Chronic obstructive pulmonary disease (COPD) is a common, preventable, treatable disorder associated with disabling symptoms, skeletal muscle dysfunction and impaired quality of life. Significant morbidity and mortality are associated with COPD, resulting in 739,000 hospitalizations and 15.4 million office visits annually.1 COPD is now the third leading cause of death in the United States, and it is the only leading cause of death that is on the rise.2
In most age and ethnic groups, COPD is more common in women than in men.3 Today, more women die of COPD than men.3 The cause of the increased prevalence among women is unknown, but it may be due to increased smoking rates.4 COPD is associated with systemic manifestations and multiple comorbidities, including cardiovascular disease, gastroesophageal reflux disease, osteoporosis and mood disorders.5 Importantly, COPD is underdiagnosed and therefore undertreated. Nurse practitioners and physician assistants play a key role in the accurate diagnosis and effective treatment of COPD.
Key areas of importance for NPs and PAs are early recognition, accurate diagnosis, ongoing effective treatment and regular follow-up to improve COPD outcomes and influence morbidity and mortality. Challenges include adherence to treatment, use of evidence-based guidelines, and prevention and timely management of exacerbations and comorbidities.
Overview of COPD
COPD is characterized by persistent airflow limitation, exacerbations and comorbidities that worsen severity and disability.5The Global Strategy for the Diagnosis, Management and Prevention of COPD was established in 2001 and its guidelines were updated in 2011. Key points of the guidelines are that COPD is a common, preventable, persistent disease characterized by airflow limitation that is often progressive and associated with chronic inflammatory airway and pulmonary response to noxious irritants. Exacerbations and comorbidities influence severity. Emphysema (destruction of lung parenchyma) and chronic bronchitis (chronic cough and sputum production) are combined under the umbrella term COPD, with each having variable contribution to the disease.6The greatest risk factor for COPD is smoking.7
Screening and Diagnosis
Screening and accurate diagnosis of COPD in patients with risk factors may improve timely diagnosis and effective treatment. A clinical diagnosis of COPD should be considered in people who have dyspnea, chronic cough and/or sputum production and a history of exposure to risk factors including smoking.6 Despite its considerable prevalence, COPD often goes undiagnosed and untreated.3,7 Assessment of COPD includes evaluation of symptoms, severity of airflow limitation, risk of exacerbation and presence of comorbidities. A primary clue to COPD is the insidious onset and progression of symptoms. COPD-related symptoms such as dyspnea, cough, wheeze, fatigue and dysphoria commonly occur in other disorders, further complicating disease assessment and detection. Patients may also underreport COPD-related symptoms.
A validated screening tool for COPD is available from the COPD Alliance at http://www.copd.org/screening/survey. The COPD Population Screener (COPD-PS) includes five questions related to the patient's smoking history and symptoms, and it is scored based on the patient's risk for COPD. All patients who score 5 or greater on the COPD-PS should undergo spirometry testing to confirm diagnosis.8 The tool can be used in office practices or can be completed online by patients.
The COPD Assessment Test (CAT), available at http://catestonline.co.uk/, measures the impact of COPD on a patient's life and changes in health status over time. The tool has eight items that describe severity or control of various respiratory symptoms and health status.9,10 Scores for the individual items may provide insight into the impact of different components of COPD on a patient's life, which can be explored further through consultation and intervention.9,10 A CAT score should be considered in the context of forced expiratory volume in 1 second (FEV1), exacerbation frequency and co-morbidities. Patients with more severe COPD and/or more frequent exacerbations tend to have higher CAT scores than patients with milder COPD. 9,10
Questionnaires such as the CAT may be useful for screening, but they are not suitable for the diagnosis of COPD.11 The gold standard for diagnosing COPD is spirometry or full pulmonary function testing. However, these diagnostic tools are underused.12 Underuse is not clearly understood but may be due to COPD-related symptoms that are common in other disorders and poor clinician awareness and use of evidence-based guidelines. In addition to accurately diagnosing COPD and staging its severity, spirometry may help differentiate COPD from asthma.13
Assessment and Goals of Management
The goals of COPD management include relief of symptoms, improvement of exercise tolerance and health status, reduced risk of disease progression, and prevention of exacerbation and mortality.6 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are international evidence-based guidelines for COPD management that outline principles for the prevention, diagnosis and treatment of COPD.6 Clinicians may not be familiar with or not use these guidelines.14
The GOLD staging system classifies COPD airflow limitation or obstruction based on post-bronchodilator spirometry or pulmonary function tests (see table). Two critical values of spirometry are forced vital capacity (FVC), which is the total forced exhaled breath volume after a maximal inhalation, and the FEV1 equal to the first second of FVC. COPD criteria include an FEV1 of at 70% or less of FVC (FEV1 /FVC ratio). Severity staging using GOLD criteria for airflow limitation uses four levels of severity based on FEV1 (see table).6 As airflow limitation worsens, FEV1 declines.
Management of COPD
GOLD recommends a stepwise approach to COPD management based on stage of severity. Management includes reducing risk factors through smoking cessation, reducing exposures to irritants such as biomass cooking, vaccination against influenza and pneumococcal pneumonia, and pulmonary rehabilitation for improvement of function, symptoms and quality of life. The cornerstone of pharmacologic management of COPD is long-acting bronchodilators, particularly in patients with moderate to very severe COPD.
Inhaled steroids should be prescribed for patients with severe COPD and frequent exacerbation. Short-acting beta-agonists may be used for rescue and exacerbations (with or without short-acting anticholinergics).6,15
It is important to note that patients with COPD should not rely on rescue medication alone. Increased frequency of rescue medication use may indicate worsening of disease.16
COPD exacerbations contribute to long-term decline in lung function17 and worsening health status. Goals of COPD exacerbation management include minimizing the impact of current exacerbations and preventing future episodes.6
Making an Impact
COPD is a common, often progressive and disabling disease. Despite the absence of cure and the broad impact of the disease on health, NPs and PAs can greatly influence the disease and its consequences through appropriate screening, accurate diagnoses, effective treatment based on evidence-based guidelines, and ongoing clinical follow-up. The cornerstone of effective pharmacologic treatment is long-acting bronchodilators. Important and effective treatment also includes vaccination against influenza and pneumococcal pneumonia, pulmonary rehabilitation and prevention, early detection, and effective management of exacerbations.
Chris Garvey is a family nurse practitioner who is manager of Pulmonary & Cardiac Rehabilitation at Seton Medical Center in Daly City, Calif. She is also a member of the treatment team at the University of California San Francisco Sleep Disorders Center in San Francisco. Garvey has completed a disclosure statement and reports that she has served on the technical advisory board for Boehringer Ingelheim.
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