KEY POINTS

The prevalence of COPD is highest in smokers and ex-smokers and increases with age

The diagnosis is suggested by characteristic clinical features and a history of exposure to risk factors for the
disease. You must confirm the diagnosis by showing airflow obstruction by quality assured spirometry

Airflow obstruction is defined as a post bronchodilator forced expiratory volume in one second (FEV1)/forced
vital capacity (FVC) ratio of less than 70%. Demonstration of the presence of airflow obstruction is critical to
making the diagnosis of COPD and a confident diagnosis of COPD can only be made with spirometry. You can
then stratify the severity of airflow obstruction (not necessarily the same as severity of disease) by comparing
the FEV1 obtained with that predicted for the patients age, sex, and height

The number of exacerbations that a patient has is an important prognostic factor in COPD and you should
ask about this in the patient review

Multidimensional assessment tools, such as the BODE and DOSE indices, may help to predict outcomes,
such as risk of exacerbations and hospital admission, in patients with COPD

CLINICAL TIPS

Think of COPD in smokers over 35 with respiratory symptoms and check their spirometry

You need to know the FEV1 percentage predicted and how many exacerbations a patient has had in the last
year to make treatment decisions about the pharmacological management of COPD

COPD is an umbrella term encompassing a number of different pathological processes. Some patients can
have radiological emphysema but preserved spirometry. These patients still have COPD and will have abnormal
lung function if a full assessment is done in a respiratory laboratory

DEFINITION OF COPD
COPD is characterised by airflow obstruction. The airflow obstruction
usually3:

Is progressive

Is not fully reversible

Does not change markedly over several months.

The disease is caused predominantly by smoking.

PREVALENCE OF COPD

In 2007, the World Health Organisation estimated that there were 210
million people with COPD globally.4 The prevalence of COPD is highest
in smokers and ex-smokers and increases with age.5
There is considerable variation in reported prevalence between
countries. It is difficult to assess the prevalence of COPD because of the
gap between measured abnormal lung function and clinically significant
disease. It also depends on how the diagnosis was made, for example,
whether it was made using symptom questionnaires, self reported
diagnoses by patients, or formal spirometry.
Estimates of the prevalence of COPD in the UK vary widely. Data from
the Quality and Outcomes Framework suggest that 1.5% of the
population, around 835 000 people, have been diagnosed in the
UK.6 Since the predicted prevalence is up to 13% of the population of the
UK aged 35 and over, it appears that around 2.2 million people remain
undiagnosed in the UK alone.7 Rates of COPD are higher in more
deprived communities.8
Awareness of COPD is low in the general population and symptoms
develop insidiously, so establishing the incidence is challenging. Most
patients are diagnosed at around the sixth decade of life, when
symptoms become severe, and they usually have moderate or advanced
disease by this time. Misdiagnosis as asthma is common, and studies
based in primary care highlight the benefits of scrutinising and validating
disease registers.9
One in eight emergency admissions (130 000) in the UK is due to
COPD, making it the second most common reason for emergency
admission to hospital. The disease also accounts for more than one
million bed days each year in the NHS.8 COPD costs the UK healthcare
system between 810 million and 930 million per year, most of which is
due to hospital care.2
Over the last 20 years admission rates have risen in all age groups, with
the highest rises occurring in people older than 85.10The National COPD
Audit 2008 found that patients with COPD admitted to hospital were
frequent users of primary care in the 12 months before hospital
admission. About 30% of patients admitted with COPD are readmitted
within three months, which has increased since 2003. Rates of

readmission vary by up to five times in different parts of the UK,

reflecting important variation in the quality of care available.11
MORTALITY FOR COPD
Inpatient mortality for COPD is about 8%, rising to 15% and 25% at three
months after admission and one year after admission, respectively.1
12
Patients needing oxygen or nebulised treatment have a five year
survival from diagnosis of around 30%. COPD accounts for 30 000
deaths per year in the UK and will be the third leading cause of death
worldwide by 2020, surpassed only by heart disease and stroke.13
Death rates for respiratory disease in the UK are almost double the
European average, and this is especially marked in females.2

OW DO I DIAGNOSE COPD?
There is no single diagnostic test for COPD. The National Institute for
Health and Clinical Excellence (NICE) guideline for managing COPD
states that the diagnosis of COPD should be based on3:

Characteristic history, examination, and chest x ray (to minimise the risk of an alternative diagnosis)

Spirometry demonstrating a post bronchodilator FEV1 of < 80% predicted along with an FEV1/FVC ratio of <
0.7.

(There is no fixed recommendation for the method of bronchodilation,

but giving two doses of 200 g salbutamol via a spacer device is a
convenient technique.)
You should consider a diagnosis of COPD in patients over 35 who have
a risk factor (usually smoking) and who present with one or more of the
following symptoms:

Exertional breathlessness

Chronic cough

Regular production of sputum

Frequent winter bronchitis

Wheeze.

Clinical features differentiating COPD from asthma, which is the most

common differential diagnosis, are shown in Table 1.
Table 1. Clinical features that differentiate COPD from asthma3
Clinical features

COPD

Asthma

Smoker or ex-smoker

Nearly all

Possibly

Symptoms below age 35

Rare

Often

Chronic productive cough

Common

Uncommon

Breathlessness

Persistent, progressive

Variable

Night time symptoms

Uncommon

Common

Diurnal or day to day variability of symptoms

Uncommon

Common

None of these symptoms is specific to COPD. Other disorders, such as

bronchiectasis or congestive cardiac failure, can present with similar
symptoms. Such conditions may also coexist in a patient with COPD.
You must confirm the diagnosis by showing airflow obstruction by quality
assured spirometry. Airflow obstruction is defined in current guidelines as
a post bronchodilator FEV1/FVC ratio of less than 70% and must be
present to diagnose COPD.3
There is some controversy in the respiratory community about the
usefulness of the fixed 70% ratio to define airflow obstruction. As this
ratio falls physiologically with time because of lung ageing, a fixed 70%
ratio may mean that COPD is being over-diagnosed in elderly people
and under-diagnosed in young people. A proposed alternative is the use
of an FEV1/FVC ratio below the lower limit of normal for age, height, sex,
and ethnic group.14
In addition to spirometry, you should arrange:

A chest x ray to exclude other pathologies

A full blood count to identify anaemia or polycythaemia

An assessment of body mass index (BMI).

CLASSIFICATION OF AIRFLOW OBSTRUCTION

Once you have made a diagnosis of COPD you can stratify the severity
of airflow obstruction (not necessarily the same as severity of disease)
by comparing the FEV1 obtained with that predicted for the patients age,
sex, and height. The predicted values are taken from standard reference
tables; currently the UK uses values from the European Coal and Steel
Community. These values may lead to under-diagnosis in elderly people
and need adjustment in black and Asian populations.
The definitions for stratifying airflow obstruction were revised in the 2010
NICE COPD guideline update to bring the UK into harmony with the rest
of Europe and the USA.3 These definitions are shown in Table 2.
Table 2. Definitions for stratifying airflow obstruction3
Severity of airflow

Post bronchodilator

Post bronchodilator FEV1 as a

Symptoms

obstruction

FEV1/FVC ratio

percentage of predicted

Mild

< 0.7

80%

Moderate

< 0.7

50-79%

++

Severe

< 0.7

30-49%

+++
Repeated
exacerbations

Very severe

< 0.7

< 30% or < 50% with respiratory failure

++++
Severely impaired
quality of life

Airflow obstruction can be present in the absence of disease; you should

make a diagnosis of mild COPD only if the patient has relevant
symptoms.

Post bronchodilator values are recommended to avoid over-diagnosis of

disease. Post bronchodilator values should not be confused with values
obtained with reversibility testing. Reversibility testing is not needed to
confirm a diagnosis of COPD, although it may help to confirm a
diagnosis of asthma. Reversibility testing does not predict response to
treatment or disease progression. Routine measurement of peak flow in
COPD is of limited value in individual patients.3
(Current guidelines state it is no longer necessary to perform oral steroid
challenges to assess COPD or guide treatment.)
STANDARDS FOR DIAGNOSTIC SPIROMETRY IN PRIMARY AND
SECONDARY CARE
Published standards for diagnostic spirometry in primary and secondary
care set out guidance on training, equipment, calibration, and infection
control measures necessary for achieving measurements that are quality
assured.15
One key feature of this is:

Measurements should involve at least three readings of FEV1 and FVC, and two of these should be within
5% or 100 ml of one another.

HOW CAN I ASSESS THE SEVERITY OF MY PATIENTS COPD?

COPD is no longer viewed simply as a smoking related disease of the
lungs involving various degrees of chronic bronchitis or emphysema, or
both. Rather it is seen as a complex condition that is long term, affecting
the lives of patients and their carers on many levels and to varying
degrees. COPD is a heterogeneous, multisystem disease, with
extrapulmonary manifestations.
Single physiological measures do not give an accurate assessment of
disease severity or prognosis. Spirometry provides a measure of severity
of airflow obstruction, but this alone can under- or over-estimate the
impact of the disease on an individual patient. When assessing the
impact of the disease on a patient you need to take several factors
beyond the degree of airflow obstruction into account. These include
patient reported factors, the number of exacerbations per year, and BMI.

Patient reported factors

Patient reported factors are probably most important in classifying
disease severity. Patients with COPD often understate the severity of
their condition, and management priorities in guidelines do not always
correspond with the priorities of patients living with the disease. Notably,
COPD has important social and psychological consequences.
It is crucial, therefore, to assess overall health status in these patients
and a simple health status questionnaire - the COPD Assessment Test
(www.catestonline.org) - can be useful in clinical practice.16 This tool
provides a composite assessment of the overall impact of COPD on an
individual patient, and allows monitoring of changes in health status over
time or in response to interventions. It is useful in patients with all stages
of FEV1 impairment, and has been validated in patients with different
reading abilities and first language.

Number of exacerbations
The number of exacerbations that a patient has is an important
prognostic factor in COPD and you should ask about this in the patient
review. An exacerbation is defined as a change in the patients baseline
dyspnoea/cough and/or sputum that is beyond normal day to day
variations, is acute in onset, and may warrant a change in regular
medication.17
Many exacerbations are not reported to healthcare professionals by
patients. This may be because patients with COPD get accustomed to
coping with multiple symptoms on a daily basis, and also because of
limited awareness among patients and clinicians about what constitutes
an exacerbation.
With increasing disease severity patients are prone to more frequent
exacerbations, which have an important impact on functional status.
Patients with frequent exacerbations (defined as two or more per year3)
experience a more rapid decline in lung function over time, and
exacerbation frequency and severity both increase mortality risk.18

19

Patients fear exacerbations, and those experiencing frequent attacks

have high levels of anxiety and depression and a steep decline in health
related quality of life.20 21
Risk factors for frequent exacerbations include:

Frequent exacerbations in the previous year

Increasing age

Increasing disease severity

Chronic production of mucus.

Pharmacological and non-pharmacological interventions, such as

smoking cessation programmes, can reduce exacerbations.3

BMI
BMI is an independent and modifiable risk factor for mortality in COPD.
You should refer patients with a BMI below 20 or above 25 for dietetic
intervention.22

Multidimensional assessment tools

Multidimensional assessment tools have been developed to try to predict
outcomes in patients with COPD. One example is the BODE index (see
Table 3), which comprises measures of:

BMI

Obstruction of airflow (FEV1 % predicted)

Dyspnoea (modified Medical Research Council dyspnoea score (see Table 4))

Exercise tolerance (six minute walking distance, recorded in metres).23 24

Table 3. The BODE index24

Variable

Points on BODE index

FEV1 (% of predicted)

65

50-64

36-49

35

Exercise tolerance (distance walked in 6 minutes (metres))

350

250-349

150-249

149

MRC dyspnoea scale

0-1

BMI

> 21

21

The BODE index is useful for stratifying prognosis of patients for risk of
exacerbations, hospital admission, and mortality. To calculate the BODE
index you should add up the score for each variable. The score ranges
from 0 to 10 and higher scores correlate with a higher risk of death.
Table 4. The modified Medical Research Council dyspnoea score

MRC dyspnoea score

Degree of breathlessness related to activities

grade

Not troubled by breathlessness except with strenuous exercise

Short of breath when hurrying or walking up a slight hill

Walks slower than contemporaries on level ground because of breathlessness, or has to stop for
breath when walking at own pace

Stops for breath after walking about 100 m or after a few minutes on level ground

Too breathless to leave the house, or breathless when dressing or undressing

Since routinely performing six minute walk tests in all patients in a

primary care setting involves extra time and cost, the DOSE index (see
Table 5) may be more practical in primary care. It comprises:

Dyspnoea (using the MRC score)

Obstruction (FEV1 % predicted)

Smoking status

Exacerbation frequency.

Table 5. The DOSE index25

Variable

Points on DOSE index

MRC dyspnoea scale score

0-1

FEV1 (% of predicted)

> 50

30-49

< 30

Smoking status

Non-smoker

Smoker

Exacerbations per year

0-1

2-3

>3

To calculate the DOSE index you should add up the score for each
variable. The score ranges from 0 to 8. A high DOSE index ( 4) is
associated with a greater risk of hospital admission, respiratory failure,
and risk of future exacerbations. The DOSE index can help clinicians to
prioritise patients for intervention.25 You should bear in mind that these
and other similar tools rely heavily on spirometry, are unlikely to indicate
patient perceived severity, and do not by themselves guide treatment
decisions.

Learning bite: alpha-1-antitrypsin deficiency

Alpha-1-antitrypsin deficiency is a congenital, co-dominant disorder, and a rare but under-recognised cause of COPD,
accounting for around 2% of episodes.26 Alpha-1-antitrypsin protects the alveoli from proteolytic damage. Its
deficiency results in development of early onset panlobular (panacinar) emphysema, which can show a predilection
for the lower lobes.27Emphysema due purely to cigarette smoking results in centrilobular (centriacinar) emphysema
and is usually associated with apical disease. In people with alpha-1-antitrypsin deficiency cigarette smoking
accelerates the onset of symptomatic disease by around 10 years.28
You should consider alpha-1-antitrypsin deficiency in patients who develop emphysema before age 45, in the
absence of risk factors, or in the context of a strong family history. Diagnosis is by measuring serum levels of alpha-1antitrypsin followed by phenotyping.
Principles of management are generally the same as for COPD, and stopping smoking is the most important
intervention for improving survival.29 Alpha-1-antitrypsin replacement therapy is available, but no controlled studies
have shown that this improves survival or slows progression of emphysema.30 When selected patients with advanced
COPD have been reviewed by a specialist, they can be considered for lung volume reduction surgery, lung
transplantation, and newer endobronchial surgical techniques.3
Learning bite: spectrum of disease
COPD is an umbrella term, describing smoking related lung damage to both the airways and the lung
parenchyma.31 This manifests to differing degrees in different patients. Obstructive spirometry occurs because the
small airways close early during expiration in COPD.32
A proportion of patients has predominantly emphysema (parenchymal rather than airway disease) as part of the
spectrum of COPD. These patients can have well preserved or even normal spirometry, out of keeping with their
degree of breathlessness. They should still be coded as having COPD on the disease register. These patients may
have a chest x ray that is reported as showing hyperinflated lungs. Pathways of care and treatment options are the
same for patients with airflow obstruction or emphysema due to smoking.
In patients where simple spirometry does not fit the clinical picture, or where emphysema or other parenchymal lung
disease is suspected, full testing of lung function with assessment of lung volumes and gas transfer can provide
useful additional information.
Centrilobular emphysema caused by cigarette smoking results in loss of alveolar units and therefore reduced gas
transfer, which is shown on full lung function testing. The patient can then still be said to have COPD and should be

treated as such, although the effectiveness of inhaled pharmacotherapy in these patients is less clear cut. They
usually need specialist review.17