1. Diagnosis and assessment of Chronic Obstructive Pulmonary Disease: COPD

2. Definition of COPD COPD is defined by GOLD (2014 update) as:*
‘a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive, and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases’
Chronic airflow limitation in COPD is caused by a combination of:
Small airways disease (bronchiolitis)
Parenchymal destruction (emphysema)
The relative contributions of each vary from person to person
Major risk factors for developing COPD are:
tobacco smoking
exposure to occupational, outdoor and indoor air pollution (e.g. burning wood)
Exacerbations and comorbidities contribute to overall severity in individual patients
Reference
GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Updated Available at
Many previous definitions of COPD have emphasized the terms 'chronic bronchitis' and 'emphysema', which are not included in the definition used in the GOLD 2014 report or earlier GOLD reports
COPD = chronic obstructive pulmonary disease
GOLD 2014 (

3. Diagnosis of COPD
Diagnosis of COPD should be considered in patients aged >40 with dyspnea, chronic cough or sputum production and/or a history of exposure to risk factors
Spirometry is the gold standard for the diagnosis and assessment of COPD
There is poor recognition of the essential role of spirometry in diagnosis of COPD and lack of adequate training in its use and interpretation
Reference
GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Updated Available at
COPD = chronic obstructive pulmonary disease
GOLD 2014 (

4. COPD is not usually diagnosed until it is clinically apparent and moderately advanced
COPD is usually not diagnosed until it is clinically apparent and moderately advanced1
By the time COPD is diagnosed, often ≥50% of lung function has been lost and need for healthcare utilization is high2
Although airway obstruction may be very mild in early COPD, patients often have significant impairment of HRQoL and reduced ADL3
Many individuals consider breathlessness and low exercise tolerance as features of ageing
Smoker’s cough may be regarded as normal
Affected individuals often do not request medical attention
ADL = activities of daily living; COPD = chronic obstructive pulmonary disease; HRQoL = health-related quality of life
Celli BR et al. Eur Respir J 2004;23:932–46
Lundbäck et al. Eur Respir J 2003;21(Suppl. 40):3s–9s
Decramer M et al. Respir Med. 2011;105:1576–87

5. COPD does not just affect elderly adults
50% of patients with COPD in the USA are <65 years old1
COPD prevalence is increasing in younger age groups, particularly in women2
N=573
References
Confronting COPD in America: executive summary. Available from: (last accessed 10 June 2013).
Hernandez P et al. Respir Med 2009;103:1004–12.
Figure adapted from Confronting COPD in America
COPD, chronic obstructive pulmonary disease.
1. Confronting COPD in America; 2. Hernandez P. Respir Med 2009;103:1004–12
AARC 2003

6. Symptoms, a history of risk factors, and spirometry all contribute to the diagnosis of COPD
Consider COPD if symptoms and/or a history of risk factors are present
Confirm the diagnosis with spirometry (post-bronchodilator FEV1/FVC <0.70)
Symptoms
Dyspnea
Chronic cough
Chronic sputum
Risk-factor history
Tobacco smoke
Home cooking/fuel smoke
Occupational dusts/chemicals
Reference
GOLD Available from:
SPIROMETRY
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity; GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2014 (

7. Forced expiratory volume (L)
Spirometry is the gold standard for the diagnosis and assessment of COPD
Patients with COPD typically show a decrease in FVC and FEV1
FVC 5 4 3 2 1
FEV1
FVC
Forced expiratory volume (L)
FEV1
FVC
FEV1/FVC
Normal
4 L
5 L
80%
COPD
1.8 L
3.2 L
56%
Spirometry is used to determine FVC and FEV1. In addition, it can be useful to calculate the ratio of these two measurements (FEV1/FVC). The ratio of FEV1/FVC is a measure of airflow limitation. A post-bronchodilator FEV1 <80% of the predicted value in combination with an FEV1/FVC <70% confirms the presence of airflow obstruction – either COPD or asthma. Where possible, values should be compared to age-related normal values to avoid over-diagnosis of COPD in the elderly.
In order to minimize variability due to varying degrees of smooth muscle contraction, it is recommended that spirometry should be performed after an adequate dose of a short-acting bronchodilator (e.g. 400μg salbutamol).
An improvement of FEV1 of >12% (either spontaneously or after inhalation of a bronchodilator and/or following a 2-week course of high dose oral steroids) indicates reversibility, and therefore suggests a diagnosis of asthma.
Note that, if spirometry is unavailable, prolongation of the forced expiratory time beyond 6 seconds is a crude but useful guide to the presence of an FEV1/FVC ratio <50%.
Reference
GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Updated Available at
Time (seconds)
The presence of a postbronchodilator FEV1/FVC <0.70 and FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity; GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2014 (

8. Obstructive lung disease has a characteristically different spirometry loop to ‘normal’
PEFR 10 8
FEF25 8 6 6
FEF50 4
FEF75 4 2 2
Volume (Litres)
Flow (Litres/sec)
Volume (Litres)
Flow (Litres/sec) –2
FEV0.5
FEV1
FEV3
FVC –2 –4 –4 –6
FIF75 –6
Reference
FIF25 –8
FIF50 –8
Normal
The first landmark reached is the PEFR. The first blast of air exhaled from the patient reaches this flow rate almost immediately. The flow rate then quickly slows as more air is exhaled. This landmark is very important in judging if the patient is giving maximal effort, overall quality of the test, strength of expiratory muscles, and the condition of the large airways, such as the trachea and main bronchi.
Emphysema
Bronchitis
This illustration shows the variety of flow volume loop shapes that often relate to particular disease. When looked at in relation to the lung volume further clinical information can be revealed.
FEV = forced expiratory volume; FVC = forced vital capacity; FIF = forced inspiratory fraction; PEFR = peak expiratory flow rate

9. COPD and asthma are distinct conditions that can be differentiated from each other
Onset
Midlife
Early in life (often childhood)
Symptoms
Slowly progressive
Dyspnea during exercise
Vary from day to day
More common at night/early morning
Airflow limitation
Largely irreversible
Largely reversible
Main risk factors for development
Tobacco smoke and airborne pollutants
Exposure to allergens, infections, diet, tobacco smoke, socioeconomic status
Additional features
Allergy, rhinitis and eczema also present
Family history of asthma
Reference
GOLD Available at
COPD = chronic obstructive pulmonary disease
GOLD 2014 (

10. High risk, Less symptoms
GOLD 2014 COPD classification determines to which Group patients belong
‘Symptoms’ should be assessed first
‘Risk’ should be assessed second (choose the highest risk according to airflow limitation or exacerbation history)
Patient will then be categorized as belonging to one of four Groups (A, B, C or D) 4
≥2 or
(C)
(D)
Risk GOLD classification of airflow limitation
Risk Exacerbation history
High risk, Less symptoms
High risk,
More symptoms,
≥1 leading to hospital admission 3 2
(A)
(B)
1 (not leading to hospital admission)
Low risk,
Less symptoms
Low risk,
More symptoms
Reference
GOLD Available from: 1
CAT <10
CAT ≥10
Symptoms
mMRC 01
mMRC ≥2
Breathlessness
CAT = COPD Assessment Test; COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity; GOLD = Global Initiative for Chronic Obstructive Lung Disease; HRQoL = health-related quality of life; mMRC = modified Medical Research Council
GOLD 2014 (

11. Despite objective measures and diagnosis guidelines, COPD is under-diagnosed globally
BOLD study showed that fewer patients are diagnosed with COPD than actually have COPD 30 25 20
Percent 15 10
References
Buist S et al. Lancet 2007;370:741–50.
Personal communication with BOLD investigators. 5
South Africa
China
USA
Turkey
Austria
Iceland
Germany
Poland
Norway
Canada
Australia
Philippines
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
Buist S et al. Lancet 2007;370:741–50

12. One third of patients have progressed to GOLD Stage III or IV by the time of diagnosis
Study of patients with COPD in a US database during 1994–2006
31% of patients were in GOLD Stage III or IV (severe or very severe airflow limitation) at diagnosis
COPD severity at initial spirometry-confirmed diagnosis
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
Mapel DW et al. Int Journal of COPD 2011;6:573–81

13. Conclusions
Diagnosis of COPD requires assessment of symptoms, history of risk factors, and spirometry1
Assessment based on symptoms alone is insufficient for correct diagnosis of COPD2
Spirometry is the gold-standard for diagnosis of COPD1
Airflow limitation that is not fully reversible is confirmed by postbronchodilator FEV1/FVC <0.70 and FEV1 <80% predicted
COPD and asthma have distinct characteristics1
Onset is typically in midlife in COPD and in early life in asthma1
Symptoms are slowly progressive in COPD and more variable in asthma1
Airflow is largely reversible in COPD and irreversible in asthma1
A clinically distinct population of patients have ‘COPD-asthma overlap’3
COPD is under-diagnosed4
By the time COPD is diagnosed, often ≥50% of lung function has been lost5
One third of patients have GOLD stage III or IV COPD by the time of diagnosis6
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity ; GOLD = Global Initiative for Chronic Obstructive Lung Disease
1. GOLD 2014 ( 2. Tálamo C, et al. Chest 2007;131:60–7; 3. Gibson PG & Simpson JL. Thorax;64:728–35; 4. Buist S et al. Lancet 2007;370:741–50; 5. Lundbäck et al. Eur Respir J 2003;21(Suppl. 40):3s–9s; 6. Mapel DW et al. Int Journal of COPD 2011;6:573–81