Chronic Obstructive Pulmonary Disease: Diagnosis and Management

 

This is a corrected version of the article that appeared in print.

The diagnosis of chronic obstructive pulmonary disease (COPD) should be suspected in patients with risk factors (primarily a history of smoking) who report dyspnea at rest or with exertion, chronic cough with or without sputum production, or a history of wheezing. COPD may be suspected based on findings from the history and physical examination, but must be confirmed by spirometry to detect airflow obstruction. Findings that are most helpful to rule in COPD include a smoking history of more than 40 pack-years, a self-reported history of COPD, maximal laryngeal height, and age older than 45 years. The combination of three clinical variables—peak flow rate less than 350 L per minute, diminished breath sounds, and a smoking history of 30 pack-years or more—is another good clinical predictor, whereas the absence of all three of these signs essentially rules out airflow obstruction. Pharmacotherapy and smoking cessation are the mainstays of treatment, and pulmonary rehabilitation, long-term oxygen therapy, and surgery may be considered in select patients. Current guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress.

A 53-year-old white man, Mr. J, has a history of hypertension, chronic bilateral knee pain, right knee replacement, tonsillectomy, and a 30 pack-year smoking history. He presents with a nonproductive cough that began approximately one year ago and shortness of breath for the past three months. He has no chest pain, fever, chills, night sweats, orthopnea, limb edema, or hemoptysis. Based on his smoking history and symptoms, you suspect that he has chronic obstructive pulmonary disease (COPD). This article reviews the diagnosis and management of COPD and concludes with the steps taken in the evaluation and initial treatment of Mr. J.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Screening for COPD in asymptomatic patients who are at increased risk is not recommended.

C

3, 4, 7

The diagnosis of COPD should be confirmed by a postbronchodilator FEV1/FVC ratio less than 0.7.

C

35, 10

Smoking cessation is recommended to reduce the rate of FEV1 decline and mortality in patients with COPD.

A

11, 12

No combination of inhaled medications has been found superior to monotherapy for initial treatment of COPD; patients should step up to combination therapy as needed.

A

10, 15

Monotherapy with a long-acting beta2 agonist or long-acting anticholinergic is recommended for symptomatic patients with COPD whose FEV1 is less than 60% of predicted.

A

3

Initial monotherapy with a long-acting beta2 agonist or long-acting anticholinergic is recommended for patients with COPD. An inhaled corticosteroid may be added as symptom severity or airflow obstruction progresses.

C

35

Long-term oxygen therapy is recommended for patients with COPD who have severe resting hypoxia (arterial partial pressure of oxygen 55 mm Hg or less, or oxygen saturation 88% or less).

A

3, 25

Pulmonary rehabilitation is recommended for symptomatic patients with COPD whose FEV1 is less than 50% of predicted.

A

3, 27


COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Screening for COPD in asymptomatic patients who are at increased risk is not recommended.

C

3, 4, 7

The diagnosis of COPD should be confirmed by a postbronchodilator FEV1/FVC ratio less than 0.7.

C

35, 10

Smoking cessation is recommended to reduce the rate of FEV1 decline and mortality in patients with COPD.

A

11, 12

No combination of inhaled medications has been found superior to monotherapy for initial treatment of COPD; patients should step up to combination therapy as needed.

A

10, 15

Monotherapy with a long-acting beta2 agonist or long-acting anticholinergic is recommended for symptomatic patients with COPD whose FEV1 is less than 60% of predicted.

A

3

Initial monotherapy with a long-acting beta2 agonist or long-acting anticholinergic is recommended for patients with COPD. An inhaled corticosteroid may be added as symptom severity or airflow obstruction progresses.

C

35

Long-term oxygen therapy is recommended for patients with COPD who have severe resting hypoxia (arterial partial pressure of oxygen 55 mm Hg or less, or oxygen saturation 88% or less).

A

3, 25

Pulmonary rehabilitation is recommended for symptomatic patients with COPD whose FEV1 is less than 50% of predicted.

The Authors

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SHARI GENTRY, MD, is a senior medical officer at Branch Health Clinic Oceana Triad, Naval Air Station Oceana, Virginia Beach, Va....

BARRY GENTRY, MD, is a senior medical officer for the USS Kearsarge, U.S. Forces Atlantic Fleet, based in Norfolk, Va.

Address correspondence to Shari Gentry, MD, Branch Health Clinic Oceana Triad, 1550 Tomcat Blvd., Virginia Beach, VA 23460 (e-mail: shari.l.gentry.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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