Definition
A.Chronic obstructive pulmonary disease (COPD) is progressive, chronic, expiratory airway obstruction due to chronic bronchitis or emphysema. The relief of bronchoconstriction due to inflammation has some reversibility. Chronic bronchitis is a chronic productive cough lasting 3 months during 2 consecutive years, after all causes of chronic cough have been excluded. Emphysema is an abnormal, permanent enlargement (hyperinflation) of the air sacs, as well as the destruction of the elastic recoil. Many patients have both types of air restriction symptoms of chronic bronchitis and emphysematous destruction leading to COPD. Patients with asthma whose airflow obstruction is completely reversible are not considered to have COPD. When asthmatic patients do not have complete reversible airflow obstruction, they are considered to have COPD.
B.Irreversible airflow obstruction is a key factor in the patient’s disability. The goal of COPD management is to improve daily quality of life (QOL) and the recurrence of exacerbations. Smoking cessation continues to be the most important therapeutic intervention.
C.The Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging criteria are as follows:
1.Stage I—Mild obstruction: forced expiratory volume in 1 second (FEV1) greater than 80% of predicted value, some sputum, and chronic cough.
2.Stage II—Moderate obstruction: FEV1 between 50% and 80% of predicted value, shortness of breath (SOB) on exertion, and chronic symptoms.
3.Stage III—Severe obstruction: FEV1 between 30% and 50% of predicted value, dyspnea, reduced exercise tolerance, exacerbations affecting QOL.
4.Stage IV—Very severe obstruction chronic respiratory failure: FEV1 less than 30% of predicted value or moderate obstruction, FEV1 less than 50% of the predicted value and chronic respiratory failure.
5.Comorbidities commonly seen with COPD include hypertension, cardiac disorders including atrial fibrillation and heart failure, diabetes/metabolic syndrome, gastrointestinal disorders, lung cancer, depression, and osteoporosis.
Incidence
A.Approximately 16 million people in the United States have been diagnosed with COPD. It is the third leading cause of death in the United States. Since 2011, COPD has been more commonly seen in females than in males. The exact worldwide prevalence is unknown as up to 50% of people with low lung function are undiagnosed.
Pathogenesis
A.Chronic bronchitis leads to the narrowing of the airway caliber and increase in airway resistance. Mucus gland enlargement is the histological hallmark of chronic bronchitis.
B.In emphysema, loss of the air sac’s elastic recoil causes air limitation. Emphysema caused by smoking is the most severe in the upper lobes. Most patients with COPD have smoked one pack of cigarettes a day for 20 or more years before the symptomatic dyspnea, cough, and sputum appear.
Predisposing Factors
A.Cigarette smoking.
B.Occupational, environmental, or atmospheric pollutants:
1.Dust.
2.Chemical fumes.
3.Secondhand smoke.
4.Air pollution.
C.Genetic factor: Alpha 1-antitrypsin (AAT) deficiency.
D.Recurrent or chronic lower respiratory infections or disease (childhood and as adult).
E.Age (most common after the fifth decade of life).
F.Females and Native Americans/Alaskan Natives have higher risk.
G.History of asthma.
H.Unemployment, including retirement.
I.Single status (divorced, widowed, or separated).
J.Less than high school education.
Common Complaints
A.Chronic cough and colorless sputum, usually worse in morning.
B.Dyspnea with exertion, progressing to dyspnea at rest.
C.Wheezing.
D.Difficulty speaking or performing tasks.
E.Weight loss (decrease in fat-free mass).
Other Signs and Symptoms
A.Pursed-lip breathing.
B.Use of accessory muscles.
C.Tripod position.
D.Barrel chest.
E.Cyanosis (fingertips, tip of nose, around lips).
F.Tachypnea.
G.Tachycardia.
H.Difficulty speaking or performing tasks.
I.Jugular venous distension.
J.Abnormal, diminished, or absent lung sounds.
K.Mental status changes.
L.Anxiety and depression.
M.Pulmonary hypertension.
N.Cor pulmonale.
O.Left-sided heart failure.
Subjective Data
A.Ask the patient about past respiratory problems and infections. Does he or she currently have fever, chills, or other signs of infection?
B.Ask about onset of cough and characteristics of sputum (amount, color, and presence of blood).
C.Determine cigar use and cigarette pack-year history (pack/day times the number of years smoked), and current interest in quitting.
D.Inquire about exposure to occupational or environmental irritants.
E.How far can the patient walk before becoming breathless? Is there more breathlessness when the patient walks on a slight incline? Have symptoms caused lost work days or productivity?
F.Does the patient become breathless or tired when performing activities of daily living (ADL)?
G.Ask about insomnia, anxiety, restlessness, edema, and weight change.
H.How many pillows does the patient sleep on? Does he or she have to sleep in a recliner or sitting up?
I.Assess the patient’s ability to perform ADL and instrumental activities of daily living (IADL), including grooming and personal hygiene, performing chores around the house, shopping, cooking, and driving.
J.Ask about alcohol use.
K.Review all medications, including over-the-counter (OTC) and herbal products.
L.Review further assessment questions based on existing comorbidities.
M.Depression screening.
N.Inquire about use of ED or need for hospitalization. Previous ventilation?
Physical Examination
A.Record temperature (if indicated), blood pressure (BP), pulse, respirations, and pulse oximetry. The respiratory rate increases proportionally to disease severity. Take height and weight to calculate the body mass index (BMI). The patient may have a normal examination early in the disease.
B.Inspect:
1.Observe general appearance: Skin color, affect, posture, gait, amount of respiratory effort when walking and speaking; note increased anterior–posterior chest diameter.
2.Examine sputum: Frothy pink signals pulmonary edema. Hemoptysis is seen in tuberculosis (TB).
3.Examine lips, fingertips, and nose for cyanosis. (Finger clubbing is not characteristic of COPD.)
4.Observe the neck for distended veins and peripheral edema (advanced disease).
5.Check for pursed-lip breathing and use of accessory muscles.
C.Auscultate:
1.Auscultate the heart.
2.Auscultate lungs for wheezes, crackles, decreased breath sounds, and prolonged forced expiratory rate.
3.Assess for vocal fremitus (vibration) and egophony (increased resonance and high-pitched bleating quality). Air trapping causes air pockets that do not transmit sound well. Absent vesicular lung sounds are a distinctive characteristic of COPD.
4.Auscultate carotids for bruits.
D.Percuss: Percuss chest for presence of hyperresonance and for signs of consolidation.
E.Palpation:
1.Palpate the neck, superior and inferior clavicular spaces for lymphadenopathy.
2.Palpate the chest.
3.Palpate/percuss abdomen for organomegaly.
4.Grade dependent edema.
F.Mental status: Assess for decreased level of consciousness (LOC).
G.Perform 6-minute walking distance (6MWD) testing to evaluate oxygen desaturation.
H.Further physical examinations are dependent on comorbidities.
Diagnostic Tests
A.Spirometry is the gold standard for diagnosing COPD. Pulmonary function tests (PFTs) are used to diagnose, determine severity, and follow the disease progression of COPD. Perform spirometry before and after using bronchodilator:
1.FEV1 is used as an index to airflow obstruction and evaluates the prognosis in emphysema.
2.Forced vital capacity (FVC).
3.FEV1/FVC ratios less than 0.70.
B.Chest radiograph (CXR) (not required to diagnose COPD but rules out other diagnoses).
C.Complete blood count (CBC): Evaluate polycythemia due to chronic hypoxia.
D.Sputum specimen for culture.
E.If the patient is younger than 40 years of age or has a family history of early onset of emphysema, measure AAT levels.
F.Arterial blood gas (ABG) for baseline.
G.ECG: Note sinus tachycardia, atrial arrhythmias.
H.Two-dimensional echocardiogram is used to evaluate secondary pulmonary hypertension.
I.Chest CT is an alternative imaging study for emphysema; however, it is not required as a diagnostic tool. Low-dose CT should be recommended as appropriate for annual lung cancer screening.
J.Perform a purified protein derivative (PPD) test if TB is suspected.
K.Brain natriuretic peptide (BNP).
L.Theophylline level (if applicable).
Differential Diagnoses
A.COPD.
B.Asthma.
C.Heart failure.
D.Bronchiectasis.
E.Pulmonary edema.
F.TB.
G.AAT deficiency.
H.Pneumonia.
I.Pulmonary embolism.
J.Cystic fibrosis.
K.Cancers.
L.Central airway stenosis.
M.Diffuse panbronchiolitis (predominately see in Asian descent).
N.Obliterative bronchiolitis.
Plan
A.General interventions:
1.Educate and encourage active participation in the plan of care, including medication adherence.
2.A smoking cessation plan is an essential part of a comprehensive treatment plan. Develop a smoking cessation plan; assess readiness to quit. Set a quit date; encourage a group smoking cessation program. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. Discuss smoking at every subsequent visit. The effectiveness and safety of e-cigarettes as a smoking cessation aide is uncertain at this time. 
See Section III: Patient Teaching Guide Nicotine Dependence.
3.The GOLD guidelines note a five-step program for smoking intervention:
a.ASK: Systematically identify all tobacco users at every visit, EVERY patient at EVERY clinic visit is queried about tobacco use status.
b.ADVISE: Strongly urge all tobacco users to quit in a clear, strong, and personalized manner.
c.ASSESS: Determine willingness and rationale of the patient’s desire to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days).
d.ASSIST: Aid in quitting, make a quit plan, provide practical counseling, provide educational materials, and help the patient to obtain social support. Pharmacotherapy if appropriate.
e.ARRANGE: Schedule a follow-up contact either in person or by telephone.
4.Advise to stay away from secondhand smoke and limit exposure to other pulmonary irritants, including aerosols/vapors and extreme temperature changes.
5.Advise exercise with provider approval.
6.Educate and counsel patients regarding advance directives.
7.Consider pulmonary rehabilitation for all stages of COPD. Pulmonary rehab programs vary in format and length. Most programs use a small group format and include the following:
a.Education about symptoms, medications, and oxygen.
b.Supervised exercise classes and instruction.
c.Breathing techniques.
d.Nutritional counseling.
e.Emotional health support.
8.The selection of inhalers is dependent on the patient’s age and ability to use the inhaler. Patients should be evaluated as to their coordination and inspiration abilities necessary to use inhalers; otherwise, aerosol medication via nebulizer is the best delivery method.