exacerbations or eosinophilia)
    • Triple therapy (ICS/LABA/LAMA) for severe disease

Common Labs, Imaging, and Tests:

  • Spirometry
  • Labs: CBC, BMP/CMP, TSH, N-terminal pro hormone BNP, alpha-1 antitrypsin testing
  • Chest x-ray
  • Thoracic CT

Common Symptoms:

  • Dyspnea
  • Chronic cough
  • Sputum production
  • Exertional and/or progressive dyspnea
  • Wheezing, chest tightness
  • Fatigue and exercise intolerance
  • Frequent respiratory infections or exacerbations
  • Weight loss or muscle wasting (advanced disease)

Per UpToDate, “Approximately 62 percent of patients with moderate to severe COPD report variability in symptoms (eg, dyspnea, cough, sputum, wheezing, or chest tightness) over the course of the day or week to week; morning is typically the worst time of day.”

Common Treatments:

  • Medication (see above)
  • Smoking cessation
  • Inhaler technique education
  • Pulmonary rehabilitation – exercise, healthy behaviors, education, medication adherence, psychological support
  • Vaccination as recommended by healthcare provider
  • Maintain optimal BMI
  • Supplemental oxygen may be indicated for some with severe COPD
  • Per UptoDate, “Selected patients with advanced COPD or emphysema may benefit from nocturnal noninvasive ventilation, bronchoscopic or surgical lung volume reduction, or lung transplantation.”
  • Exacerbation action plan and early treatment

Physical Findings:

  • May have normal physical exam, especially with mild disease
  • Prolonged expiratory time
  • Faint end-expiratory wheezes on forced exhalation
  • Hyperinflation
  • Decreased breath sounds, wheezes, crackles at lung bases
  • Distant heart sounds
  • “Barrel-shaped” chest = increased AP diameter of chest
  • Use of accessory muscles
  • Cyanosis or signs of chronic hypoxia in severe disease

Potential Complications and Contraindications:

  • Potential complications:
    • Acute COPD exacerbations
    • Respiratory failure
    • Pulmonary hypertension and cor pulmonale
    • Recurrent infections
    • Reduced mobility and frailty
    • Per UpToDate, “Patients with COPD may experience weight gain (due to activity limitations), weight loss (possibly due to dyspnea while eating or increased metabolic work of breathing), limitation of activity (including sexual), cough, syncope, or feelings of depression or anxiety. Weight loss generally reflects more advanced disease and is associated with a worse prognosis.”
  • Contraindications / cautions:
    • Overuse of systemic steroids (osteoporosis, hyperglycemia)
    • Inhaled corticosteroids increase pneumonia risk in some patients
    • Sedatives and opioids may worsen respiratory drive
    • Beta-blockers require careful selection (cardioselective preferred)

General Health and Lifestyle Guidance:

  • Reinforce smoking cessation support at every contact
  • Ensure correct inhaler technique and adherence
  • Encourage physical activity and pulmonary rehab participation
  • Avoid respiratory irritants and poor air quality
  • Maintain nutrition and muscle strength
  • Recognize and act early on exacerbation symptoms
    • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Suggested Questions to Ask Patients:

  1. How often are you short of breath during daily activities?
  2. How frequently do you use your rescue inhaler?
  3. Any recent exacerbations, ER visits, or hospitalizations?
  4. Any increase in cough, sputum color, or volume?
  5. Are you using your inhalers as prescribed? Any technique issues?
  6. Do you smoke or have exposure to secondhand smoke?
  7. Are symptoms limiting your ability to walk or perform self-care?

Suggested Talking Points:

  • COPD is chronic and progressive, but symptoms can be managed effectively.
  • Stopping smoking is the most important step to slow disease progression.
  • Daily inhalers help keep airways open and reduce flare-ups.
  • Early treatment of exacerbations can prevent hospitalizations.
  • Pulmonary rehab improves breathing, strength, and quality of life.
  • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.