occupational dust, vapors, fumes, gases and other chemicals
family history of COPD and/or childhood factors
e.g. – low birthweight, childhood respiratory infections etc(1).
When thinking about a diagnosis of COPD, ask the person if they have:
weight loss
reduced exercise tolerance
waking at night with breathlessness
ankle swelling
fatigue
occupational hazards
chest pain
haemoptysis
these last 2 symptoms are uncommon in COPD and raise the possibility of alternative diagnoses
one of the primary symptoms of COPD is breathlessness
the Medical Research Council (MRC) dyspnoea scale (see linked item) should be used to grade the breathlessness according to the level of exertion required to elicit it
If COPD seems likely then perform post bronchodilator spirometry to confirm the diagnosis (2):
presence of a post bronchodilatory FEV1/FVC < 0.7 confirms persistence airflow limitation and thus a diagnosis of COPD in patients with appropriate history and symptoms
consider alternative diagnoses or investigations in:
older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7
younger people with symptoms of COPD where the FEV1/FVC ratio is ≥ 0.7
in most patients routine spirometric reversibility testing is not necessary as a part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading because:
repeated FEV1 measurements can show small spontaneous fluctuations
the results of a reversibility test performed on different occasions can be inconsistent and not reproducible
over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml
asthma may be present if:
there is a large ( > 400 ml) response to bronchodilators
serial peak flow measurements show significant diurnal or day-to-day variability
there is a large ( > 400 ml) response to 30 mg prednisolone daily for 2 weeks
the definition of the magnitude of a significant change is purely arbitrary
response to long-term therapy is not predicted by acute reversibility testing (2,3)
If COPD seems likely then perform post bronchodilator spirometry to confirm the diagnosis (1):
identifying airflow obstruction in COPD patients is critical in making the diagnosis
airflow obstruction is defined as (1):
FEV1 < 80% predicted
and FEV1/FVC < 0.7
if still doubt about diagnosis consider the following pointers (1) :
clinically significant COPD is not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy
asthma may be present if:
there is a large ( > 400 ml) response to bronchodilators
serial peak flow measurements show significant diurnal or day-to-day variability
there is a large ( > 400 ml) response to 30 mg prednisolone daily for 2 weeks
Notes:
identifying early disease
perform spirometry in people who are over 35, current or ex-smokers, and have a chronic cough
consider spirometry in people with chronic bronchitis. A significant proportion of these people will go on to develop airflow limitation
NICE suggest that post-bronchodilator spirometry should be measured to confirm the diagnosis of COPD (2). The use of post-bronchilator spirometry is used in the updated classification of COPD (2):
Post-bronchodilator FEV1/FVC
FEV1 % predicted
Severity of airflow obstruction
Using NICE clinical guideline 12 (2004)
Severity of airflow obstruction
Using ATS/ERS 2004
Severity of airflow obstruction
Using GOLD 2021
Severity of airflow obstruction
Using NICE clinical guideline 101 (2010)
Post-bronchodilator
Post-bronchodilator
Post-bronchodilator
< 0.7
>80%
Mild
Stage 1 - Mild Stage
Stage 1 - Mild*
< 0.7
50-79%
Mild
Moderate
Stage 2 - Moderate
Stage 2 - Moderate
< 0.7
30-49%
Moderate
Severe
Stage 3 - Severe
Stage 3 - Severe
< 0.7
< 30%
Severe
Very severe
Stage 4 - Very severe
Stage 4 - Very severe **
GOLD guidance categories patients based on Symptoms via the ABCD categories:
The refined ABCD assessment tool (3)
The categories are therefore defined via consideration of two specific features:
exacerbation history and
symptom Score (either assessment of dyspnoea via mMRC OR assessment of symptoms via CAT)
Category A is defined by:
Moderate or Severe Exacerbation History
Symptom Score
0 or 1 (not leading to hospital admission)
mMRC 0 or 1 or CAT <10
Category B is defined by:
Moderate or Severe Exacerbation History
Symptom Score
0 or 1 (not leading to hospital admission)
mMRC >=2 or CAT >=10
Category C is defined by:
Moderate or Severe Exacerbation History
Symptom Score
>=2 or 1 leading to hospital admission
mMRC 0 or 1 or CAT <10
Category D is defined by:
Moderate or Severe Exacerbation History
Symptom Score
>=2 or 1 leading to hospital admission
mMRC >=2 or CAT >=10
The combined COPD assessment allows patients with the same FEV1 (defined by the GOLD criteria) to be differentiated based on symptomatology, for example
a subject with an FEV1 <30% with an mMRC of 2 and three exacerbations in the past year would be labelled GOLD grade 4, group D;
wheres a subject with an FEV1 < 30% with an mMRC of 1 and zero exacerbations in the past year would be labelled GOLD grade 4, group A
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