Chronic obstructive pulmonary disease (COPD) is a common, preventable, treatable, and often progressive disorder characterized by airflow limitation that is not fully reversible.1 COPD is associated with airway obstruction and lung hyperinflation that contribute to increased symptom burden, exercise intolerance, and diminished quality of life. In addition to pulmonary abnormalities, COPD is associated with significant systemic manifestations including skeletal muscle dysfunction, osteoporosis, cor pulmonale, body mass abnormalities, and mood disorders.2,3
COPD guideline statements
National evidence-based guidelines provide recommendations for prevention, diagnosis, and a stepwise approach to treatment based on disease severity, symptoms, and disability. Guidelines include the American Thoracic Society (ATS)/European Respiratory Society (ERS) Standards for the diagnosis and treatment of patients with COPD http://www.thoracic.org/sections/copd/ and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) http://www.goldcopd.com/.1,4 NPs play a key role in accurately diagnosing and collaboratively managing these patients. Key management principles include ongoing preventive care to reduce disease progression whenever possible and control disabling symptoms.
Although COPD is fairly common, it often goes undiagnosed.5,6 According to the Third National Health and Nutrition Examination Survey (NHANES III) survey, 10 million individuals in the United States suffer from provider-diagnosed COPD, yet 24 million have evidence of COPD.6 COPD is associated with significant healthcare utilization, including 8 million primary care provider and hospital outpatient visits, 1.5 million ED visits, and 726,000 hospitalizations in the United States.5 Over 126,000 people die annually in the United States from COPD.5 Deaths increased 8% between 2000 and 2005 with the greatest increases seen in women.7 COPD currently ranks as the fourth-leading cause of death in the United States and the only major cause of death that is on the rise.
The ATS/ERS defines COPD as a preventable and treatable disease characterized by airflow limitation that is not fully reversible. Airflow limitation is usually progressive and is associated with an abnormal inflammatory pulmonary response to noxious particles or gases, primarily from cigarette smoke. COPD is a heterogeneous disorder that includes chronic bronchitis and/or emphysema. Chronic bronchitis is defined as a chronic, productive cough for at least 3 months in 2 consecutive years when other causes of productive cough have been excluded.1 Emphysema is associated with abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of alveolar walls without obvious fibrosis.1 Both conditions may occur simultaneously in COPD. GOLD guidelines define COPD by pulmonary function abnormality as the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of less than 70% predicted. Severity is defined by the patient's FEV1.4 The GOLD guidelines classify COPD according to four stages. Stage I is considered mild disease and the patient's FEV1 is 80% predicted or greater. Stage II is moderate disease and the patient's FEV1 is 50% to 80% predicted. Stage III disease is considered severe and the FEV1 will range between 30% and 50% predicted. Stage IV COPD is a very severe disease; the patient's FEV1 will be less than 30% predicted or the FEV1 will be less than 50% predicted with chronic respiratory failure.4
Although COPD affects the lungs, it also produces significant systemic consequences. The natural history of COPD includes exacerbations and progressive exercise intolerance.
Despite its high prevalence, COPD often goes undiagnosed and untreated.5 Potential barriers to accurate diagnosis and treatment include disease heterogeneity and inadequate screening for risk factors and disease-related symptoms. Accurate diagnosis and treatment can potentially improve symptom control and facilitate strategies to reduce disease progression such as smoking cessation and exacerbation prevention. Accurate clinical diagnosis begins with assessing the patient for symptoms such as dyspnea, cough, sputum and/or wheezing, and evaluation of the patient's exposure to risk factors including smoking (both active and passive), environmental exposures including biomass fuel smoke, industrial fumes or particulates, and air pollution.4 Other risk factors that may influence the development of COPD include premature birth, childhood infections, nutrition such as a low-antioxidant diet, and the genetic risk factor, alpha-1 antitrypsin deficiency, found in some patients with emphysema.8
The diagnostic tool of choice for COPD is spirometry or pulmonary function testing. Accuracy, reliability, and effective use of spirometry require effective skills, training, demonstrated competency, and quality assurance based on ATS guidelines.9–11 Identifying one well-trained staff person in a primary care office to perform and interpret spirometry and use of expert review can improve the quality and accuracy of the testing. Symptom-based questionnaires including the COPD-Population Screener (COPD-PS)12 and Lung Function Questionnaire (LFQ)13 followed by spirometry may promote an efficient and coordinated approach to identifying COPD.5
Contributing to the underdiagnosis of COPD are the often insidious onset and progression of symptoms that may be common in other disorders. Although often considered a disease associated with advancing age, approximately 70% of persons with COPD are under 65 years of age15 and 46% are currently employed.16 Although it is estimated that 15% of smokers will develop COPD, large population-based studies tell a different story. In the Copenhagen Heart Study, persons who continued to smoke for 25 years had a 35.5% incidence of COPD compared to 7.8% in those who never smoked15 The Framingham Offspring Study followed current smokers for approximately 23 years, finding that COPD developed in 33% of men and 24% of women, compared to 7.4% and 5.6% respectively in never-smokers.16
Tools such as the BODE index have been developed to further refine predicting hospitalization and mortality in COPD. In addition to pulmonary function abnormalities, this tool considers the relationship of COPD to weight, dyspnea, and exercise. The BODE index uses body mass index, obstruction (using FEV1) dyspnea (using the Modified Medical Research Council scale or MMRC), and exercise tolerance (using a 6-minute walk distance) to aide in prediction of risk of hospitalization and mortality.17 The MMRC rates a patient's dyspnea from 0 to 4, with 4 indicating that the patient is too breathless to leave the house or becomes breathless when dressing or undressing.
The Framingham Offspring Study demonstrated that early smoking cessation has the greatest potential for normalizing and reducing loss of lung function.18 In the study, smokers who quit later than age 45 to 50 experienced a slowed rate of decline in lung function. Every COPD patient interaction should include questioning about smoking (cessation intentions, past or planned quit date, any relapses) and an offer of assistance to quit in the presence of ongoing nicotine use. Clinicians should use national, evidence-based guidelines for effective smoking cessation.19
Immunizations against influenza and Streptococcus pneumoniae are recommended in COPD to reduce negative outcomes including exacerbations caused by viral or bacterial respiratory infections. Influenza vaccinations should be given annually.20 Pneumococcal vaccinations should be given to COPD patients at the time of diagnosis and repeated after 5 years or more if the first dose was prior to 65 years of age.20
Once COPD has been diagnosed, a collaborative model should be used for ongoing management, including symptom control, prevention and early management of exacerbations, and regular follow-up. Maintenance pharmacotherapy with long-acting bronchodilators is the cornerstone of COPD management, effectively improving pulmonary symptoms and potentially reducing risk of exacerbations. Distinguishing COPD from asthma is important because maintenance treatment in COPD focuses on bronchodilation whereas the cornerstone of treatment in persistent asthma is inhaled corticosteroids (ICSs). Pulmonary rehabilitation improves physical function, quality of life, disabling symptoms and reduces healthcare utilization in COPD.21 Pulmonary rehabilitation includes monitored, supervised exercise and education on disease self-management strategies to improve independence and symptom control.21 Self-management education has an important role in improving health-related quality of life and reducing both inpatient and ED visits.22
An evidence-based approach to pharmacotherapy is recommended to improve airflow limitation, symptom control, function and reduce exacerbations.4 Pharmacologic management generally includes use of rescue and maintenance inhalers. Short-acting beta-agonists (SABAs) such as albuterol or levalbuterol quickly improve acute dyspnea in all stages of COPD and may be the only pharmacologic treatment needed for management of mild COPD. Maintenance treatment with one or more long-acting bronchodilators is the cornerstone for management of moderate to very severe disease (Stages II to IV)4 to provide ongoing bronchodilation, reduce exacerbations, and improve health-related quality of life.
Long-acting beta-agonists (LABAs) and ICS combinations are recommended for patients with severe to very severe COPD (Stages III to IV)4 who experience frequent exacerbations. Fluticasone 250 mcg/salmeterol 50 mcg twice daily is FDA-approved to treat airflow obstruction in COPD. A 4-year study evaluating salmeterol 50 mcg/fluticasone 500 mcg versus its single components or placebo in patients with FEV1 less than 60% predicted found fewer exacerbations versus placebo (P < 0.001), salmeterol (P = 0.002), and fluticasone alone (P = 0.024).23 Study participants receiving fluticasone alone or in combination with salmeterol had higher pneumonia incidence than those receiving salmeterol alone or placebo.23 Budesonide 160 mcg/formoterol 4.5 mcg is also FDA-approved for maintenance treatment of airflow obstruction in COPD.
Tiotropium is indicated for the long-term daily maintenance treatment of bronchospasm and prevention of exacerbation in COPD. A 4-year study of 5,993 patients with GOLD Stages II to IV COPD found that tiotropium reduced the risk of exacerbation-related hospitalizations 14% compared to controls (P < 0.002).24
Exacerbations of COPD worsen health-related quality of life and accelerate FEV1 decline.25 The ATS/ERS COPD guidelines define a COPD exacerbation as "an acute change in a patient's baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy".1 Risk factors include viral and/or bacterial infection, environmental exposures including air pollution, lack of supplemental oxygen adherence, and lack of pulmonary rehabilitation.1 Evaluation should include severity of COPD, comorbid conditions, and history of previous exacerbation. Physical exam should include at a minimum evaluation of hemodynamic stability, use of accessory muscles of breathing, tachypnea, persistent symptoms after initial treatment, and monitoring with oxygen saturation, and/or arterial blood gas (ABG). Chest X-ray, blood work, sputum Gram stain, culture and sensitivities, and ECG are important for any level of complexity and/or advanced severity. Collaborative clinical decision making with a physician such as a pulmonologist should be a priority for this population. The ATS/ERS COPD guidelines include a comprehensive guide to assessment and management of COPD exacerbations that can be found at the website: http://www.thoracic.org/clinical/copd-guidelines/for-health-professionals/exacerbation/index.php.
Primary care has the potential to improve the comprehensive multidisciplinary care of patients with COPD. Ongoing primary care follow-up of patients with COPD should include monitoring of exposure to risk factors including tobacco, particulate, or smoke exposure in the workplace or home, changes in symptoms and physical activity levels, adherence to treatments including medications, correct inhaler technique, monitoring, and prevention and management of exacerbations.4 Clinicians should consider asking patients "How would you rate your health in general?", a helpful question in predicting acute exacerbations and hospitalizations associated with ratings of poor or very poor health.26 In addition to asking patients "How are you doing?", patients should be asked "What are you doing?" to help detect the impact of symptoms on physical activity and independence.27
Adherence to therapy is critical in improving patient outcomes and is a key area of focus for NPs. Patient education and collaborative decision making that considers patient understanding of disease processes, treatment benefits, therapeutic goals, and financial considerations in the context of the patient's lifestyle and preferences offer greater potential for improved adherence (see Resources for clinicians and patients). Device selection, patient training for using the inhaler, and technique monitoring and maintenance are critical to treatment effectiveness in COPD. A comprehensive resource for device selection and technique recommendations is available at http://www.aarc.org/education/aerosol_devices/aerosol_delivery_guide2.pdf.
Management of hypoxemia
Patients with COPD may experience hypoxemia, particularly in the advanced stages of disease. ABG analysis is the preferred measure to determine the need for supplemental oxygen and ABG results also provide information about acid-base balance, carbon dioxide retention, and chronic and acute respiratory failure.
Arterial oxygen saturation as measured peripherally by pulse oximetry (SpO2) is adequate for trending and evaluation during exercise. Long-term supplemental oxygen therapy improves survival, exercise, sleep, and cognitive performance in hypoxemic patients with COPD. Supplemental oxygen delivery systems include gas and liquid systems, as well as concentrators in stationary and portable format. Oxygen delivery modes include continuous flow and pulse demand systems. Interfaces include traditional nasal cannula, reservoir cannulas, and transtracheal catheters. Mask interfaces are usually reserved for inpatient settings. Physiologic indications for oxygen include an arterial oxygen tension (PaO2) of less than 55 mm Hg. Oxygen is prescribed with a therapeutic goal to maintain SpO2 greater than 90% during rest, sleep, and exertion. Active patients require portable ambulatory oxygen systems. Portable systems are available weighting 3.5 to 10 pounds. If oxygen was prescribed during an exacerbation, ABGs should be rechecked in 30 to 90 days. Effective oxygen use and adherence requires patient education and ongoing evaluation. Air travel may impact patients with advanced disease and/or hypoxemia. Preflight assessment by a pulmonologist can help determine oxygen needs and prescription related to high altitude.
Management of comorbid conditions
Mood disorders including depression and anxiety disorders are common in COPD and often go undiagnosed and untreated. Patients should be screened for depression and anxiety disorders and offered treatment, which may include medication, counseling, cognitive behavioral therapy, and social support. Pulmonary rehabilitation may also help control depressive symptoms.21
Sleep impairment in persons with COPD may include respiratory symptoms such as cough or wheeze and desaturation greater than during maximum exercise. Sleep apnea prevalence in COPD is generally that of the general population, but oxygen desaturation during sleep is more severe when the two disorders occur simultaneously. Assessment should include questions about sleep quality and findings suggestive of sleep apnea. A sleep study is indicated if clinical suspicion of sleep apnea is present or for complications of hypoxemia not explained by awake arterial oxygen levels. Management of sleep abnormalities in COPD should focus on controlling sleep disturbance by managing cough, dyspnea, and significant nocturnal desaturation. Hypnotics generally should be avoided. Patients who continue to have disturbed sleep may benefit from referral to a sleep specialist.
A subset of patients with advanced COPD may be candidates for surgical treatment of COPD.1 Bullectomy removes severely enlarged air sacs that compress healthier lung tissue.1 Lung volume reduction surgery removes lung tissue with excessive damage due to emphysema to improve chronic hyperinflation. In the National Emphysema Treatment Trial, lung volume reduction improved survival and reduced exacerbations when compared to medical therapy in persons with upper lobe emphysema and poor exercise tolerance.28 Lung transplantation improves function and health-related quality of life in patients with FEV1 less than 35% predicted, hypoxemia, carbon dioxide retention, and pulmonary hypertension. Beneficial impact of lung transplantation on survival has been less clear.4 ABG testing, full pulmonary function testing and thoracic computed tomography are important in surgical decision making for advanced COPD.1 The patient with COPD who will be undergoing surgery should be evaluated following ATS guidelines available at http://www.thoracic.org/clinical/copd-guidelines/resources/copddoc.pdf.
Pulmonary rehabilitation is the standard of care for chronic, symptomatic lung disease, yet it is underutilized in COPD.21 Evidence-based research has found pulmonary rehabilitation results in improved dyspnea, function, quality of life, and reduced healthcare utilization in all stages (I to IV) of COPD.4 Potential for greater utilization is now in place with recent establishment of Medicare coverage for Stages II to IV COPD and many other chronic lung diseases. A directory of programs is available at http://www.aacvpr.org/programdirectory.
Implications for practice
Patient education focusing on self-management strategies is essential in COPD to reduce long-term consequences of the disease. Primary care delivery models, including the Chronic Care Model (CCM)29 and the Patient-Centered Medical Home (PCMH),30 utilize enhanced education and self-management as part of planned, proactive care. Care of persons with COPD should address short- and long-term prevention of complications and symptom control, function, and quality of life. This contrasts with solely focusing on managing acute exacerbations and missing the potential for prevention of disease progression by preventing exacerbations and facilitating control of symptoms, management of skeletal muscle dysfunction, and evaluation and management of hypoxemia and nonpulmonary complications of COPD.
Hospice, palliative care, and end-of-life services are often underutilized in COPD. Patients and their surrogate decision makers should be involved in frank discussions with their clinicians to elicit care preferences and anticipation of potential complexities of care and uncertainties in advanced care of COPD. The patient's care preferences should be the overriding consideration in advanced care and end-of-life decision making.
NPs play a critical role in prevention, screening, accurate diagnosis, management, and follow-up in persons with COPD. Early diagnosis and ongoing management and prevention of complications has the potential for improving patient outcomes, including enhanced patient symptom control, function, quality of life, and reduction of exacerbations and healthcare utilization.
Resources for clinicians and patients
* COPD Action plan: http://www.lungusa.org/lung-disease/copd/living-with-copd/action-management-plan.pdf
* Pulmonary Education and Research Foundation: perf2ndwind.org
* Pulmonary Rehabilitation Tool Kit: http://www.pulmonaryrehab.com.au/index.asp?page=63
* American Lung Association: 1-800-LUNGUSA or http://www.lungusa.org/ Better Breathers clubs, Freedom from Smoking online & classes, COPD call line
* American Thoracic Society patient education resources: thoracic.org/sections/education/patient-education
* American College of Chest Physicians patient resources: http://www.chestnet.org/patients/guides/
* COPD-alert: www.copd-alert.com/
* COPD Foundation: http://www.copdfoundation.org/
* EFFORTS: http://www.emphysema.net
* The Pulmonary Paper: http://www.pulmonarypaper.org/
* Pulmonary Education and Research Foundation: perf2ndwind.org
Spirometry resources for clinicians
* NIOSH Spirometry Training Program: http://cdc.gov/niosh/topics/spirometry/training.html
* ATS Spirometry standards, interpretation six minute walk test: http://www.thoracic.org/statements/index.php
* National Lung Health Education Program: http://www.nlhep.org/
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4. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of COPD. http://www.goldcopd.com/
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