September 1, 2023
COPD SCREENING AND TREATMENT
BACKGROUND:
Chronic Obstructive Pulmonary Disease (COPD) affects around 15 million people in the U.S. and costs more than $32 billion annually. Chronic lower respiratory diseases, including COPD, are the fourth leading cause of death in the U.S. and the third leading cause of death worldwide. GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2023 defines COPD as a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, expectoration, and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.1
DIAGNOSIS:
A post-bronchodilator spirometry ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) between 0.60 and 0.80 confirms the diagnosis of COPD when obtained on 2 separate occasions, but for a busy clinician, 0.70 will usually suffice. When the initial post-bronchodilator FEV1/FVC ratio is <0.6, it is very unlikely to rise spontaneously above 0.7, thus is diagnostic.
- Airflow obstruction that is not fully reversible is not specific for COPD. For instance, it may also be found in patients with asthma and other diseases.
- The FEV1 also serves to determine the severity of airflow obstruction (mild, moderate, severe, and very severe)
RISKS:
Cigarette smoking is the leading cause of COPD in the US,2 but it can also occur due to long-term exposure to lung irritants other than smoke. This includes exposure to air pollution, chemical fumes, cooking fumes, and dust.
STAGING AND TREATMENT:
The 2023 GOLD COPD treatment recommendations3 were updated to clarify and simplify medication selection for patients newly initiating inhaler therapy, and for those patients requiring an escalation of therapy due to dyspnea or an acute exacerbation. Recommendations have simplified COPD staging criteria to just 3 groups: A, B, and E (previously A, B, C, D).
COPD ASSESSMENT TEST (CATTM)
(The CATâ„¢ is an 8-item questionnaire that assesses health status in patients with COPD)
Group A patients: patients with low symptom burden (CAT<10), with 0 to 1 moderate exacerbations.
- Initiate a bronchodilator (remains consistent with 2022 recommendations)
Group B patients: patients with high symptom burden (CAT≥10), with 0 to 1 moderate exacerbations.
- Treatment with Long-Acting Beta Agonist (LABA)+ Long-Acting Muscarinic Antagonist (LAMA) is recommended
Group E patients: combination of previous Groups C and D, or patients with at least 2 moderate or 1 severe exacerbation(s).
- Treatment with dual bronchodilation (LABA+LAMA) is recommended (similar to Group B patients)
- May consider LABA+LAMA+ Inhaled Corticosteroid (ICS) if blood eosinophils are >300
Single inhaler therapy may be more convenient and effective than multiple inhalers.
LABA/ICS use is no longer encouraged in central role for bronchodilator therapy.
Triple therapy is NOT recommended as an initial treatment therapy for patients with COPD.
CONCLUSION:
Although there is no recommended routine screening for COPD in the general population using any method, screening questionnaires and spirometry without a bronchodilator have sometimes been used to identify persons at increased risk for COPD. If results are positive, such screening tests would require follow-up diagnostic testing.4
COPD is a complex disease comprising many different diseases including asthma, bronchiectasis, small airways disease, etc., and many patients will have an overlap syndrome, i.e., features of two or three different diseases. This can make it more challenging to treat and most patients should see a specialist.
REFERENCES:
- https://www.atsjournals.org/doi/10.1164/rccm.202301-0106PP
- https://www.cdc.gov/copd/basics-about.html
- https://goldcopd.org/2023-gold-report-2/.
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chronic-obstructive-pulmonary-disease-screening
COPD Assessment Test: https://www.mdcalc.com/calc/10161/copd-assessment-test-cat