Approximately 24 million Americans have airway obstruction that is suggestive of COPD. With close to 125,000 annual deaths attributed to the disease, COPD now ranks as the third leading cause of death in the United States. Despite the disease’s wide scope, about 50% of patients are undiagnosed, largely because it’s underrecognized by the public. COPD progresses slowly, with early disease presenting with mild symptoms that patients learn to live with. Many COPD sufferers view their symptoms as a part of aging. Only few link them to smoking, the primary cause of the disease.
Clinicians Play a Vital Role in Diagnosing COPD
Despite recommendations from national guidelines, many clinicians throughout the U.S. do not utilize spirometry, an important tool in diagnosing COPD, because they feel it’s too time-consuming or expensive. This can lead to under-diagnosis, a problem commonly seen in the outpatient setting. Further complicating the issue is that many patients with COPD don’t receive a diagnosis until they are hospitalized from exacerbations that are usually triggered by infections. About 750,000 patients with COPD require hospitalizations each year. These patients tend to have poorer long-term outcomes than those diagnosed and treated effectively in the outpatient setting. Prevention of hospitalizations due to exacerbations through early diagnosis and treatment, smoking cessation, and increased awareness of COPD among patients and providers is important.
7 Key Recommendations for COPD
There are several guidelines for COPD, including those from the American Thoracic Society, European Respiratory Society, American College of Physicians, and American College of Chest Physicians. In the August 2, 2011 Annals of Internal Medicine, my colleagues and I published a consensus that brings together recommendations from each of these well-respected societies into one document. We posed several questions and addressed them based on the latest literature. The result was the following recommendations on COPD diagnosis and treatment:
1. Spirometry should be used to diagnose airflow obstruction in patients with respiratory symptoms, but not used to screen in those without these symptoms.
2. Treatment with bronchodilators is recommended for stable COPD patients with respiratory symptoms and FEV1 less than 60%.
3. Based on patient preference, cost, and adverse effect profile, clinicians should prescribe monotherapy with longacting inhaled anticholinergics or inhaled β-agonists for symptomatic patients with COPD and FEV1 less than 60%.
4. Bronchodilators may be used in stable COPD patients with respiratory symptoms and FEV1 from 60% to 80%.
5. Combination long-acting inhaled anticholinergics, longacting inhaled β-agonists, or inhaled corticosteroids may be used in symptomatic patients with stable COPD and FEV1 less than 60%.
6. Pulmonary rehabilitation should be used for symptomatic patients with FEV1 less than 50% and considered in symptomatic or exercise-limited patients with FEV1 greater than 50%.
7. Continuous oxygen therapy should be used in patients with COPD and severe resting hypoxemia.
A patient’s history alone isn’t enough to diagnose COPD because the problem is often underestimated or underreported. In addition to taking a patient’s history, clinicians must recognize that spirometry continues to be the most important objective measure for diagnosing COPD and staging its severity. Smoking cessation remains the most important intervention in managing COPD. Once diagnosed, symptomatic patients should also receive maintenance medications. Hopefully, the release of our consensus recommendations will help clinicians better diagnose and manage stable COPD, prevent and treat its exacerbations, improve quality of life, and reduce mortality in these individuals.
Readings & Resources (click to view)
Qaseem A, Wilt T, Weinberger S, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-191.
Qaseem A, Snow V, Owens D, Shekelle P. The development of clinical practice guidelines and guidance statements of the American College of Physicians: Summary of methods. Ann Intern Med. 2010;153:194-199.
Regvat J, Zmitek A, Vegnuti M, et al. Anxiety and depression during hospital treatment of exacerbation of chronic obstructive pulmonary disease. J Int Med Res. 2011;39:1028-1038.
Vogelmeier C, Wouters E. Treating the systemic effects of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2011;8:376-379.
Rennard S, Wachenfeldt K. Rationale and emerging approaches for targeting lung repair and regeneration in the treatment of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2011;8:368-375.