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An 83-year-old male with chronic obstructive pulmonary disease (COPD) attended the respiratory clinic for a routine check-up. He also has a history of basal bronchiectasis. He is an ex-smoker since the age of 50, with a 30 pack-year history. His father and sister had chronic respiratory problems. The patient worked as a mechanic and had exposure to asbestos through brake linings. His current medications include tiotropium, ipratropium bromide/salbutamol nebuliser as required, and lansoprazole. He takes clarithromycin and oral steroids for exacerbations of COPD and suffered four episodes, managed at home, in the last year.
The patient continues to be very active and plays golf. His modified Medical Research Council (mMRC) score for breathlessness is 1/4. On examination, his oxygen saturations are 96 per cent on room air. His chest is hyperinflated but clear on auscultation. He weighs 80kg, giving him a BMI of 24.7 kg/m2. His FEV1 is 1.4 litres, or 45 per cent predicted, and there is a 17 per cent increase with salbutamol. The patient was commenced on budesonide/formoterol twice daily and was referred for outpatient physiotherapy for further assessment and management of his respiratory disease.
A series of questionnaires were completed by the patient at this session, including the COPD Assessment Test (CAT), in which he scored 13/40. He scored 1 on the mMRC score. The patient scored 7 on the Hospital Anxiety and Depression Scale (HADS). He also completed the St George’s Respiratory Questionnaire (SGRQ) and scored 30/100. He completed a 360-metre distance during a six-minute walk test. His BODE Index is 2, which indicates a 52-month mortality of approximately 20 per cent.
The physiotherapist also assessed several other areas, including the patient’s inhaler technique, airway clearance and breathlessness management. The patient received advice regarding daily exercise.
COPD is a major public health issue, resulting in chronic morbidity and mortality in global populations. The World Health Organisation (WHO) estimates that over 65 million people globally have moderate-to-severe COPD. COPD was the third-leading cause of death in 2012, with 3.1 million (5.6 per cent) of global deaths directly attributed to COPD. This figure is projected to rise to 8.6 per cent by 2030.
COPD affects over 23 million people in the EU and results in an estimated 1.1 million hospital admissions in the region per annum. Ireland has one of the highest rates of hospital admissions for exacerbations of COPD in the OECD, at 364 per 100,000, compared to 198 per 100,000 for the OECD. In 2011, the age-standardised death rate for COPD was 27.87 per 100,000 for Ireland, compared with 18 per 100,000 for the WHO European region.
Patients with COPD experience a wide variation in their level of disability. Several studies have shown that pulmonary rehabilitation can greatly benefit patients with COPD by reducing symptoms, improving activity and functional levels, leading to a reduction in the overall burden on the healthcare system.
COPD is a preventable and progressive disease, characterised by persistent airflow limitation and associated with a chronic inflammatory response in the airways and lung to noxious particles or gases, such as those found in tobacco smoke. The frequency of exacerbations and severity of pre-existing comorbidities contribute to disability. A diagnosis of COPD is made in the correct clinical context using spirometry.
Spirometry with a post-brochodilator FEV1 /FVC ratio of less than 0.7 is diagnostic of COPD, in combination with symptoms and in the absence of an alternative explanation for the symptoms of airflow obstruction. Despite a poor correlation with symptom burden, disease severity is often described using spirometric indices (Table 1).
Table 1: Grading of severity of airflow limitation in COPD (based on post-bronchodilator FEV1)
The 2015 Global Initiative for Chronic Obstructive Lung Disease (GOLD) revised guidelines determined that the main goals of assessment of COPD are to determine the severity of the disease, the severity of airflow limitation, the impact on the patient’s health status and the risk of future events, including exacerbations, hospital admissions or death, in order to guide treatment.
GOLD recommends that comorbidities such as cardiovascular disease, metabolic syndrome, osteoporosis, depression and lung cancer should be actively managed and optimised in order to reduce the impact on the patient’s overall health.
Management of stable COPD
All individuals who smoke should be encouraged to quit. The FEV1 value is a poor guide to the impact of the disease on patients. Consequently, each patient must be assessed in terms of their symptoms and future risk of exacerbation. This should also be incorporated into an individualised management strategy for stable COPD.
Influenza vaccines can reduce the risk of serious illness, including hospital admissions, due to lower respiratory tract infection and death in COPD patients by approximately 50 per cent.
Pharmacologic therapy is used to reduce symptoms, as well as the frequency and severity of exacerbations.
It can also improve health status and exercise tolerance. Long-acting β2 agonists and anticholinergics are preferred over short-acting formulations. Based on efficacy and side-effects, inhaled bronchodilators are preferred over oral bronchodilators. Long-term treatment with inhaled corticosteroids, added to long-acting bronchodilators, is recommended for patients at high risk of exacerbations. Long-term monotherapy with oral or inhaled corticosteroids is not recommended. The phosphodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV1 <50 per cent predicted, chronic bronchitis, and frequent exacerbations.
Assessment of the COPD patient
The main aims of assessing a patient with COPD are to determine: (1) the impact of the disease on the patient’s overall health status in terms of symptoms and restriction on daily functions; (2) the extent of airflow limitation; (3) the risk of hospital admissions, exacerbations or death; and (4) the presence of comorbidities that may be exacerbating the symptoms. This information is used to guide treatment of the disease.
There are several tools that are used to assess the severity symptoms in a patient with COPD, including the modified Medical Research Council Scale (mMRC), COPD Assessment Test (CAT), St George’s Respiratory Questionnaire (SGRQ) and the Body mass index, airflow Obstruction, Dyspnoea and Exercise (BODE) Index. GOLD recommends using the mMRC or CAT to assess the severity of symptoms, with higher scores indicating greater impact on the patient’s daily life.
Combined COPD assessment
A combined COPD assessment involves categorising the severity of airflow obstruction in terms of the FEV1. The grading ranges from GOLD stage 1 to 4. Stage 1 indicates mild airflow limitation with FEV1 >80 per cent predicted, while stage 4 indicates severe airflow limitation with FEV1 <30 per cent predicted. This staging is used in combination with a symptom assessment, either the mMRC or CAT scores, to give an indication as to the severity of symptoms. The risk of exacerbation can be determined using either the FEV1 values or the number of exacerbations in the preceding year. If the patient has two or more exacerbations in the preceding year, this indicates the patient is at high risk for further exacerbations. A combination of FEV1 staging, mMRC or CAT scores and the number of exacerbations allows the patient to be staged as GOLD A, B, C or D (see Figure 1).
Figure 1: GOLD A, B, C, D staging diagram
There are several tools available that can be used to assess the level of disability due to COPD, including the mMRC, CAT, Chronic Respiratory Disease Questionnaire (CRQ), Clinical COPD Questionnaire (CCQ) and the SGRQ. While some of these are quite complex to administer, the mMRC provides a simple method to grade the effect of dyspnoea on a patient’s daily activities and mobility. The scale is subjective, measuring a patient’s perceived respiratory disability. It is a five-point scale graded from 0 to 4, with those who have dyspnoea only during rigorous exercise scoring 0, while those who are too breathless to leave home scoring 4. The mMRC is used to calculate the BODE Index, which is a tool used to predict the life expectancy for a patient with COPD.
The CAT was developed to provide healthcare professionals with a simple tool for quantifying the severity of symptoms in a patient with COPD. CAT consists of eight items, each presented on a six-point differential scale, providing a score out of 40, which indicates the impact of the disease. It is completed by the patient and the result is immediately available by adding together the scores on individual items. Scores of 0-10, 11-20, 21-30 and 31-40 represent mild, moderate, severe or very severe clinical impact. The CAT is freely available online at www.catestonline.org.
The BODE Index is a tool used to grade the severity of COPD. The severity of airflow obstruction is indicated by the FEV1, while dyspnoea is measured using the mMRC and exercise tolerance is indicated by the six-minute walk test. The BODE Index is an excellent predictor of the risk of death in patients with COPD. The BODE Index provides a comprehensive assessment as it includes one domain that quantifies the degree of pulmonary impairment (FEV1), one that captures the patient’s perception of symptoms (mMRC dyspnoea scale), and two independent domains (the distance walked in six minutes and the BMI) that express the systemic consequences of COPD.
The SGRQ is designed to measure health impairment in patients with asthma and COPD. The questionnaire assesses three main areas, including symptoms, activity and impacts. The symptoms component is concerned with the effect of respiratory symptoms, including their frequency and severity, while the activity part looks at which activities cause or are limited by dyspnoea. The impact section looks at the psychosocial disturbances that may result from COPD. A total score is calculated that summarises the impact of the disease on overall health status.
Scores are expressed as a percentage of overall impairment, where 100 represents worst possible health status, and 0 indicates the best possible health status. This questionnaire can be time-consuming to administer and while sensitive to clinically-significant changes in health status, it is often limited to research settings.
The Hospital Anxiety and Depression Scale (HADS) is a tool commonly used to determine the levels of anxiety or depression in people with physical health problems. There are 14 items on the scale, seven of which refer to anxiety and seven to depression. Each item is scored from 0 to 3 and a maximum score of 21 for both anxiety and depression. A score greater than 8 indicates some psychological distress, with higher scores indicating greater severity.
HADS can be applied to a patient with any disease. A study by Dowson et al showed that clinically-relevant anxiety, indicated by higher HADS scores, was more common in patients with severe COPD.
COPD is a common, chronic and progressive condition. It has a significant impact on health status. Health resources and medical interventions often focus on the acutely unstable patient or those in exacerbation. The patient, however, spends longer in a chronic, stable state than acute crisis. Treatment decisions taken in the management of stable patients have implications both for exacerbation frequency and overall quality of life. Interventions include pharmacotherapy, psychosocial support and physical therapy. A range of well-validated tools now exists to assist the physician in defining disease severity and tailoring the therapeutic response.
References available on request