COPD: Should a Clinician Treat or Refer?

Bethany Rettberg, NPC, is a family nurse practitioner at CVS MinuteClinic in Mokena, Illinois.

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that affects more than 5% of the population.¹

Associated with high morbidity and mortality, it is the third-ranked cause of death in the United States.^1,2

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines the condition as follows:²“COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.”

Because of the chronic nature and high prevalence of COPD, patients suffering from this disease use a lot of resources, including chronic therapies, such as inhalers and oxygen; frequent clinician office visits; and recurrent hospitalizations, because of acute exacerbations.¹These patients can present toclinics in an acute exacerbation or with stable disease or undiagnosed symptoms. As front-line providers it is imperative that clinicians triage these patients efficiently so that care is neither delayed nor misguided.

The majority of pathological changes that occur as a result of COPD include airway collapse, because of the loss of tethering caused by alveolar wall destruction in emphysema; chronic inflammation; fibrosis; increased number of goblet cells; mucus gland hyperplasia; and narrowing and reduction in the number of small airways.³As a result, the 3 cardinal symptoms of COPD are chronic cough, dyspnea, and sputum production, with the most common early symptom being exertional dyspnea.⁴Patients who lead sedentary lifestyles require careful history questioning. Some patients unknowingly avoid exertional dyspnea by shifting their expectations and limiting their activity.⁴

Evaluating a patient for COPD includes not only assessing for these main symptoms but also risk factors. Risk factors for COPD include biomass fuel exposure, cigarette smoking, and exposure to secondhand smoke.^1,2Eighty percent of patients diagnosed with COPD have a history of smoking, and identifying the number of pack years smoked (packs of cigarettes per day multiplied by the number of years) is significant for the patient’s evaluation. The amount and duration of smoking usually dictates the severity of the disease.^1,2

The physical exam findings vary with the severity of the COPD. In early disease, the respiratory exam may only show prolonged expiration or wheezes with forced exhalation, if anything abnormal at all. As the disease progresses and airway obstruction becomes more significant, a physical exam may show crackles at the lung bases, decreased breath sounds, distant heart sounds, hyperinflation, and/or wheezing.⁵End-stage COPD will force the patient to adopt positions that relieve dyspnea, such as the tripod position (patient leans forward and supports weight on outstretched arms/palms). Other physical exam findings at this stage include breathing through pursed lips and using accessory respiratory muscles of the neck and shoulders.^4,5

Practitioners who suspect that a patient may have COPD should usepulmonary function tests, specifically spirometry, as the cornerstone of a diagnostic evaluation. Screening spirometry is not recommended and should only be performed on those patients who demonstrate COPD symptoms.²Spirometry is performed pre- and post-bronchodilator to determine whether airflow limitation is present and whether it is fully or partially reversible. Airflow limitation that is either irreversible or partially reversible is considered diagnostic for COPD.²

Patients who present with a history of COPD but no acute symptoms should be asked about their medications, smoking cessation, and vaccination status(seeTable). Touching on these topics with a stable COPD patient can help prevent exacerbations and unnecessary medication changes.

An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond typical daily variations. This includes an acute change to 1 of the 3 cardinal symptoms: changes in sputum character and/or changes in sputum character; an increase in cough frequency and severity; and an increase in dyspnea.^2,6About 70% of COPD exacerbations are triggered by respiratory infections. The remaining 30% are to the results of environmental pollution, pulmonary embolism, or an unknown etiology.^2,7

The decision to triage the patient with a COPD exacerbation to home or the hospital is an important step in the initial evaluation. More than 80% of COPD exacerbations can be managed on an outpatient basis. However, the following criteria should prompt the provider to initiate emergency care for the patient: decreased mental status, suggestive of hypercapnia or hypoxemia; difficulty speaking because of respiratory effort; paradoxical abdominal or chest wall movements; resting dyspnea or respiratory distress; and use of accessory respiratory muscles.⁶

Other criteria that can lead to a decision to hospitalize proposed by the GOLD guidelines are:

a history of frequent exacerbations or prior hospitalizations for exacerbations;

inadequate response to outpatient therapy (patients treated for a COPD exacerbation in a retail health setting should follow up with their primary care provider within 48 to72 hours); insufficient home support;

onset of new symptoms following initiation of outpatient treatment such as altered mental status or cyanosis; and

serious comorbidities, such ascardiac arrhythmia, diabetes, heart failure, kidney or liver failure, or pneumonia.²

If a patient is deemed appropriate to be treated on an outpatient basis for a COPD exacerbation, management typically includes intensification of bronchodilator therapy and initiation of oral glucocorticoids. Oral antibiotics are also used in a select group of patients.^2,6Inhaled short-acting beta adrenergic agonists (SABAs), such asalbuterol, are the cornerstone of therapy for COPD exacerbations. Evidence also shows that the concurrent use of a SABA and a short-acting anticholinergic agent, such as Ipratropium Bromide,, during COPD exacerbations produces bronchodilation in excess of either agent individually.^2,6Current guidelines for systemic glucocorticoid therapy suggest a dose equivalent to prednisone 40 mg per day for 5 days.²Many clinical practice guidelines recommend antibiotic therapy only for those patients who are most ill or most likely to have a bacterial infection. A mild exacerbation (1 of the 3 cardinal symptoms present and no hospitalization) does not warrant antibiotic treatment.^2,6GOLD guidelines specifically recommend antibiotics for moderately or severely ill patients with COPD exacerbation who have increased cough and sputum purulence.²

Some additional clinical pearls specific to the retail health/urgent care setting regarding whether to refer include:

• Follow-up plays an important role for many reasons. Even if a patient is scheduled to follow up with the primary care physician within 48 to 72 hours, call them 24 to 48 hours after the visit to check in. This will not only allow a quick assessment of how symptoms are progressing but it will also increase reliability and trust with the patient.
• If a patient has a primary care physician, attempt to contact him or her to collaborate on the case. The physician may not be able to fit the patient in for a visit but most likely would be appreciative of a clinical consult. This collaboration can only improve the patient’s treatment plan.

• Listen to patients to learn about them and their health journeys.

Table. Chronic Care Topics to Review for COPD

Patient Education:

• Avoid triggers of exacerbations (ie, biomass fuel, cigarette smoke, cooking fires, and wood-burning fires.^2,8
• Recognize exacerbations, such as an increase in dyspnea, sputum production, and sputum purulence.^2,8
• Review inhaler technique at every visit.^2,8

Vaccinations

Influenza and pneumococcal vaccinations can help reduce infections and exacerbations.⁹

Smoking Cessation

• Address e-cigarette use. E-cigarettes have been linked to the same inflammatory response in the lungs as smoking a conventional cigarette.¹⁰
• The best cessation rates are achieved when counseling is combined with medication therapy, such as bupropion, nicotine replacement therapy, or varenicline.⁹7

• Reduces the rate of decline in lung function that occurs in smokers with COPD.⁸

Nutrition

• Obesity can contribute to dyspnea. Weight loss can help improve exercise tolerance and reduce dyspnea.⁹
• Vitamin D deficiency has been linked to reduced lung function and hospitalization for COPD exacerbations.⁸

COPD indicates chronic obstructive pulmonary disease.

References

1. Wheaton AG, Liu Y, Croft JB, et al. Chronic obstructive pulmonary disease and smoking status — United States, 2017.MMWR Morb Mortal Wkly Rep.2019; 68(24):533—538. doi: 10.15585/mmwr.mm6824a1.
2. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: 2019 report. Global Initiative for Chronic Obstructive Lung Disease.goldcopd.org. Accessed July 10, 2019.
3. McDonough, JE, Yuan R, Suzuki, M, et al. Small-airway obstruction and emphysema in chronic obstructive pulmonary disease.N Engl J Med.2011;365(17):1567-75. doi: 10.1056/NEJMoa1106955..
4. Han MK, Dransfield MT, Martinez FJ. Chronic obstructive pulmonary disease: definition, clinical manifestations, diagnosis and staging. UpToDate website.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-staging?source=autocomplete&index=3~4&search=copd. Updated July 16, 2018. Accessed September 20, 2019.
5. Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD.Eur Respir J. 2009;33(5):1165-85. doi: 10.1183/09031936.00128008.
6. Stoller JK. Management of exacerbations of chronic obstructive pulmonary disease. UpToDate website.uptodate.com/contents/management-of-exacerbations-of-chronic-obstructive-pulmonary-disease?source=history_widget. Updated August 5, 2019. Accessed September 20, 2019.
7. Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease.N Engl J Med.2008:359(22):2355-2365. doi: 10.1056/NEJMra0800353.

1. Ferguson GT, Make B. Management of stable chronic obstructive pulmonary disease. UpToDate website.uptodate.com/contents/management-of-stable-chronic-obstructive-pulmonary-disease?source=autocomplete&index=2~4&search=copd. Updated January 16, 2019. Accessed July 10, 2019.

9. Warnier MJ, van Reit EE, Rutten FH, De Bruin ML, Sachs AP. Smoking cessation strategies in patients with COPD.Eur Respir J.2013;41(3):727-34. doi: 10.1183/09031936.00014012.

10. Higham A, Rattray NJ, Dewhurst JA, et al. Electronic cigarette exposure triggers neutrophil

inflammatory responses.Respir Res.2016;17(1):56. doi: 10.1186/s12931-016-0368x.