C h ro n i c O b s t r u c t i v e

Pulmonary Disease
Evaluation and Management

Sean P. Duffy, MD*, Gerard J. Criner, MD

KEYWORDS
 COPD  Emphysema  Chronic bronchitis  Acute exacerbation

KEY POINTS
 COPD is a common, preventable disease of fixed airflow limitation that accounts for the
third most deaths of any disease process in the United States.
 Cigarette smoking is by far the most important risk factor in the development of COPD and
smoking cessation is the intervention with the greatest impact on the natural history of the
disease.
 Pharmacologic therapy with inhaled corticosteroids and long-acting bronchodilators has
proven to reduce exacerbations and improve symptoms.
 Advanced treatments, such as lung volume reduction surgery and bronchoscopic lung
volume reduction, have been shown to improve symptoms in patients with significant hy-
perinflation and gas trapping.

BURDEN OF DISEASE

As the third leading cause of death in the United States in 2014, chronic obstructive
pulmonary disease (COPD) presents a significant challenge to the health care
provider.1 Worldwide, it is the fourth leading cause of death.2 It is estimated that up
to 40% of these deaths are attributed to smoking.3 Additionally, the financial burden
of COPD is significant accounting for nearly $50 billion in US government spending
in 2010.3 As a result, a great deal of emphasis has been placed on combatting the
morbidity and mortality associated with COPD. The Global Initiative for Chronic
Obstructive Lung Disease (GOLD) 2017 defines COPD as a common, preventable dis-
ease characterized by airflow limitation and frequent respiratory symptoms.4

Disclosure Statement: S.P. Duffy, none. G.J. Criner reports grants from Boehringer Ingelheim,
Novartis, AstraZeneca, Respironics, MedImmune, Actelion, Forest, Pearl, Ikaria, Aeris, PneumRx,
and Pulmonx; other from HGE Health Care Solutions, Inc, Amirall, Boehringer-Ingelheim, and
Holaira outside the submitted work.
Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple
University, 3401 North Broad Street, 7th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA
* Corresponding author.
E-mail address: Sean.duffy2@tuhs.temple.edu

Med Clin N Am - (2019) -–-

https://doi.org/10.1016/j.mcna.2018.12.005 medical.theclinics.com
0025-7125/19/ª 2019 Elsevier Inc. All rights reserved.
2 Duffy & Criner

OVERVIEW OF PATHOPHYSIOLOGY

The chronic airflow obstruction characteristic of COPD is a result of chronic lung

inflammation and occurs as a result of two distinct, but often overlapping processes5:
 Small airways disease: this refers to obstructive bronchiolitis, airway remodeling,
and narrowing and loss of the peripheral airways
 Emphysema: this refers to parenchymal destruction that causes loss of alveolar
units and the characteristic gas trapping and hyperinflation that is found in pa-
tients with COPD
Lung inflammation that causes COPD is most commonly caused by cigarette smoke
but can also be induced by other harmful particles, such as smoke from biomass fuels.
In patients with COPD the normal inflammatory response of the lung is amplified
because of factors that are genetically determined but not fully understood at present.
Accelerated lung inflammation is mediated by multiple types of inflammatory cells
including macrophages, neutrophils, and T and B lymphocytes that populate the
airway lumen in COPD.6 A minority of patients with COPD have been found to have
eosinophil-mediated inflammation, an important distinction because this cohort may
respond more favorably to corticosteroids.7 Additionally, systemic inflammation is
increased in COPD, especially in severe disease and during exacerbation as evi-
denced by increased levels of inflammatory biomarkers. Persistent systemic inflam-
mation is associated with the development of comorbid cardiac disease and poorer
clinical outcomes.8 Further study is warranted in this field because the identification
of therapeutic phenotypes could improve personalization of therapy and clinical
response.

RISK FACTORS

Cigarette smoking is the most well-established risk factor for the development of
COPD. However, lifelong nonsmokers can develop COPD and less than half of heavy
smokers go on to develop COPD.9 Despite reaching normal peak lung function in early
adulthood, some patients develop COPD because of accelerated lung function
decline presumably caused by inhalation of noxious particles. Another mechanism
of development of chronic airflow limitation is related to poor lung growth and devel-
opment with subsequent normal lung function decline with aging. This may be a
contributory mechanism in nonsmokers.10 Additional risk factors for the development
of chronic airflow limitation include
 Occupational exposures: 10% to 20% of COPD cases11
 Dust
 Chemical agents
 Fumes
 Indoor air pollution
 Biomass fuel
 Wood burning stove
 Asthma and airway hyperresponsiveness
 Second leading risk factor to cigarette smoking when studied in a group of
young adults aged 20 to 4412
Genetic risk factors also contribute to the development of airflow limitation. Most
notably, hereditary a1-antitrypsin deficiency contributes to chronic airflow obstruction
and emphysema.13 Additional genes have been studied and implicated in the devel-
opment of airflow obstruction, but a causal relationship has not been established.4
 COPD Evaluation and Management 3

CLINICAL PRESENTATION

The clinical presentation can vary widely in COPD, although most patients are at least
40 years of age and have a significant cigarette smoking or exposure history. Accord-
ing to a large European study of patients with COPD, the most commonly reported
symptoms are as follows14:
 Dyspnea
 Reported by more than 70%
 Typically, worse with exertion
 Chronic cough
 Reported by nearly 60% of patients
 Often dismissed as “smoker’s cough” by patients
 Mucous production
 Reported by 63% of patients
 May be indicative of chronic bronchitis if occurring for more than 3 months in
two consecutive years15
The patients reported that symptoms were most problematic on awakening but also
reported significant day-to-day and week-to-week variability.14 Wheezing and chest
tightness have also been noted as highly variable yet commons symptoms.14 Physical
examination is not likely to be helpful in establishing the diagnosis of mild or moderate
COPD. Wheezing may be present but is subject to significant variability. Often physical
examination signs, such as poor air movement, accessory muscle use, and muscle
wasting, are not apparent until the patient has entered the advanced stage of
disease.16

DIAGNOSIS AND TESTING

Spirometry is necessary for the diagnosis of COPD and should be the initial test of
choice. Values are reported as raw measures of flow and as percentage of predicted
after correction for height, age, and sex. The diagnosis is established by finding the
forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio
(FEV1/FVC) is less than 70%. Severity of airflow obstruction is then established by
the FEV1 as (GOLD)4:
 GOLD 1: mild obstructive defect, FEV1 80% predicted
 GOLD 2: moderate obstructive defect, 50% FEV1 less than 80%
 GOLD 3: severe obstructive defect, 30% FEV1 less than 50%
 GOLD 4: very severe obstructive defect, FEV1 <30%
Symptomatic patients with risk factors for COPD should certainly be sent for
spirometry. Screening the general population is not recommended because this
endeavor has not proven to benefit asymptomatic patients regarding management
of symptoms or clinical outcomes.17 Complete lung function testing with lung volumes
and diffusion capacity is not necessary for diagnosis but is performed to assess for
hyperinflation, gas trapping, and gas exchange abnormalities. Symptoms should be
assessed at each office visit because FEV1 does not provide a strong correlation
with symptoms on an individual level.18 The most commonly used and validated
scales are the modified British Medical Research Council (mMRC) questionnaire
and the COPD Assessment Test (CAT). The mMRC provides a simple assessment
of breathlessness with a 0 to 5 score ranging from “breathless only with strenuous ex-
ercise” to “too breathless to leave the house.”19 The CAT is an eight-item assessment
score with a maximum possible score of 40. The assessment accounts for a wider
4 Duffy & Criner

range of symptoms, such as cough, phlegm, chest tightness, sleep quality, and en-
ergy level.20 A score of 10 or greater on the CAT is consistent with significant
symptoms.21
Patients should also be assessed for exacerbation history. The 2017 GOLD update
has categorized COPD patients into four (ABCD) groups based on symptoms and
exacerbation history. The ABCD groups are listed next (GOLD):
 Group A: low symptom score, low exacerbation risk
 mMRC 0 or 1, CAT <10
 0 to 1 exacerbation in past year, no hospitalizations
 Group B: high symptom score, low exacerbation risk
 mMRC 2, CAT 10
 0 to 1 exacerbation in past year, no hospitalizations
 Group C: low symptom score, high exacerbation risk
 mMRC 0 or 1, CAT <10
 2 exacerbations in past year or one or more hospitalizations
 Group D: high symptom score, high exacerbation risk
 mMRC 2, CAT 10
 2 exacerbations in past year or one or more hospitalizations
These groups should be used in combination with spirometry to classify patients
with COPD. For instance, a patient with an FEV1 of 56% predicted, CAT score of
12, and one mild exacerbation the past year is categorized as GOLD grade 2, group B.

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The therapeutic intervention with the greatest impact on COPD is smoking cessation.
Smoking cessation has been shown to improve lung function in the year after quitting
and reduce the rate of decline by half over the long term when compared with
continuing smokers.22 Additionally, smoking cessation has been shown to improve
mortality when compared with continued smoking in patients with COPD.23
The goal of pharmacologic treatment in stable COPD is to prevent acute exacerba-
tions of COPD (AECOPD), to reduce symptoms, and to minimize the rate of lung func-
tion decline. Inhaled corticosteroids (ICS) and long-acting bronchodilators, long-
acting b-agonists (LABA), and long-acting muscarinic antagonists (LAMA) are the
mainstays of therapy. Symptomatic patients often require some combination of
inhaled therapy. Therapy should be tailored to the individual patient with respect to in-
surance coverage, device preference, and the side effect profile of the medications
(GOLD).4 Current data suggest that the best initial therapy in most stable mild-to-
moderate patients with COPD (GOLD group A) is combination inhaled LAMA/LABA.
The combination has proven to be more effective at reducing exacerbations than
either bronchodilator alone24 and ICS/LABA combination inhaler in patients with a
prior low burden of exacerbations.25 Triple inhaler therapy (ICS/LABA/LAMA) has
been shown to be superior compared with ICS/LABA and LAMA/LABA in reducing
the risk of moderate or severe COPD exacerbations in a population of symptomatic
patients with moderate or severe airflow limitation and a prior history of frequent or se-
vere exacerbations.26 There is a slight increase in the risk of pneumonia in the study
cohort receiving ICS; ICS therapy should be carefully considered in patients with a sig-
nificant history of pneumonia.26 Table 1 provides a guideline for the initiation of ther-
apy by GOLD grade. The treatment options, risks, adverse effects, and potential
benefits should be discussed with the patient and treatment decisions should be
tailored to the individual.
 Table 1
Initial treatment options by GOLD grade for COPD

COPD Severity SABD (Rescue) LAMA LAMA or LABA LAMA D LABA LABA D ICS LAMA D LABA D ICS
Group A O O
Group B O O
Group C O O
Group D O O O (asthma features) O

COPD Evaluation and Management

Abbreviation: SABD, short-acting bronchodilator.
Data from Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Avail-
able at: http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed September 5, 2018.

5
6 Duffy & Criner

Patients with more severe obstruction, frequent exacerbations (>1 per year), or
persistent symptoms despite first-line inhaler therapy may require adjunctive ther-
apies. For instance, patients with chronic bronchitis tend to have increased rates of
exacerbation when compared with the general COPD population.27 In this popula-
tion roflumilast, a phosphodiesterase-4 inhibitor designed to reduce inflamma-
tion,28 has been shown to reduce the rate of moderate and severe
exacerbations, especially in those with prior repeated hospitalizations.29,30 Daily
azithromycin, a macrolide antibiotic, has also been studied and shown to reduce
the exacerbation rate in an at-risk COPD population by up to 30%, especially in
those that are not current smokers.31 Pulmonary rehabilitation incorporates exer-
cise training, education, and behavioral disease management strategies and has
been shown to improve dyspnea and exercise tolerance especially in patients
with moderate-to-severe disease.32

ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

AECOPD confers a substantial negative impact on patients’ health status and quality
of life.33 AECOPD is defined as an acute increase in respiratory symptoms requiring
therapy. They are classified by severity as follows4:
 Mild: treated as an outpatient with increased frequency of short-acting
bronchodilators
 Moderate: treated as an outpatient with short-acting bronchodilators plus antibi-
otics and/or oral corticosteroids
 Severe: requires hospitalization or emergency room care
The most common trigger for an AECOPD is an upper respiratory infection and the
most commonly isolated organism is rhinovirus.34 Short-acting bronchodilators and
oral corticosteroids are the mainstay of therapy in exacerbation. A 5-day course of
40 mg of oral prednisone has been shown to be as efficacious as a 14-day course
of glucocorticoid in preventing recurrent exacerbation within 6 months.35 Historically,
antibiotics have been a controversial topic in treatment of AECOPD, but recent guide-
lines endorse the use of a 5- to 7-day course of antibiotics if patients have increased
purulence of sputum along with dyspnea or increased volume of sputum.4 Adjunctive
therapies, such as noninvasive ventilation and high-flow nasal cannula, may prevent
intubation36 and reintubation37 in patients with respiratory failure (Fig. 1).

ADVANCED THERAPIES FOR SEVERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Advanced therapies, such as lung volume reduction surgery and bronchoscopic lung
volume reduction, are treatments that aim to reduce hyperinflation by decreasing the
volume of emphysematous lung tissue in patients with severe COPD with significant
hyperinflation and gas trapping. Lung volume reduction surgery has been shown to
improve mortality in patients with COPD with severe, predominantly upper lobe
emphysema who have low exercise tolerance.38 Despite the evidence, lung volume
reduction surgery remains an uncommonly performed procedure because of the sur-
gical morbidity, specialized nature of the surgery, and difficulty identifying suitable
candidates in the community.39 Bronchoscopic lung volume reduction has since
been developed as a less-invasive means of achieving lung volume reduction. Endo-
bronchial valves placed into the airways of emphysematous lung tissue have proven to
effectively reduce the target lobe volume of emphysematous lung.40 This has proven
to be an effective means of symptom relief and quality of life improvement in patients
with severe heterogenous40 and homogenous emphysema.41 Finally, lung transplant
 COPD Evaluation and Management 7

Fig. 1. Indications for a pulmonary consultation or referral.

evaluation remains an option in patients with severe COPD, typically FEV1 less than
25%, hypercapnia, and/or frequent COPD-related hospitalizations.42 These advanced
therapeutic options should be undertaken in a specialized center after thorough eval-
uation by a multidisciplinary team.

SUMMARY

COPD is a highly prevalent and heterogeneous disease with high morbidity and mor-
tality that imparts a significant burden on health care providers worldwide. It is a
chronic progressive illness that accounts for a large and increasing percentage of
deaths worldwide. Pharmacologic and nonpharmacologic treatment options abound
although rarely do these therapies confer a mortality benefit to the patient. Smoking
cessation remains the most impactful therapeutic and preventative intervention in
the care of these patients. Thus, smoking cessation and abstinence should be a key
focus of any physician-patient interaction that involves a current or former smoker.
Otherwise, COPD may continue to rise in the ranks of worldwide causes of death.

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