Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and follows cancer as the fourth-leading cause of death in the United States (N=156,979 deaths annually).¹ The direct costs for COPD admissions in the United States are approximately $50 billion annually.² The percentage of US adults who have ever been diagnosed with COPD (including emphysema and chronic bronchitis) is 4.6%,1 and the prevalence is 2-fold higher in rural areas of the country than in large metropolitan areas (8.2% vs 4.7%; Figure 1).3,4
In the United States, COPD is mainly diagnosed and managed in the primary care setting; however, misdiagnosis rates range from 10% to 40%.5 The primary goal of COPD management is to effectively manage symptoms and improve quality of life. Understanding and implementing the Global Initiative for Chronic Obstructive Lung Disease (GOLD) standards will guide providers in diagnosing and staging patients with COPD accurately and selecting appropriate prescriptive therapy.6 Using the GOLD standards for COPD will help clinicians more effectively identify high-risk patients, improve delivery of care, and reduce exorbitant spending of health care dollars.
Pulmonary Function Tests
Diagnosis of COPD should be considered in any patient presenting with dyspnea, chronic cough or sputum production, history of recurrent lower respiratory tract infections or low birth weight, and/or a history of exposure to COPD risk factors (eg, genetic factors or congenital/developmental abnormalities; tobacco smoking; exposure to occupational dusts, vapors, fumes, gases, or other chemicals; exposure to smoke from home cooking/heating fuels).
After completion of a thorough patient assessment, pulmonary function tests (PFTs) should be ordered for patients with suspected COPD.7 Spirometry is the preferred tool for detecting airflow limitation and diagnosing COPD.6,7 Spirometry performed in a primary care clinic is as reliable as that performed in a pulmonary function laboratory as long as the clinician is skilled with calibration of the machine, administration of the test, and interpretation of the results.6,7 Many hospitals complete outpatient PFTs in the respiratory department, and clinicians must be proficient in interpreting the results.
Key components of spirometric assessment are as follows6:
- Forced expiratory volume (FEV1): the amount of air exhaled in the first second of expiration
- Forced vital capacity (FVC): volume of air forcibly exhaled from the point of maximal inspiration
- FEV1/FVC: ratio of these 2 measurements expressed as a fraction
A postbronchodilator FEV1/FVC <0.7 confirms airflow limitation and COPD diagnosis in patients with appropriate symptoms and exposures to noxious stimuli. Suggested bronchodilator doses include 400 µg short-acting β2-agonist, 160 µg short-acting anticholinergic, or both agents combined. Timing of FEV1 measurement is based on which agent is used: at 10 to 15 minutes after a short-acting β2-agonist or 30 to 45 minutes after a short-acting anticholinergic or combination of both agents. These measurements should be compared with reference volumes based on age, height, sex, and race.6
Additional spirometry tips provided in the GOLD report include recording long enough for a volume plateau to be reached, which may be more than 15 seconds in a patient with severe disease. Practitioners should use the largest of the individual FEV1 and FVC measurements taken from any of 3 technically satisfactory curves, with the curves varying no more than 5% or 150 mL, whichever is the greater value. The FEV1/FVC ratio should be derived from the technically acceptable curve that has the largest sum of FEV1 and FVC.6
The GOLD report provides guidance on assessing the level of airflow limitation, impact of COPD on patient’s health status, and risk for future exacerbations. The FEV1 will guide clinicians in determining GOLD stage of disease severity (Table 1).
Previously, a measure of breathlessness such as the Modified British Medical Research Council (mMRC) dyspnea scale was used as the sole assessment of symptom severity.6 The revised GOLD assessment scheme includes use of spirometry to assess severity of airflow limitation; assessment of either dyspnea via the mMRC or symptoms using the COPD Assessment Test (CAT); and history of moderate and severe exacerbations, including prior hospitalizations (Figure 2).6
Modified British Medical Research Council Dyspnea Scale
The mMRC dyspnea scale is a concise, patient-centered tool that measures the level of dyspnea when walking or exercising. Patients with scores of 0 to 1 are in group A or C, and patients with scores of 2 to 5 are in group B or D (Table 2).5,8
COPD Assessment Test
The CAT is an easily administered, 8-item health questionnaire that assesses dyspnea and activity limitations to calculate a score that captures symptom burden and impact of COPD on activities of daily living.9 Results range from a score of 0 to 40, and 10 is a cutoff for consideration of regular treatment for symptoms, including breathlessness.6 This information also can improve communication between the patient and the health care team when assessing the impact of symptoms beyond dyspnea on activities of daily living.6,10
COPD Classification Group Guides Treatment
Initiation of pharmacotherapy for COPD is based on the ABCD assessment scheme in the GOLD report (Figure 2).6 Patients in group A should be prescribed a long- or short-acting bronchodilator. Patients in group B should be prescribed a long-acting muscarinic antagonist (LAMA) or a long-acting β agonist (LABA); there is no evidence to recommend one class over the other, and the choice should be dependent upon the patient’s perception of symptom relief. If a patient in group B continues to have symptoms, a combination LAMA plus LABA may be used as control therapy. A LAMA is the choice for initial therapy among patients in groups C and D. Group D patients may be more symptomatic and may benefit from combination therapy with a LAMA plus LABA (for persons with CAT ≥20) or a LABA plus inhaled corticosteroid (ICS) (for persons with blood eosinophil counts ≥300 cells/µL). If the patient is experiencing persistent breathlessness or is exercise-intolerant, combination treatment should be used.
If there is no improvement with dual therapy, treatment should be changed to triple therapy with LAMA, LABA, and ICS. If patients on triple therapy still have exacerbations, treatment options are to add roflumilast, add a macrolide, or stop ICSs if the patient reports lack of efficacy or adverse effects (eg, pneumonia).
Nonpharmacologic Management of COPD
Smoking cessation and physical activity are recommended for all patients with COPD.6 For patients in groups B, C, and D, pulmonary rehabilitation is also recommended. The GOLD report has added COVID-19 vaccination to its list of recommended vaccines, which also includes influenza, pneumococcal, and pertussis vaccinations.
Long-term oxygen therapy is recommended for stable patients with:
- Partial pressure arterial oxygen (PaO2) ≤55 mm Hg or arterial oxygen saturation (SaO2) ≤88% with or without hypercapnia confirmed twice over 3 weeks; or
- PaO2 55 mm Hg to 60 mm Hg or SaO2 88% in patients with pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia.
COVID-19 and COPD
The GOLD report recommends COVID-19 testing for patients with COPD who present with new or worsening respiratory symptoms, fever, or other COVID-19 symptoms.6 Patients should continue taking ICSs, long-acting bronchodilators, roflumilast, chronic macrolides, systemic steroids, and antibiotics as indicated during the pandemic.6
Most patients with COPD have not undergone appropriate PFTs or are receiving inadequate mediations according to their GOLD class.12 The estimated $50 billion spent annually on COPD therapy cost could be decreased by improving diagnosis and staging of this disease and implementing appropriate therapy.2 Using the GOLD standards to classify COPD stage and prescribe the correct pharmaceutical management may reduce daily symptoms, reduce hospital admissions, and improve quality of life.
Shannon Harris, DNP, FNP-BC, CCRN, is an assistant professor at the University of South Alabama College of Nursing and a nurse practitioner at Diagnostic Medical Clinic, both in Mobile, Alabama. Lori Prewitt Moore, DNP, FNP-BC, RN, CHSE, is an assistant professor at the University of South Alabama College of Nursing.
1. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease (COPD) includes: Chronic bronchitis and emphysema. Updated September 13, 2021. Accessed December 9, 2021.
2. Press VG, Konetzka RT, White SR. Insights about the economic impact of chronic obstructive pulmonary disease readmissions post implementation of the hospital readmission reduction program. Curr Opin Pulm Med. 2018;24(2):138-146. doi:10.1097/MCP.0000000000000454
3. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205-211. doi:10.15585/mmwr.mm6707a1
4. Centers for Disease Control and Prevention. Data and statistics: COPD death rates in the United States. Updated June 14, 2021. Accessed December 13, 2021.
5. Ragaišienė G, Kibarskytė R, Gauronskaitė R, et al. Diagnosing COPD in primary care: what has real life practice got to do with guidelines? Multidiscip Respir Med. 2019;14:28. doi:10.1186/s40248-019-0191-6
6. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2022 Report. Accessed December 10, 2021.
7. Graham BL, Steenbruggen I, Miller MR, et al. Standardization of spirometry 2019 update. An official American Thoracic Society and European Respiratory Society technical statement. Am J Respir Crit Care Med. 2019;200(8):e70-e88. doi:10.1164/rccm.201908-1590ST
8. Fletcher CM. Standardised questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on Aetiology of Chronic Bronchitis (MRC breathlessness score). BMJ. 1960;2:1662.
9. Gil HI, Zo S, Jones PW, et al. Clinical characteristics of COPD patients according to COPD assessment test (CAT) score level: cross-sectional study. Int J Chron Obstruct Pulmon Dis. 2021;16:1509-1517. doi:10.2147/COPD.S297089
10. Munari AB, Gulart AA, Dos Santos K, Venâncio RS, Karloh M, Mayer AF. Modified Medical Research Council dyspnea scale in GOLD classification better reflects physical activities of daily living. Respir Care. 2018;63(1):77-85. doi:10.4187/respcare.05636
11. Halpin DMG, Criner GJ, Papi A, et al. Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee report on COVID-19 and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;203(1):24-36. doi:10.1164/rccm.202009-3533SO
12. Rohde J, Joseph A, Tambedou B, et al. Reducing 30-day all-cause acute exacerbation of chronic obstructive pulmonary disease readmission rate with a multidisciplinary quality improvement project. Cureus. 2021:13(11): e19917. doi:10.7759/cureus.19917