COPD—The Primary Care Perspective: Addressing Epidemiology, Pathology, Diagnosis, Treatment of Smoking's Multiple Morbidities and the Patient's Perspective

Figures & data

Figure 1 COPD compared to other chronic diseases treated in primary care. Information taken from: *All About Diabetes. American Diabetes Association Web site: www.diabetes.org. (90% to 95% of Americans with diabetes have type 2 diabetes.) AHA. Heart Disease and Stroke Statistics—2004 Update. Dallas, TX: AHA, 2003. Overweight and Obesity FAQs. CDC Web site: <www.cdc.gov/nccdphp/dnpa/|obesity/|faq.htm#adults>.

Figure 2 COPD competes for our attention and loses. *For COPD, physician office visits and hospital outpatient visits are combined. Information taken from Mannino DM. MMWR Surveill Summ 2002; 51(6):1–16. Fast Stats A to Z. National Center for Health Statistics. CDC Web site: www.cdc.gov/nchs/fastats/default.htm#A.

Figure 3 Percent change in age-adjusted death rates, U.S., 1965–1998. Information taken from NHLBI/NIH/DHHS.

Figure 4 COPD pathogenesis. Adapted with permission. Barnes PJ. Chest 2000; 117:10S–14S. © American College of Chest Physicians.

Figure 5 COPD: Pathology. Reproduced with permission. Barnes PJ. N Engl J Med 2000; 343:269–280. © 2000 Massachusetts Medical Society. All rights reserved.

Table 1 Causes of airflow limitation

• Irreversible

• Fibrosis and narrowing of the airways

• Loss of elastic recoil due to alveolar destruction

• Destruction of alveolar support that

maintains patency of small airways

• Reversible

• Accumulation of inflammatory cells, mucus,

and plasma exudate in bronchi

• Smooth muscle contraction in peripheral and central airways

• Dynamic hyperinflation during exercise

Information taken from: www.copdgold.org (from <www.guidelines.gov>)

Figure 6 The change in lung volumes during exercise in healthy lungs (A) and COPD (B). TLC, total lung capacity; IC, inspiratory capacity; EELV, end-expiratory lung volume; EILV, end-inspiratory lung volume.

Table 2 COPD questionnaire

COPD questionnaire
Question	Response choices	Points
1. What is your age in years?	40–49 years	0
	50–59 years	4
	60–69 years	8
	70 years or older	10
2. How many cigarettes do you currently smoke each day	0–14 pack-years	0
(if you are an ex-smoker, how many did you smoke each day)?	5–24 pack-years	2
What is the total number of years you have smoked cigarettes?	25–49 pack-years	3
Packs per day = cigarettes per day/20 per pack	50+ pack-years	7
Pack-years = packs per day × years smoked
3. What is your weight in kilograms?	BMI < 25.4	5
What is your height in meters?	BMI 25.4–29.7	1
BMI = weight in kg/(height in m)^2	BMI > 29.7	0
4. Does the weather affect your cough?	Yes	3
	I do not have a cough	0
	Yes	3
5. Do you ever cough up phlegm (sputum) from your chest when you don't have a cold?	Yes	3
6. Do you usually cough up phlegm (sputum) from your chest first thing in the morning?	No	0
	No	3
7. How frequently do you wheeze?	Never	0
	Occasionally or more often	4
8. Do you have or have you had any allergies?	Yes	0
	No	3

References: Price D, Tinkelman D, Nordyke RJ, Isonaka S, Halbert RJ. Utility of a symptom-based questionnaire for identifying COPD in smokers (Session C46; Poster F44). Orlando, Florida, American Thoracic Society 100th International Conference, May 21–26, 2004. [abstract] Am J Respir Crit Care Med 2004; 169 (7 Suppl):A605.

Table 3 Diagnosis–suggestive features

Diagnosis	Suggestive features
COPD	Onset of symptoms typically mid-life or older
	Slowly progressive symptoms and/or exacerbations
	History of smoking
Asthma	Onset usually at an earlier age
	Variable and intermittent symptoms
	Symptoms may worsen during the night and in the early morning
	Presence of allergy, rhinitis, chronic sinusitis, and/or eczema
	Positive family history of asthma
	Airflow limitation that is largely reversible
Congestive heart failure	Fine basilar crackles on auscultation
	Enlarged heart on chest X-ray
	Pulmonary edema
Bronchiectasis	Classically large volume of purulent sputum
	Course punctuated by recurrent lower respiratory infections
	Coarse crackles on auscultation
	Bronchial dilation and bronchial wall thickening on chest CT scan

Table 4 Indicators for COPD diagnosis

Chronic cough:	Present intermittently or every day Often present throughout the day—seldom only nocturnal
Chronic sputum production:	Any pattern of chronic sputum production may indicate COPD
Dyspnea that is:	Progressive (worsens over time) Persistent (present every day) Described by the patient as increased effort to breathe, heaviness, air hunger, or gasping
	Worse on exercise
	Worse during respiratory infections
History of exposure to risk factors:	Tobacco smoke
	Occupational dusts and chemicals
	Smoke from home cooking, especially, and heating fuels

Table 5 Differential diagnosis questionnaire

Differential diagnosis questionnaire
Question	Response Choices	Points
What is your age in years?	40–49 years	0
	50–59 years	5
	60–69 years	9
	70 years or older	11
How many cigarettes do you	0–14 pack-years	0
currently smoke each day	15–24 pack-years	3
(if you are an ex-smoker,	25–49 pack-years	7
how many did you smoke
each day)?
What is the total number	50+ pack-years	9
of years you have smoked
cigarettes?
Packs per day = cigarettes
per day/20 per pack
Pack-years = packs
per day x years smoked
Have you coughed more in the	Yes	0
past few years?	No	1
During the past 3 years, have you had any breathing problems that have kept you off work, indoors, at home, or in bed?	Yes	0
	No	3
Have you ever been admitted to the hospital with breathing problems?	Yes	6
	No	0
Have you been short of breath more often in the past few years?	Yes	1
	No	0
On average, how much phlegm (sputum) do you cough up most days?	None, or less than 1 Tbs (15 ml, or 1/2 oz) per day	0
	1 Tbs (15 ml, or 1/2 oz) or more per day	4
If you get a cold, does it usually go to your chest?	Yes	4
	No	0
Are you taking any treatment to help your breathing?	Yes	5
	No	0

References: Tinkelman D, Price D, Nordyke RJ, Isonaka S, Halbert RJ. Questionnaire for differential diagnosis of obstructive lung disease (Session 295, Poster P2956). Glasgow, Scotland; European Respiratory Society 14th Annual Congress. September 4–8, 2004 [abstract] Eur Respir J 2004; 24(Suppl 48):473s.

Table 6 Classifying COPD

Stage	Lung function	Symptoms
0: At risk	•Normal spirometry	Chronic symptoms
I: Mild	•FEV1/FVC** < 70%	With or without chronic
	•FEV1 ≥ 80% predicted	symptoms
II: Moderate	•FEV1/FVC < 70%	With or without chronic
	•FEV1 50%–80% predicted	symptoms
III: Severe	•FEV1/FVC < 70%	With or without chronic
	•FEV130%–50% predicted	symptoms
IV: Very severe	•FEV1/FVC < 70%
	•FEV1 < 30% predicted or < 50% predicted failure	With chronic respiratory failure

*FEV₁; forced expiratory volume in 1 second.

**FVC, forced vital capacity.

Table 7 Pathological distinctions between asthma and COPD

	Asthma	COPD
Cells involved	•Eosinophil infiltration in bronchi	•High neutrophil counts in bronchoalveolar lavage
	•Small increases in macrophages	•Large increases in macrophages
	•Increases in CD4+ TH2 lymphocytes	•Increases in CD8+ T lymphocytes
	•Activation of mast cells	•Mediators: LTD4, IL-8, TNF-α
	•Mediators: LTD4, IL-4, IL-5, others
Structural and pathologic changes	•Fragile epithelium	•Squamous metaplasia of epithelium
	•Thickening of basement membrane	•Mucus metaplasia
	•Mucus metaplasia	•Glandular enlargement
	•Glandular enlargement	•Parenchymal destruction
		•Smooth muscle hypertrophy
Physiologic consequences	•Airflow limitation is reversible	•Airflow limitation is not fully reversible and progressive
	•Airway hyper responsiveness is present	•Airway hyper responsiveness is variable or minimal

Table 8 Structural and functional distinctions between asthma and COPD

Characteristics	Asthma	COPD
Airflow limitation	Often reversible with the treatment of an inhaled bronchodilator or inhaled corticosteroids ([57])	Not fully reversible; usually results from airway remodeling, causing fibrosis and narrowing of small airways ([16], [17])
Fixed airflow limitation	Evidence of eosinophilia underlying destroyed epithelium; thickening of basement membrane ([58])	Destruction of alveoli and bronchioles; disruption of lung parenchyma ([16], [17], [59])
Airway remodeling	Often reversible ([60]); epithelium is more fragile, with significantly thicker epithelial reticular basement membrane	Signs of epithelial mucus metaplasia, airway wall fibrosis, and inflammation resulting from loss of alveolar attachments to small airways
Changes in pulmonary vasculature	Changes present at the beginning of disease process; may be present in children	Changes occur later in life and are associated with inflammatory response that is distinct from that seen in asthma
Airway hyper responsiveness	Key component, leading to the clinical features of asthma ([60])	Minimal ([53])

Figure 7 In general, what comorbidities are prevalent for your patients diagnosed with COPD?

Figure 8 Patient Health Questionnaire—PHQ-9.

Figure 9 Therapy additions with change in stage of disease. *Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2006).

Table 9 GOLD goals of COPD management

• Prevent disease progression

• Relieve symptoms

• Improve exercise tolerance

• Improve health status

• Prevent and treat complications

• Prevent and treat exacerbations

• Reduce mortality

Global Initiative for Chronic Obstructive Lung Disease (GOLD) Executive Summary. Updated 2003. Available at <http://www.goldcopd.com>.

Table 10 The five “A”s: Strategies for smoking cessation

1. Ask—Identify all tobacco users at every office visit; add tobacco use as a vital sign to the medical record.

2. Advise—Urge all smokers to quit, using a clear, strong, personalized message.

3. Assess—Determine patient's willingness to quit.

4. Assist—Help patient with quit plan, set date, anticipate challenges, offer support and pharmacotherapy.

5. Arrange— Schedule follow-up, consider referral to more intensive program if needed.

Table 11 Goals of pulmonary rehabilitation

1. Symptom and physical function management.

2. Education about the disease COPD, use of medications, side effects, and administration (including early treatment of exacerbations).

3. Psychosocial assessment, counseling, support, discussion of end-of-life issues.

4. Nutritional assessment and counseling.

5. Family and caregiver support.

Table 12 Pharmacologic agents to aid in smoking cessation

Product type	Dose	Usual treatment duration	Common side effects
Nicotine transdermal patch	7-, 14-, or 21-mg patch worn for 24 hours	8 weeks	Skin irritation, insomnia
	15-mg patch worn for 16 hours
Nicotine polacrilex gum	2 mg (< 25 cigarettes/day)	8–12 weeks	Mouth irritation, sore jaw, dyspepsia, hiccups
	4 mg (≥ 25 cigarettes/day
Nicotine vapor inhaler	6–16 cartridges/day (delivered dose, 4 mg per cartridge); taper use in last 6–12weeks for therapy	3–6 months	Mouth and throat irritation, cough, dyspepsia
Nicotine nasal spray	1-2 doses/hour (1 mg total; 0.5 mg in each nostril); 8 doses/day; maximum treatment, 40mg/day	3–6 months	Nasal irritation, sneezing, cough, teary eyes, rhinorrhea
Nicotine lozenge	1 lozenge/1–2 hours	12 weeks	Nausea, hiccups, coughing, heartburn, headache, insomnia (< 5% of users)
Sustained-release bupropion	150 mg/day for 3 days, then 150 mg BID; treatment should be started 1 week before quit date	7–12 weeks (up to 6 months to maintain abstinence from smoking)	Insomnia, dry mouth agitation
Varenicline	Beginning 7 days before quitting smoking take 0.5 mg/d for the first 3 days, then increase to 0.5 mg BID for the next 4 days, on the day of quitting increase to 1 mg BID and continue that dose for 12 weeks	12 weeks	Dry mouth, headache, constipation, increased sweating, anxiety, fatigue

Figure 10 What type of information about COPD diagnosis and treatment do you want?

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