Mount Carmel Health Partners Clinical Guidelines Chronic Obstructive Pulmonary Disease

Diagnosis of COPD The diagnosis of COPD should be confirmed by spirometry. When performing spirometry, measure: • Forced vital capacity (FVC) • Forced expiratory volume in one second (FEV1) • Calculate the FEV1/FVC ratio: postbronchodilator FEV1 is recommended for the diagnosis and assessment of the severity of COPD. FEV1/FVC ratio should be confirmed by repeat spirometry on a separate occasion if ratio is between 0.6 and 0.8. A FEV1/FVC ratio less than 0.7 con firm the presence of airflow limitation that is not fully reversible Other diagnostic tests that may be performed prior to establishing the diagnosis of COPD: • Bronchodilator reversibility to exclude asthma and establish a lung function baseline • Chest x-ray to rule out other causes for lung diseases • Arterial blood gas or pulse oximetry • Alpha-1 antitrypsin (AAT) deficiency screening; this deficiency is caused by an inherited deficiency of the hepatically-produced protein alpha-1 antitrypsin, a known lung protector. This test should be performed on patients with COPD of Caucasian descent under the age of 45 or in patients who have a strong family history of COPD • CBC to assess for anemia • BNP or NT-proBNP to assess and/or evaluate for heart failure Goals of COPD Management 1. 2. 3. 4. 5. 6. 7. 8. Improve health status Relieve symptoms Prevent disease progression Prevent and treat exacerbations Prevent and treat complications Improve exercise tolerance Prevent or minimize side effects from treatment Reduce mortality Differential Diagnosis of COPD Diagnosis COPD Asthma Heart Failure Bronchiectasis Tuberculosis Obliterative bronchiolitis Diffuse Panbronchiolitis Suggestive Features Onset mid-life (onset early adulthood–suspicion for alpha-1 antitrypsin deficiency) Symptoms progress slowly Long smoking history, although can occur in nonsmokers. Largely irreversible airflow limitation Dyspnea during exercise Onset early in life, often childhood Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis and/or eczema Family history of asthma Largely reversible airflow limitation Obesity coexistence Fine basilar crackles on auscultation Chest radiograph shows dilated heart, pulmonary edema Pulmonary function tests typically indicate volume restriction, not airflow limitation Large volumes of purulent sputum Commonly associated with recurrent or persistent bacterial infection Coarse crackles on auscultation, clubbing of digits Chest radiograph/High-resolution computed tomography (HRCT) shows bronchial dilation, bronchial wall thickening Onset all ages Chest x-ray shows lung infiltrate Microbiological confirmation High local prevelence of tuberculosis Onset younger age, nonsmokers May have history or rheumatoid arthritis or acute fume exposure Seen after lung or bone marrow transplant CT on expiration shows hypodense areas Predominantly seen in patients of Asian descent Most patients are male and nonsmokers Almost all have chronic sinusitis Chest x-ray and HRCT show diffuse small centrilobular nodular opacities and hyperinflation COPD - 3

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