PCPs can treat COPD without referral
The updated GOLD guidelines stress the importance of spirometry
Chronic obstructive pulmonary disease (COPD), a major health problem and cause of death in the United States and throughout the world, is "preventable and treatable," according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), a group formed by the World Health Organization and the National Heart, Lung and Blood Institute.
While improving symptoms and avoiding exacerbations remain the primary goals of therapy, the most recent update of GOLD's practice guidelines presents new evidence that certain treatments may also slow lung-function decline.
"Primary-care providers [PCPs] are the front line: They are the ones diagnosing these patients," says Antonio R. Anzueto, MD, professor of medicine at University of Texas, San Antonio, and a member of the committee that developed the update. "These clinicians can care for 90% of COPD cases. If patients are properly diagnosed and treated, there's often no need to refer to anyone else."
A definitive diagnosis of COPD requires spirometry, and while pulmonary-function screening need not be universal, it should be offered widely. The guidelines recommend testing—forced vital capacity (FVC) and forced expiratory volume in one second (FEV1)—for individuals older than age 40 years with dyspnea, chronic cough, or sputum production, or a history suggesting increased risk—particularly exposure to tobacco smoke or occupational toxins or irritants.
Postbronchodilator FEV1/FVC <0.70 is the standard threshold for diagnosis, although this should ideally be adjusted to age-related norms to avoid over- or under-diagnosis.
The GOLD guidelines stress the importance of high-quality spirometry, which requires up-to-date equipment and appropriate training. If this is not available in the primary-care setting, patients should be referred to an appropriate facility in a hospital or elsewhere in the community. "You don't want to make decisions on the basis of a bad test," Dr. Anzueto advises.
Once diagnosed, COPD should be staged (mild, moderate, severe, or very severe) by comparing FEV1 to age-adjusted predicted values.
Because COPD is typically progressive, treatment regimens should be revised periodically. Regular follow-up visits should include physical examination and discussion of symptoms, with repeat spirometry to assess for deterioration. Measure arterial oxygen pressure in patients with advanced disease to screen for respiratory failure, the guidelines recommend.