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Chronic obstructive pulmonary disease

Definition
COPD is a chronic lung disease characterized by non-reversible airflow obstruction and persistent symptoms of dyspnea and productive cough.
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Pathophysiology
COPD is caused by airway inflammation and remodeling due to environmental exposures, primarily tobacco smoke. Inflammation and oxidative stress in the airway, alveoli, and pulmonary microvasculature causes destruction of lung parenchyma, and loss of elastic recoil in the lung tissue.
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Epidemiology
In the US, the prevalence of the COPD is estimated at approximately 12,000 persons per 100,000 population.
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Disease course
These pathologic changes lead to manifestations of irreversible airflow obstruction, as well as a progressive decline in lung function, which can progress to chronic respiratory failure.
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Prognosis and risk of recurrence
The standardized mortality rate of patients with COPD is estimated at 2.7 (95% CI, 2.5-3.0) in men and 4.8 (95% CI, 4.2-5.4) in women, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of chronic obstructive pulmonary disease are prepared by our editorial team based on guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2023), the Canadian Thoracic Society (CTS 2023; 2012; 2011), the American Thoracic Society (ATS 2023; 2020), the United States Department of Defense (DoD/VA 2021), the American College of Physicians (ACP 2021; 2011), the American Association for Thoracic Surgery (AATS 2021), the British Thoracic Society (BTS 2020), the European Respiratory Society (ERS/ATS 2017), the European Respiratory Society (ERS 2017), the British Thoracic Society (BTS/ICS 2016), the U.S. Preventive Services Task Force (USPSTF 2016), the Alpha-1 Foundation (Alpha-1 2016), and the International Society for Heart and Lung Transplantation (ISHLT 2015).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per USPSTF 2016 guidelines, do not obtain screening for COPD in asymptomatic adults.
D
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  • Diagnosis

2.Classification and risk stratification

Severity assessment: use the modified MRC dyspnea scale, based on the level of dyspnea, for severity assessment:
Situation
Guidance
Grade 0
I only get breathless with strenuous exercise
Grade 1
I get short of breath when hurrying on the level or walking up a slight hill
Grade 2
I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level
Grade 3
I stop for breath after walking about 100 meters or after a few minutes on the level
Grade 4
I am too breathless to leave the house or I am breathless when dressing or undressing
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3.Diagnostic investigations

History and physical examination
Elicit a detailed medical history in patients with known or suspected COPD, including:
Situation
Guidance
Exposures
Smoking
Occupational exposures
Environmental exposures (household/outdoor)
Past medical history
Early life events (prematurity, low birth weight, maternal smoking during pregnancy, passive smoking exposure during infancy)
Asthma, allergy, sinusitis, or nasal polyps
Respiratory infections in childhood
HIV
Tuberculosis
Family history
COPD
Other chronic respiratory diseases
Pattern of symptom development
COPD typically develops in adult life and most patients are conscious of increased breathlessness, more frequent or prolonged "winter colds," and some social restriction for a number of years before seeking medical help
Exacerbations
History of exacerbations or previous hospitalizations for a respiratory disorder
Comorbidities
CVDs
Osteoporosis
Musculoskeletal disorders
Anxiety and depression
Malignancies
Impact on patient's life
Limitation of activity
Missed work and economic impact
Effect on wellbeing
Effect on family routines
Effect on sexual activity
Feelings of depression or anxiety
Social factors
Availability of social and family support
Recognize that physical signs of airflow limitation are usually not present until significant impairment of lung function is present, and a physical examination is rarely diagnostic in COPD.

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  • Spirometry

4.Respiratory support

Long-term oxygen therapy: as per GOLD 2023 guidelines, initiate long-term oxygen therapy to increase survival in patients with severe resting hypoxemia.
A
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  • Noninvasive ventilation

5.Medical management

General principles: aim treatment at reduction of symptoms and future risk of exacerbations.
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  • Short-acting bronchodilators

  • Long-acting bronchodilators

  • ICSs

  • Combination therapy

  • Phosphodiesterase inhibitors

  • Oral corticosteroids

  • Mucolytics

  • Long-term antibiotics

  • Other pharmacological agents

  • Management of acute exacerbations (setting of care)

  • Management of acute exacerbations (SABA)

  • Management of acute exacerbations (corticosteroids)

  • Management of acute exacerbations (antibiotics)

  • Management of acute exacerbations (PDE4 inhibitors)

  • Management of acute exacerbations (supplemental oxygen)

  • Management of acute exacerbations (noninvasive ventilation, indications)

  • Management of acute exacerbations (noninvasive ventilation, technical considerations)

  • Management of acute exacerbations (invasive ventilation)

  • Management of acute exacerbations (pulmonary rehabilitation)

  • Palliative care (nonpharmacological measures)

  • Palliative care (nutritional support)

  • Palliative care (supplemental oxygen)

  • Palliative care (opioids)

  • Palliative care (neuromuscular electrical stimulation)

  • Palliative care (therapies with no evidence for benefit)

  • Palliative care (end-of-life care)

6.Nonpharmacologic interventions

Smoking cessation: as per GOLD 2023 guidelines, offer smoking cessation interventions actively in all patients with COPD.
A

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  • Avoidance of exposures

  • Physical activity

  • Pulmonary rehabilitation

7.Therapeutic procedures

Bronchoscopic interventions: offer bronchoscopic interventions, such as endobronchial valves,
A
lung coils,
B
and vapor ablation,
B
to reduce end-expiratory lung volume and improve exercise tolerance, health status, QoL, and lung function at 6-12 months following treatment in selected patients with advanced emphysema.
B

8.Surgical interventions

Lung volume reduction surgery: offer lung volume reduction surgery to improve survival in patients with severe upper-lobe emphysema and low post-rehabilitation exercise capacity.
A

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  • Surgical bullectomy

  • Lung transplantation

9.Specific circumstances

Patients with alpha-1 antitrypsin deficiency: as per GOLD 2023 guidelines, consider initiating IV augmentation therapy to slow down the progression of emphysema in patients with AAT deficiency and COPD (with never or ex-smokers with an FEV1 of 35-60% of predicted and patients with severe hereditary AAT deficiency with established emphysema being the most suitable candidates).
C

10.Patient education

General counseling
As per GOLD 2023 guidelines:
Provide education in patients with COPD, although education alone has not been shown to be effective to change the patient's behavior.
B
Provide self-management intervention skills to be communicated with a healthcare professional, with or without the use of a written action plan, to improve health status and prevent exacerbation complications decrease (such as hospitalizations and emergency department visits).
B

11.Preventative measures

Routine immunizations: as per GOLD 2023 guidelines, offer influenza and SARS-CoV-2 vaccination in patients with COPD.
B
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12.Follow-up and surveillance

Follow-up: monitor symptoms, exacerbations, and objective measures of airflow limitation during routine follow-ups of patients with COPD to determine when to modify management and to identify any complications and/or comorbidities that may develop.