ECI COPD Course, www.copdegypt.org

1. Assessment of the Patient
with COPD

2. Patient Assessment: COPD
History
Combined GOLD 2011 assessment
Physical findings
Radiography

3. History: COPD
Family history
Smoking
Occupation
Dyspnea
Wheezing
Sputum production

4. Genetic Factors: COPD
α-1 antitrypsin deficiency
▫ COPD before age 45
▫ COPD but have never smoked or been exposed to
toxins
▫ Family history of COPD
▫ Concomitant liver disease
▫ Alpha-l antitrypsin level measured in the blood to
confirm diagnosis
Other single nucleotide polymorphisms

5. Exposure to Noxious Particles
GOLD 2013

6. Stop smoking Strategies

7. COPD Phenotypes
Pink Puffer Blue Bloater

8. COPD Phenotypes

9. COPD versus Asthma
COPD Asthma
• Onset in mid-life • Onset early in life
• Slowly progressive • Symptoms vary day to day
• Long smoking history • Symptoms at night
• Dyspnea during exercise • Allergy, rhinitis, and/or
• Irreversible airflow eczema present
limitation • Family history of asthma
• Reversible airflow
limitation

10. The Goals of COPD assessment
To Determine:
The severity of the disease
The impact on the patient’s health status
The risk of future events.( such as exacerbations,
hospital admissions or death)
GOLD 2013

11. GOLD 2013
Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using spirometry
 Assess risk of exacerbations
 Assess comorbidities
GOLD 2013

12. GOLD 2013
Assessment of COPD based on symptoms and
future risk
Assess symptoms
COPD Assessment Test (CAT)
Modified Medical Research Council
Breathlessness scale (mMRC)
Adapted from GOLD 2013

13. COPD Assessment Test (CAT)
Largely
patient-driven
item inclusion
25% of items
concerned with
breathlessness
or activity
Scoring range 0-40
Jones et al; Eur Respir J 2009; 34: 648–654

14. Modified MRC Dyspnoea Scale (mMRC)
Grade 0: Breathless on strenuous exercise
Grade 1: Short of breath when hurrying or
walking up a slight hill
Grade 2: Walk slower than others or stop
when walking at own pace on level
ground
Grade 3: Stop every 100m or after a few
minutes
Grade 4: Too breathless to leave the house or
breathless on washing/dressing
Am Rev Respir Dis;1987;135(6):1229-33

15. GOLD 2013
Assessment of COPD based on symptoms and future risk
Assess degree of airflow limitation
(Spirometry)
Spirometric classification of airflow limitation (in patients with FEV1/FVC<0.70)
GOLD 1 (Mild; FEV1 ≥80% predicted)
GOLD 2 (Moderate; 50% ≤FEV1 <80%
predicted)
GOLD 3 (Severe; 30% ≤FEV1 <50% predicted)
GOLD 4* (Very severe; FEV1 <30% predicted)
Adapted from GOLD 2013

16. Assessment of Exacerbation Risk
An exacerbation of COPD is defined as:
“an acute event characterized by a worsening of
the patient’s respiratory symptoms that is
beyond normal day-to-day variations and leads
to a change in medication”
The best predictor of having frequent
exacerbations (2 or more exacerbations per
year) is a history of previous treated events

17. Assessment of Exacerbation Risk
“The patients own history of exacerbations
appears to be the most powerful predictor of
future exacerbations”
The risk of Exacerbations significantly increases in GOLD
3 (Severe) and GOLD 4 (Very Severe)
There are two methods of assessing exacerbation risk.
▫ Using the GOLD spirometric classification with GOLD
3 or GOLD 4 categories indicating high risk
▫ The other is based on individual patient’s history of
exacerbation with two or more exacerbations in the
preceding year indicating high risk

18. Assessment of COPD based on
symptoms and future risk
Assess risk of exacerbations
History of exacerbations
Spirometry
Adapted from GOLD 2013

19. Combined assessment of COPD
 Assess symptoms first
 Assess risk of exacerbations next
 When assessing risk, choose the highest risk
according to GOLD grade or exacerbation history.
(one or more hospitalizations for COPD exacerbations should be
considered high risk)
 Patient is now in one of four categories
Adapted from GOLD 2013

20. Combined assessment of COPD
GOLD 4
≥2
More symptoms
GOLD 3 Less symptoms
EXACERBATION /YEAR
SPIROMETRIC CLASSIFICATION
high risk
High risk
GOLD 2
<2
Less symptoms More symptoms
GOLD 1 Low risk low risk
mMRC 01 mMRC ≥2
Adapted from GOLD 2013 CAT <10 SYMPTOMS CAT ≥10

21. Assessment of COPD based on
symptoms and future risk
Assess comorbidities
Comorbidities should be actively
looked for and treated appropriately
Most frequent comorbidities are
cardiovascular disease, depression and
osteoporosis
Adapted from GOLD 2013

22. Comorbidities: COPD
Increased risk for: Significant systemic
• Myocardial infarction
effects:
• Angina • Weight loss/gain
• Diabetes • Nutritional abnormalities
• Respiratory infection • Skeletal muscle
• Bone fractures dysfunction
• Depression
• Osteoporosis
• Lung cancer
• Sleep disorders
• Anemia

23. Comorbidities in COPD
Comorbidities
COPD
If smoker

24. Physical Exam: COPD
Hyperinflation
Accessory muscle use
Pursed lips
Edema
Breathing pattern
Auscultation
Body mass index (BMI)

25. Barrel Chest
Clubbing does not occur
with COPD; if present,
seek an alternative or
comorbid condition

26. Pursed Lips; Prolonged
Exhalation

27. COPD: Auscultation
Decreased breath sounds: hyperinflation
Prolonged exhalation
Wheezing, rhonchi
Crackles: heart failure

28. Body Mass index, airflow Obstruction,
Dyspnea and Exercise capacity

29. COPD: 6MWT
Walking course 30m in length.
Corridor marked every 3m.
Turnaround points marked with a
cone (such as orange traffic cone).
Starting line, which marks the
beginning and end of each 6o-m
lap, marked on the floor using
brightly colored tape.

30. COPD: Radiography
Hyperinflation: lowered flattened diaphragm
Infiltrates with infection
Pneumothorax

31. Arterial Blood Gases
Hypoxemia and hypercapnia develop as disease
process worsens
Sp02 can be problematic: accuracy ±5o/o, not
good assessment of hypercapnia
Capnography underestimates PaC02 due to
dead space

32. COPD Exacerbations
Primary Symptoms: Secondary Symptoms:
• Malaise
▫ Increased dyspnea
• Insomnia
▫ Increased cough and • Sleepiness
sputum • Fatigue
▫ Change sputum • Depression
▫ Impaired daily activities • Confusion
• Wheezing
• Tightness of chest
• Chest pain
• Tachycardia
• Tachypnea

33. Diagnosis of COPD
 A clinical diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough or sputum production and a
history of exposure to risk factors for the
disease.
 Spirometry is required to make the
diagnosis; the presence of a post-
bronchodilator FEV1/FVC < 0.70 confirms
the presence of persistent airflow limitation and
thus of COPD.

34. COPD diagnosis
SYMPTOMS HISTORY OF EXPOSURE FAMILY
Dyspnea-progressive TO RISK FACTORS HISTORY OF
(worsens over time and Tobacco smoke COPD
with exercise) Smoke from home
Chronic cough cooking/heating fuels
Sputum Occupational dusts and
chemicals
SPIROMETRY REQUIRED TO DIAGNOSE COPD
presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
Adapted from GOLD 2013