Chronic lower respiratory disease, primarily chronic obstructive pulmonary disease (COPD), is the fourth leading cause of death in the United States.1,2 Almost 15.7 million Americans (6.4%) have been diagnosed with COPD.1 More than 50% of adults with low pulmonary function are undiagnosed and unaware that they have this disease. Once thought to be a disease predominantly affecting men, more women than men are currently living with (and dying from) COPD in the United States.1,3 Best practices for the diagnosis and management of COPD are evolving, as reflected in the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report.
The GOLD Science Committee updated the definition of COPD to reflect the heterogeneous nature of this condition, stating that COPD is characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, exacerbations) caused by abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that result in persistent, often progressive, airflow obstruction.4 The 2023 GOLD report also updated risk factors and revised treatment guidelines.4
Table of Contents
Etiology and Risk Factors
Chronic obstructive pulmonary disease is caused by a combination of genetic predisposition, inflammatory changes in the airways, immune reactivity, and environmental factors.4 Although tobacco smoking is a leading cause of COPD globally, the 2023 GOLD Report also emphasizes the role of inhalation of smoke from biomass fuel or ambient particulate matter from household and outdoor air pollution in the risk for COPD.4 Exposure to indoor smoke from biomass fuels is estimated to account for 35% of COPD cases globally.5 Occupational exposures are also associated with COPD. A study based on the Third National Health and Nutrition Examination Survey (NHANES III) reported that occupational exposure was attributable to COPD in 31.1% of nonsmokers, reflecting an increased prevalence of COPD among nonsmokers in certain industries and occupations.6 For example, different occupational dust and fumes, industrial and agricultural, have been associated with COPD and respiratory symptoms.4
Alpha-1 antitrypsin deficiency (AATD) is also a rare genetic disorder that causes COPD.4 Alpha-1 antitrypsin (AAT) is a serine protease inhibitor that protects lung tissue from proteolytic damage by inhibiting elastase, an enzyme secreted by white blood cells. The disorder is caused by a single genetic variant and clinical manifestations include panacinar emphysema, airway hyperresponsiveness, and bronchiectasis.7
Chronic obstructive pulmonary disease causes a range of symptoms that lead to a daily burden and limitations of daily activity in the affected individual. The most common symptoms are dyspnea, cough, and sputum production.4 Patients also experience wheezing, fatigue, chest tightness, and chest congestion.4 Many persons report breathlessness that varies daily, weekly, or seasonally. Of the patients who report seasonal variability in their COPD symptoms, 56% report their symptom burden is greatest during the winter months.8 Winter is associated with an increased risk of COPD exacerbations and it is thought that the cold, damp environment prevailing during the winter months as well as increased exposure to respiratory viral infections at that time of year may partly explain this seasonal association.9
Physical findings that are associated with COPD include cyanosis, enlarged chest diameter, prolonged exhalation phase in breathing, and breathlessness with exertion. Cyanosis may be observed particularly in the lips and mucous membranes in persons with severe COPD and hypoxia. A large amount of retained air in the chest can create a barrel shape. Patients tend to have orthopnea; difficulty breathing in the supine position. Sitting forward or tripoding eases breathing. When auscultating the chest, diminished breath sounds, prolonged exhalation, and wheezing are found. Patients with cor pulmonale can have bilateral crackles and signs of right ventricular failure such as jugular venous distension and ankle edema.10
Diagnosis of COPD
Although COPD may be suspected based on findings from the history and physical examination, the diagnosis must be confirmed by spirometry to detect airflow obstruction and its severity, according to the GOLD 2023 Report.4 Spirometry measures 2 key factors: forced expiratory volume in 1 second (FEV1) and expiratory forced vital capacity (FVC). Chronic obstructive pulmonary disease is diagnosed when the postbronchodilator FEV1/FVC ratio is less than 0.7. Accurate assessment of the patient’s maximal effort is important, and testing should be repeated at least 3 times to get the best results.
The GOLD 2023 Report also recommends a comprehensive assessment of the patient with COPD based on spirometry postbronchodilator. The recommended bronchodilator is 400 mcg of a short-acting β-agonists (SABA), 160 mcg of a short-acting muscarinic antagonist (SAMA), or the 2 agents combined. The FEV1 should be measured 10 to 15 minutes after administration of the SABA or 30 to 45 minutes after the SAMA or combination is administered. Appropriate reference values should be used based on age, height, sex, and race.4
Patient Questionnaires Added to Assessment
In addition to spirometry, the patient’s self-assessment of their condition is considered an important factor in the management of COPD. The modified Medical Research Council (mMRC) dyspnea scale was the first questionnaire developed to measure breathlessness, which is a key symptom in many patients with COPD, although often unrecognized. The mMRC includes a question about the level of activity that causes breathlessness for the patient on a 0 to 4 scale. Zero indicates that the patient only experiences breathlessness with strenuous exercise, whereas a 4 indicates that the patient experiences too much breathlessness to leave the house or when dressing and undressing.4
COPD impacts patients in more ways beyond dyspnea. For this reason, multidimensional questionnaires are recommended. The most comprehensive disease-specific health status questionnaires such as the Chronic Respiratory Questionnaire (CRQ) and St. George’s Respiratory Questionnaire (SGRQ) are important research tools (but are too complex to use in routine practice). Shorter comprehensive measures, such as the COPD Assessment Test (CAT) and The COPD Control Questionnaire (CCQ) have been developed and are suitable for use in the clinic. The CAT tool is a Likert scale that asks questions about level of activity, episodes of cough, chest tightness, sleeping ability, with scores from 0 to 40.4
The GOLD 2023 diagnostic guidelines recommend use of the mMRC and CAT tools in the assessment of the patient.4
Other Laboratory Tests
Other tests that are useful in the clinical diagnosis of COPD include arterial blood gas test, which can reveal chronic hypercapnia and may prompt evaluation for oxygen therapy in select patients. A 6-minute walk test should be ordered in patients with progressively worsening dyspnea or lung function to assess for hypoxia on exertion and determine the need for long-term oxygen therapy. Eosinophil count on a complete blood count with differential can help guide the decision to initiate or discontinue inhaled corticosteroids (ICSs). Patients with high eosinophil counts (>300 cells/µL) respond to ICSs added to the regimen. Obtaining a chest computed tomography (CT) scan is important to rule out pulmonary embolism and assess for the presence of other coexisting pulmonary abnormalities including bronchiectasis, interstitial lung disease, and lung mass.4
Once the diagnosis is established, the FEV1 is used to define the severity of lung function impairment. The GOLD Report classifies the severity of airflow obstruction in COPD as4:
- Mild: FEV1 ≥80% of predicted (GOLD Grade: 1)
- Moderate: FEV1 of 50% to 79% of predicted (GOLD Grade: 2)
- Severe: FEV1 of 30% to 49% of predicted (GOLD Grade: 3)
- Very severe: FEV1 <30% predicted (Gold Grade: 4)
2023 GOLD Report COPD Treatment Guidelines
The goals of COPD treatment are to manage symptoms and prevent exacerbations. Classes of pharmacologic agents used to treat COPD are shown in the Table. Because most COPD pharmacotherapies are inhalers, patients need instruction on the proper inhaler technique. The choice of inhaler device needs to be individualized based on access as well as the patient’s ability and preference. Demonstration of the inhaler technique is critical and should be assessed at each visit. Studies show that improper inhaler technique is common and responsible for inadequate treatment.4
Table. Common Medications Used to Treat COPD
|Class||Drug (brand name)|
|Combination: SABA + anticholinergic agents||Fenoterol/ipratropium
|Combination: LABA + LAMA||Formoterol/aclidinium
|Combination: LABA + ICS||Formoterol/budesonide
In general, long-acting agents are preferred for initial treatment of COPD except in patients with occasional dyspnea in whom short-acting agents may be used. Short-acting agents can also be used for immediate symptom relief during acute exacerbations in patients taking long-acting bronchodilators as maintenance therapy.
The 2023 GOLD Report updated its recommended treatment strategy to an ABE plan based on the control of the patient’s disorder, exacerbation frequency, scores on the mMRC and CAT assessment tools, and eosinophil count (Figure)4:
- Group A: bronchodilator is recommended
- Group B: long-acting muscarinic antagonist (LAMA) plus long-acting β2-agonist (LABA) is recommended and may be available in a single combination canister
- Group E: LAMA plus LABA is recommended and may be available in a single combination canister. If the patient has a high eosinophil count >300 cells/µL, an ICS should be added to the regimen.
Other Treatments for COPD Exacerbations
Between 30% and 50% of COPD exacerbations have a bacterial cause (Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Chlamydia pneumoniae).10 The majority of patients can be managed with antibiotics and stepped-up bronchodilator and corticosteroid therapies; however, some patients may require hospitalization.
The GOLD Report recommends antibiotics in patients with COPD exacerbations who meet one of the following criteria:
- Have all 3 cardinal symptoms of exacerbation: dyspnea, increased sputum volume, and increased sputum purulence.
- Have increased sputum purulence plus one other cardinal symptom (dyspnea or increased sputum volume)
- Require mechanical ventilation (invasive or noninvasive)
The selection of the antibiotic agent should be based on local bacterial flora and the recommended duration for outpatient treatment of COPD exacerbations is 5 days or less.4 The recommended initial empirical treatment is an aminopenicillin with clavulanic acid, macrolide, tetracycline, or quinolone. Azithromycin or other macrolides should be avoided in patients with a prolonged corrected QT interval on electrocardiography and cardiac arrhythmias. Care should be taken to monitor patients for the development of bacterial resistance in sputum and for impaired hearing.
The role of antitussive agents in the treatment of COPD is inconclusive and the Gold Report does not recommend vasodilators for pulmonary hypertension in this population.4 Low doses of oral or parenteral long-acting opiates may ease dyspnea in patients with severe COPD, according to the report.4
In patients with FEV1 less than 50% and chronic bronchitis, clinicians may consider adding the selective phosphodiesterase-4 inhibitor roflumilast or a macrolide to the treatment regimen.4
Pulmonary rehabilitation is recommended after a COPD exacerbation and should be considered an important component of integrated patient management in combination with pharmacologic therapies.11 Findings from a Cochrane review of 65 randomized controlled trials involving 3822 patients show that pulmonary rehabilitation can relieve dyspnea and fatigue, improve emotional function, and enhance the sense of control that patients have over their condition.11
Supplemental Oxygen Therapy
All patients with COPD should be evaluated for hypoxemia at rest. In patients with oxygen saturation that is lower than 88% or partial pressure of arterial oxygen (PaO2) less than 55 mm Hg while the patient is breathing ambient air at sea level on 2 occasions over a 3-week period, supplemental oxygen is indicated. 4
In patients whose oxygen saturation is less than 90%, arterial blood gases should be measured while the patients are breathing room air. In those with hypoxemia without hypercapnia, low-flow oxygen is indicated to achieve a PaO2 value of 60 to 65 mm Hg (oxygen saturation, 91 to 94%).12 Oxygen supplementation should be titrated to maintain the patient at an SaO2 of 90% or more.12
Patients should also be considered for oxygen therapy if they have persistent hypercapnia with a pH of less than 7.35 but more than 7.15.14,15
Indications for Hospitalization
Patients that have worsening resting dyspnea, decreased oxygen saturation, high respiratory rate, drowsiness, or confusion may need hospitalization. The primary care provider should look for signs of low oxygenation such as cyanosis and the effort of the patient to breathe. Assess if accessory muscles are being used and if wheezing has increased. If the patient has comorbidities, worsening peripheral edema can indicate heart failure. If an exacerbation is not responding to treatment or if there is inadequate home support, the patient commonly needs hospitalization.4
Lifestyle Changes and Vaccinations
Basic lifestyle modifications include smoking cessation, reducing exposure to pollutants and infection, regular physical activity, healthy diet, and preventive vaccinations. Treatment to assist the patient cease smoking includes varenicline, sustained-release bupropion, nortriptyline, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patches, and are recommended in the absence of contraindications.16
Given that COPD exacerbations are often triggered by viral infection, COVID-19, influenza, and pneumococcal (PCV13 and PPSV23) vaccinations are recommended to decrease the risk of infection.4 The Centers for Disease Control and Prevention (CDC) recommends 1 dose of the 20 valent pneumococcal conjugate vaccine (PCV20) or 1 dose of 15 valent pneumococcal conjugate vaccine (PCV15) followed by 23 valent pneumococcal polysaccharide vaccine (PPSV23) in persons with COPD.17 The CDC also recommends Tdap vaccination for adults not vaccinated in adolescence as well as shingles vaccination for those 50 years and older.18
Primary care clinicians are often the primary health care provider for patients with COPD. All clinicians should consult the GOLD 2023 Report for up-to-date recommendations on the diagnosis and management of COPD patients.
Theresa Capriotti, DO, MSN, CRNP, RN, is a clinical professor at Villanova University M. Louise Fitzpatrick College of Nursing in Villanova, Pennsylvania. Rose Tomy and Mia Morales are BSN Honor Students at Villanova University M. Louise Fitzpatrick College of Nursing.
- National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Basics about COPD. Centers for Disease Control and Prevention: June 9, 2021. Accessed April 28, 2023. www.cdc.gov/copd/basics-about.html
- Xu J, Murphy SL, Kockanek KD, Arias E. Mortality in the United States, 2018. NCHS Data Brief. 2020;(355):1-8.
- Aryal S, Diaz-Guzman E, Mannino DM. Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes. Int J Chron Obstruct Pulmon Dis. 2014;9:1145-1154. doi:10.2147/COPD.S54476
- Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2023 Report. Global Initiative for Chronic Obstructive Lung Disease.
- Safiri S, Carson-Chahhoud K, Noori M, et al. Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019. BMJ. 2022;378:e069679. doi:10.1136/bmj-2021-069679
- Hnizdo E, Sullivan PA, Bang KM, Wagner G. Association between chronic obstructive pulmonary disease and employment by industry and occupation in the US population: a study of data from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2002;156(8):738-46. doi:10.1093/aje/kwf105
- Strange C. Alpha-1 antitrypsin deficiency associated COPD. Clin Chest Med. 2020;41(3):339-345. doi:10.1016/j.ccm.2020.05.003
- Kessler R, Partridge MR, Miravitlles M, et al. Symptom variability in patients with severe COPD: a pan-European cross-sectional study. Eur Respir J. 2011;37(2):264-72. doi:10.1183/09031936.00051110
- Donaldson GC, Wedzicha JA. The causes and consequences of seasonal variation in COPD exacerbations. Int J Chron Obstruct Pulmon Dis. 2014 6;9:1101-10. doi:10.2147/COPD.S54475
- Sheikh K, Coxson HO, Parraga G. This is what COPD looks like. Respirology. 2016;21(2):224-36. doi:10.1111/resp.12611
- Celli BR, Wedzicha JA. Update on clinical aspects of chronic obstructive pulmonary disease. N Engl J Med. 2019;381(13):1257-1266. doi:10.1056/NEJMra1900500
- Lacasse Y, Casaburi R, Sliwinski P, Chaouat A, Fletcher E, Haidl P, Maltais F. Home oxygen for moderate hypoxaemia in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Lancet Respir Med. 2022;10(11):1029-1037. doi:10.1016/S2213-2600(22)00179-5
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2015(2):CD003793. doi:10.1002/14651858.CD003793.pub3
- Wedzicha JA, Calverley PMA, Albert RK, et al. Prevention of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;50(3):1602265. doi:10.1183/13993003.02265-2016
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426. doi:10.1183/13993003.02426-2016
- Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;2013(5):CD009329. doi:10.1002/14651858.CD009329.pub2
- Centers for Disease Control and Prevention. Pneumococcal vaccine recommendations. Updated February 13, 2023. Accessed May 2, 2023. www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html
- Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: updated recommendations of the Advisory Committee on Immunization Practices — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69:77-83. doi:dx.doi.org/10.15585/mmwr.mm6903a5external icon