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1 Chapter 1 : Diagnosis of chronic obstructive pulmonary disease in the primary care setting Chronic Obstructive Pulmonary Disease (COPD) ICSI has endorsed with qualifications the Veteran's Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Chronic Obstructive Pulmonary Disease. What are the complications or effects of COPD? Compared to adults without COPD, those with this disease are more likely to: Have activity limitations like difficulty walking or climbing stairs. A simple test, called spirometry, can be used to measure pulmonaryâ or lungâ function and detect COPD in anyone with breathing problems. Treatment of COPD requires a careful and thorough evaluation by a physician. Treatment options that your physician may consider include: For people who smoke, the most important part of treatment is smoking cessation. Avoid tobacco smoke and other air pollutants at home and at work. Ask your doctor about pulmonary rehabilitation, which is a personalized treatment program that teaches COPD management strategies to improve quality of life. Programs may include plans that teach people how to breathe better and conserve their energy, as well as provide advice on food and exercise. Symptoms such as coughing or wheezing can be treated with medication. Lung infections can cause serious problems in people with COPD. Certain vaccines, such as flu and pneumococcal vaccines, are especially important for people with COPD. Learn more about vaccination recommendations. Respiratory infections should be treated with antibiotics, if appropriate. Some people may need to use a portable oxygen tank if their blood oxygen levels are low. References National Center for Health Statistics. Employment and activity limitations among adults with chronic obstructive pulmonary disease â United States, Obstructive lung disease and low lung function in adults in the United States: Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses â United States, â Association of chronic obstructive pulmonary disease with increased confusion or memory loss and functional limitations among adults in 21 states, Behavioral Risk Factor Surveillance System. The association of chronic obstructive pulmonary disease, disability, engagement in social activities, and mortality among US adults aged 70 years or older: Chronic obstructive pulmonary disease, hospital visits, and comorbiditiesâ National Survey of Residential Care Facilities, Association of self-reported cigarette smoking with chronic obstructive pulmonary disease and co-morbid chronic conditions in the United States. Pulmonary function, chronic respiratory symptoms, and health-related quality of life among adults in the United Statesâ National Health and Nutrition Examination Survey Diagnosis and management of stable chronic obstructive pulmonary disease: Page 1

2 Chapter 2 : Chronic Obstructive Pulmonary Disease (COPD) Management and Treatment Cleveland Clini Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Print Overview Chronic obstructive pulmonary disease COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus sputum production and wheezing. People with COPD are at increased risk of developing heart disease, lung cancer and a variety of other conditions. Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD. Chronic bronchitis is inflammation of the lining of the bronchial tubes, which carry air to and from the air sacs alveoli of the lungs. Emphysema is a condition in which the alveoli at the end of the smallest air passages bronchioles of the lungs are destroyed as a result of damaging exposure to cigarette smoke and other irritating gases and particulate matter. With proper management, most people with COPD can achieve good symptom control and quality of life, as well as reduced risk of other associated conditions. For chronic bronchitis, the main symptom is a daily cough and mucus sputum production at least three months a year for two consecutive years. Other signs and symptoms of COPD may include: Shortness of breath, especially during physical activities Wheezing Chest tightness Having to clear your throat first thing in the morning, due to excess mucus in your lungs A chronic cough that may produce mucus sputum that may be clear, white, yellow or greenish Blueness of the lips or fingernail beds cyanosis Frequent respiratory infections Unintended weight loss in later stages Swelling in ankles, feet or legs People with COPD are also likely to experience episodes called exacerbations, during which their symptoms become worse than usual day-to-day variation and persist for at least several days. In the developing world, COPD often occurs in people exposed to fumes from burning fuel for cooking and heating in poorly ventilated homes. Only about 20 to 30 percent of chronic smokers may develop clinically apparent COPD, although many smokers with long smoking histories may develop reduced lung function. Some smokers develop less common lung conditions. They may be misdiagnosed as having COPD until a more thorough evaluation is performed. How your lungs are affected Air travels down your windpipe trachea and into your lungs through two large tubes bronchi. Inside your lungs, these tubes divide many times â like the branches of a tree â into many smaller tubes bronchioles that end in clusters of tiny air sacs alveoli. The air sacs have very thin walls full of tiny blood vessels capillaries. The oxygen in the air you inhale passes into these blood vessels and enters your bloodstream. At the same time, carbon dioxide â a gas that is a waste product of metabolism â is exhaled. Your lungs rely on the natural elasticity of the bronchial tubes and air sacs to force air out of your body. COPD causes them to lose their elasticity and overexpand, which leaves some air trapped in your lungs when you exhale. This creates one larger air space instead of many small ones and reduces the surface area available for gas exchange. Bronchitis Bronchitis Bronchitis is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. People who have bronchitis often cough up thickened mucus, which can be discolored. Causes of airway obstruction Causes of airway obstruction include: This lung disease causes destruction of the fragile walls and elastic fibers of the alveoli. Small airways collapse when you exhale, impairing airflow out of your lungs. In this condition, your bronchial tubes become inflamed and narrowed and your lungs produce more mucus, which can further block the narrowed tubes. You develop a chronic cough trying to clear your airways. Cigarette smoke and other irritants In the vast majority of cases, the lung damage that leads to COPD is caused by long-term cigarette smoking. But there are likely other factors at play in the development of COPD, such as a genetic susceptibility to the disease, because only about 20 to 30 percent of smokers may develop COPD. Other irritants can cause COPD, including cigar smoke, secondhand smoke, pipe smoke, air pollution and workplace exposure to dust, smoke or fumes. Alphaantitrypsin deficiency In about 1 percent of people with COPD, the disease results from a genetic disorder that causes Page 2

3 low levels of a protein called alphaantitrypsin. Alphaantitrypsin AAt is made in the liver and secreted into the bloodstream to help protect the lungs. Alphaantitrypsin deficiency can affect the liver as well as the lungs. Damage to the lung can occur in infants and children, not only adults with long smoking histories. In addition, some people can be treated by replacing the missing AAt protein, which may prevent further damage to the lungs. Exposure to tobacco smoke. The most significant risk factor for COPD is long-term cigarette smoking. The more years you smoke and the more packs you smoke, the greater your risk. Pipe smokers, cigar smokers and marijuana smokers also may be at risk, as well as people exposed to large amounts of secondhand smoke. People with asthma who smoke. The combination of asthma, a chronic inflammatory airway disease, and smoking increases the risk of COPD even more. Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes, vapors and dusts in the workplace can irritate and inflame your lungs. Exposure to fumes from burning fuel. In the developing world, people exposed to fumes from burning fuel for cooking and heating in poorly ventilated homes are at higher risk of developing COPD. COPD develops slowly over years, so most people are at least 40 years old when symptoms begin. The uncommon genetic disorder alphaantitrypsin deficiency is the cause of some cases of COPD. Other genetic factors likely make certain smokers more susceptible to the disease. Complications COPD can cause many complications, including: People with COPD are more likely to catch colds, the flu and pneumonia. Any respiratory infection can make it much more difficult to breathe and could cause further damage to lung tissue. An annual flu vaccination and regular vaccination against pneumococcal pneumonia can prevent some infections. Quitting smoking may reduce this risk. People with COPD have a higher risk of developing lung cancer. High blood pressure in lung arteries. COPD may cause high blood pressure in the arteries that bring blood to your lungs pulmonary hypertension. Difficulty breathing can keep you from doing activities that you enjoy. And dealing with serious illness can contribute to development of depression. Talk to your doctor if you feel sad or helpless or think that you may be experiencing depression. The majority of cases are directly related to cigarette smoking, and the best way to prevent COPD is to never smoke â or to stop smoking now. But keep trying to quit. Occupational exposure to chemical fumes and dust is another risk factor for COPD. If you work with this type of lung irritant, talk to your supervisor about the best ways to protect yourself, such as using respiratory protective equipment. Page 3

4 Chapter 3 : Chronic Obstructive Pulmonary Disease Michigan Care Management Resource Center The diagnosis of chronic obstructive pulmonary disease (COPD) should be suspected in patients with risk factors (primarily a history of smoking) who report dyspnea at rest or with exertion. Weinberger, MD; Nicola A. Weinberger, MD Nicola A. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued. The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U. Department of Health and Human Services. The authors thank Dr. Vincenza Snow for critical review and comments. Financial support for the development of this guideline comes exclusively from the ACP operating budget. Potential Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. American College of Physicians; Payment for manuscript preparation: American College of Physicians. Aeris Therapeutics, Emphysas Medica. Saskatchewan Medical Association; Consultancy money to institution: Boehringer Ingelheim; Board membership: Chiesi; Consultancy money to institution: Disclosures can also be viewed at www. Requests for Single Reprints: American College of Physicians, N. Analysis and interpretation of the data: Drafting of the article: Critical revision of the article for important intellectual content: Final approval of the article: Administrative, technical, or logistic support: Collection and assembly of data: Mir, MD; Douglas K. Sweet, MD; and David S. Page 4

5 Chapter 4 : CDC - COPD Home Page - Chronic Obstructive Pulmonary Disease (COPD) In, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. The sound of wheezing as heard with a stethoscope. Problems playing this file? The most common symptoms of COPD are sputum production, shortness of breath, and a productive cough. When it persists for more than three months each year for at least two years, in combination with sputum production and without another explanation, it is by definition chronic bronchitis. This condition can occur before COPD fully develops. The amount of sputum produced can change over hours to days. In some cases, the cough may not be present or may only occur occasionally and may not be productive. Sputum may be swallowed or spat out, depending often on social and cultural factors. Vigorous coughing may lead to rib fractures or a brief loss of consciousness. Those with COPD often have a history of " common colds " that last a long time. Note the scales used for females and males differ. The risk is greater in those who are poor, although if this is due to poverty itself or other risk factors associated with poverty, such as air pollution and malnutrition, is not clear. On the right are lungs damaged by COPD with an inset showing a cross-section of damaged bronchioles and alveoli. COPD is a type of obstructive lung disease in which chronic, incompletely reversible poor airflow airflow limitation and inability to breathe out fully air trapping exist. The relative contributions of these two factors vary between people. This form of disease is called bullous emphysema. Those who smoke additionally have Tc1 lymphocyte involvement and some people with COPD have eosinophil involvement similar to that in asthma. Part of this cell response is brought on by inflammatory mediators such as chemotactic factors. Other processes involved with lung damage include oxidative stress produced by high concentrations of free radicals in tobacco smoke and released by inflammatory cells, and breakdown of the connective tissue of the lungs by proteases that are insufficiently inhibited by protease inhibitors. The destruction of the connective tissue of the lungs leads to emphysema, which then contributes to the poor airflow, and finally, poor absorption and release of respiratory gases. This contributes to the inability to breathe out fully. The greatest reduction in air flow occurs when breathing out, as the pressure in the chest is compressing the airways at this time. This can also lead to insufficient ventilation, and eventually, low blood oxygen levels. Both of these changes result in increased blood pressure in the pulmonary arteries, which may cause cor pulmonale. Smaller handheld devices are available for office use. The diagnosis of COPD should be considered in anyone over the age of 35 to 40 who has shortness of breath, a chronic cough, sputum production, or frequent winter colds and a history of exposure to risk factors for the disease. Page 5

6 Chapter 5 : Chronic obstructive pulmonary disease Information Mount Sinai - New York Centers for Disease Control and Prevention: Chronic Obstructive Pulmonary Disease (COPD) American College of Chest Physicians: Living Well With COPD This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or healthcare provider. Having COPD makes it hard to breathe. There are two main forms of COPD: Chronic bronchitis, which involves a long-term cough with mucus Emphysema, which involves damage to the lungs over time Most people with COPD have a combination of both conditions. Spirometry is a painless study of air volume and flow rate within the lungs. Spirometry is frequently used to evaluate lung function in people with obstructive or restrictive lung diseases such as asthma or cystic fibrosis. Emphysema is a lung disease involving damage to the air sacs alveoli. There is progressive destruction of alveoli and the surrounding tissue that supports the alveoli. With more advanced disease, large air cysts develop where normal lung tissue used to be. Air is trapped in the lungs due to lack of supportive tissue which decreases oxygenation. Bronchitis is the inflammation of the bronchi, the main air passages to the lungs, it generally follows a viral respiratory infection. Symptoms include; coughing, shortness of breath, wheezing and fatigue. The many methods of quitting smoking include counseling and support groups, nicotine patches, gums and sprays, and incremental reduction. Chronic obstructive pulmonary disease COPD refers to chronic lung disorders that result in blocked air flow in the lungs. The two main COPD disorders are emphysema and chronic bronchitis, the most common causes of respiratory failure. Damage from COPD is usually permanent and irreversible. Air is breathed in through the nasal passageways, travels through the trachea and bronchi to the lungs. Could you have chronic obstructive pulmonary disease? The symptoms of COPD can sneak up on you slowly. Only your doctor can tell for sure whether this is COPD. You may also need to have a blood test to determine how much oxygen and carbon dioxide is in your blood. However, there are ways to control the condition and help you breathe more easily. The first thing you do, absolutely need to do, is stop smoking, which will help slow down the damage to your lungs. A few medicines can help relieve COPD symptoms. You may breathe in a bronchodilator medicine through an inhaler to open up your airways, or take steroids to bring down the swelling in your lungs. You may need to visit the hospital for oxygen or breathing assistance. You may also need to take antibiotics during flare-ups, because getting an infection can make your COPD worse. Your doctor can teach you how to breathe in a different way so that you can exercise with COPD. You can help avoid the shortness of breath, the coughing, and the wheezing of COPD by butting out, kicking your cigarette habit as soon as possible. Not smoking is the absolute best way to prevent COPD. Ask your doctor about programs and medicines that may make it easier for you to quit. The more a person smokes, the more likely that person will develop COPD. But some people smoke for years and never get COPD. In rare cases, nonsmokers who lack a protein called alpha-1 antitrypsin can develop emphysema. Other risk factors for COPD are: Exposure to certain gases or fumes in the workplace Exposure to heavy amounts of secondhand smoke and pollution Frequent use of a cooking fire without proper ventilation Symptoms Symptoms may include any of the following: This involves blowing out as hard as possible into a small machine that tests lung capacity. The results can be checked right away. Using a stethoscope to listen to the lungs can also be helpful. But sometimes, the lungs sound normal, even when a person has COPD. Imaging tests of the lungs, such as x-rays and CT scans, can be helpful. With an x-ray, the lungs may look normal, even when a person has COPD. Sometimes, a blood test called arterial blood gas may be done to measure the amounts of oxygen and carbon dioxide in the blood. Page 6

7 Chapter 6 : COPD - Diagnosis and treatment - Mayo Clinic Keywords: chronic obstructive pulmonary disease, primary care, diagnosis, questionnaires, spirometry, case-identification, review Chronic Obstructive Lung Disease (COPD) is a preventable and treatable disease that characterized by airflow limitation that is not fully reversible. COPD is commonly misdiagnosed â former smokers may sometimes be told they have COPD, when in reality they may have simple deconditioning or another less common lung condition. Likewise, many people who have COPD may not be diagnosed until the disease is advanced and interventions are less effective. Your doctor may order several tests to diagnose your condition. Lung pulmonary function tests. Pulmonary function tests measure the amount of air you can inhale and exhale, and if your lungs are delivering enough oxygen to your blood. Spirometry is the most common lung function test. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs. Spirometry can detect COPD even before you have symptoms of the disease. It can also be used to track the progression of disease and to monitor how well treatment is working. Spirometry often includes measurement of the effect of bronchodilator administration. Other lung function tests include measurement of lung volumes, diffusing capacity and pulse oximetry. An X-ray can also rule out other lung problems or heart failure. CT scans can also be used to screen for lung cancer. Arterial blood gas analysis. This blood test measures how well your lungs are bringing oxygen into your blood and removing carbon dioxide. For example, laboratory tests may be used to determine if you have the genetic disorder alphaantitrypsin AAt deficiency, which may be the cause of some cases of COPD. Most people have mild forms of the disease for which little therapy is needed other than smoking cessation. Even for more advanced stages of disease, effective therapy is available that can control symptoms, reduce your risk of complications and exacerbations, and improve your ability to lead an active life. Talk to your doctor about nicotine replacement products and medications that might help, as well as how to handle relapses. Your doctor may also recommend a support group for people who want to quit smoking. Medications Doctors use several kinds of medications to treat the symptoms and complications of COPD. You may take some medications on a regular basis and others as needed. Bronchodilators These medications â which usually come in an inhaler â relax the muscles around your airways. This can help relieve coughing and shortness of breath and make breathing easier. Depending on the severity of your disease, you may need a short-acting bronchodilator before activities, a long-acting bronchodilator that you use every day or both. The long-acting bronchodilators include tiotropium Spiriva, salmeterol Serevent, formoterol Foradil, Perforomist, arformoterol Brovana, indacaterol Arcapta and aclidinium Tudorza. Inhaled steroids Inhaled corticosteroid medications can reduce airway inflammation and help prevent exacerbations. Side effects may include bruising, oral infections and hoarseness. These medications are useful for people with frequent exacerbations of COPD. Combination inhalers Some medications combine bronchodilators and inhaled steroids. Salmeterol and fluticasone Advair and formoterol and budesonide Symbicort are examples of combination inhalers. Oral steroids For people who have a moderate or severe acute exacerbation, short courses for example, five days of oral corticosteroids prevent further worsening of COPD. However, long-term use of these medications can have serious side effects, such as weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection. Phosphodiesterase-4 inhibitors A new type of medication approved for people with severe COPD and symptoms of chronic bronchitis is roflumilast Daliresp, a phosphodiesterase-4 inhibitor. This drug decreases airway inflammation and relaxes the airways. Common side effects include diarrhea and weight loss. Theophylline This very inexpensive medication may help improve breathing and prevent exacerbations. Side effects may include nausea, headache, fast heartbeat and tremor. Side effects are dose related, and low doses are recommended. Antibiotics Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate COPD symptoms. There are several devices to deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town. Some Page 7

8 people with COPD use oxygen only during activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy proven to extend life. Talk to your doctor about your needs and options. These programs generally combine education, exercise training, nutrition advice and counseling. Pulmonary rehabilitation may shorten hospitalizations, increase your ability to participate in everyday activities and improve your quality of life. Talk to your doctor about referral to a program. Managing exacerbations Even with ongoing treatment, you may experience times when symptoms become worse for days or weeks. Exacerbations may be caused by a respiratory infection, air pollution or other triggers of inflammation. When exacerbations occur, you may need additional medications such as antibiotics, steroids or both, supplemental oxygen or treatment in the hospital. Once symptoms improve, your doctor will talk with you about measures to prevent future exacerbations, such as quitting smoking, taking inhaled steroids, long-acting bronchodilators or other medications, getting your annual flu vaccine, and avoiding air pollution whenever possible. Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung tissue from the upper lungs. This creates extra space in your chest cavity so that the remaining healthier lung tissue can expand and the diaphragm can work more efficiently. In some people, this surgery can improve quality of life and prolong survival. Lung transplantation may be an option for certain people who meet specific criteria. Transplantation can improve your ability to breathe and to be active. Large air spaces bullae form in the lungs when the walls of the air sacs are destroyed. These bullae can become very large and cause breathing problems. In a bullectomy, doctors remove bullae from the lungs to help improve air flow. Request an Appointment at Mayo Clinic Clinical trials Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease. Lifestyle and home remedies If you have COPD, you can take steps to feel better and slow the damage to your lungs: Talk to your doctor or respiratory therapist about techniques for breathing more efficiently throughout the day. With COPD, mucus tends to collect in your air passages and can be difficult to clear. Controlled coughing, drinking plenty of water and using a humidifier may help. It may seem difficult to exercise when you have trouble breathing, but regular exercise can improve your overall strength and endurance and strengthen your respiratory muscles. Discuss with your doctor which activities are appropriate for you. A healthy diet can help you maintain your strength. Avoid smoke and air pollution. Secondhand smoke may contribute to further lung damage. Other types of air pollution also can irritate your lungs. See your doctor regularly. And be sure to get your annual flu vaccine in the fall to help prevent infections that can worsen your COPD. Ask your doctor when you need the pneumococcal vaccine. Let your doctor know if you have worsening symptoms or you notice signs of infection. Coping and support Living with COPD can be a challenge â especially as it becomes harder to catch your breath. You may have to give up some activities you previously enjoyed. Your family and friends may have difficulty adjusting to some of the changes. It can help to share your fears and feelings with your family, friends and doctor. You may also want to consider joining a support group for people with COPD. And you may benefit from counseling or medication if you feel depressed or overwhelmed. What you can do Before your appointment, you might want to write a list of answers to the following questions: What symptoms are you experiencing? When did they start? What makes your symptoms worse? Does anyone in your family have COPD? Have you had any treatment for COPD? If so, what was it and did it help? Have you ever taken beta blockers for your high blood pressure or heart? Are you being treated for any other medical conditions? What medications and supplements do you take regularly? You might want to have a friend or family member accompany you to your appointment. Take notes if this helps. What to expect from your doctor Your doctor may ask some of the following questions: How long have you had a cough? Do you get short of breath easily? Have you noticed any wheezing when you breathe? Do you or have you ever smoked cigarettes? Page 8

9 Chapter 7 : COPD - Symptoms and causes - Mayo Clinic Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term breathing problems and poor airflow. The main symptoms include shortness of breath and cough with sputum production. Dil 3, Thessaloniki, Greece,Tel. Abstract Chronic obstructive pulmonary disease COPD remains a major cause of morbidity and mortality with increasing rates during the last decades. Due to the progressive nature of the disease, underestimation of symptoms by the patients, lack of knowledge and underuse of spirometry by the Primary Care providers the disease remains under-diagnosed in about half of the cases. Measurement of spirometric parameters after administration of a short acting bronchodilator confirms the presence of irreversible airflow obstruction and establishes the diagnosis. However in the primary care spirometry is usually not available and differential diagnosis with other obstructive pulmonary diseases e. General Practitioners GPs need simple screening tools to decide if a patient belong to a high risk group and pulmonary consultation is necessary. Early and accurate diagnosis of COPD in the primary care setting allowing for a timely and effective management which reduces the rate of decline in lung function improves survival of patients, their quality of life and reduces health-care utilization. The aim of the present review is to provide the existing information about COPD diagnosis and the related problems in the Primary Care. Also we reviewed numerous simple COPD diagnosis questionnaires as well as the use of hand-held flow meters which could be used as effective screening tools. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to cigarette smoke and other noxious particles or gases 1. It was estimated that 1 every 4 men and 1 every 6 women without COPD at the age of 55 years will eventually develop COPD at some time during their further life 3. Prevalence rates of COPD are expected to increase in next decades, notably among women and in developing countries populations 4. By, COPD is expected to become the third leading cause of death in middle-income countries 5. Trends in age-standardized death rates for the 6 leading causes of death in the USA from through indicates that, while mortality from several these chronic conditions decline over the period, COPD mortality increased 6. The majority of this cost is attributed to hospitalizations for exacerbations 8. Patients with COPD face a significantly increased risk for premature death 9. COPD exacerbations influence mortality, pulmonary function, physical activity and quality of life of patients 10 - Patients with more advanced stages are also at increased risk for comorbid conditions e. Smoking cessation is the only effective way to change the natural history of the disease and to oppose the deleterious effects of smoking on lung function In a large epidemiologic, multicenter, population-based study conducted in Spain, a total of 4, men and women 40 to 69 years who were randomly selected from a target population of, subjects, had answered a relevant questionnaire and underwent spirometry. The prevalence of COPD was 9. There was no previous diagnosis of COPD in During, an estimated 10 million U. COPD underdiagnosis could be attributed to underestimation of symptoms by the patients. Chronic obstructive lung diseases e. Despite this increased burden of respiratory patients, spirometry remains largely underused in the primary care 23, This problem has been repeatedly observed even in countries with advanced health care systems. It has been observed in Italy 25, but also for diagnosis and treatment of patients in Spain, where only one third of patients with COPD had post-bronchodilator spirometry while about half of them had not undergone spirometry at all In the USA a recent epidemiological survey, among more than 1. The limited use of spirometry within primary care has been attributed to cost constraints, lack of access and time, low quality of examinations, inaccurate interpretation of results, and inadequately trained staff 24, 28, Furthermore, evidence suggests that drugs are frequently prescribed inappropriately and not according to recommendations based on spirometric disease severity 26, After publication of the results of a large randomized controlled trial conducted in Italy, which failed to prove a significant advantage of office spirometry in improving the diagnosis of asthma and COPD in general practice 31, Enright argued against its use for COPD screening by Page 9

10 primary care physicians A recent study from Australia 33 showed that establishing spirometry into general use is difficult but repeated training courses, review of the results by specialists and feedback regarding the quality of the manoeuvres could improve and maintain competency and minimize error rates. Taking into account that the cost of COPD treatment is constantly increasing while health-related budget is continuously declining, the need for accurate diagnosis is imperative. All patients who are suspected to have COPD based on history and clinical examination should undergo official spirometry after bronchodilation by respiratory specialists to minimize overdiagnosis and overtreatment, a rather common situation in the primary care setting Evaluating medical history, risk factors, clinical examination and using validated questionnaires Even though performing high-quality spirometry in the primary care setting and evaluating the results correctly is a matter of debate, taking a detailed medical history, using validated questionnaires and identifying common comorbidities is an effective initial approach for screening subjects who visit a GP. Diagnosis and management of COPD should always be based on post-bronchodilator official spirometry. The most common respiratory related symptoms of COPD are dyspnea, chronic cough, sputum production, chest tightness and wheezing 1. All these symptoms are usually progressive and persistent over time while the adoption of a sedentary way of living may mask breathlessness. Taking into account that symptoms are nonspecific, a GP should always ask about the characteristics of chronic cough in order to reveal other causes Table 1, other medical conditions that may explain dyspnea Table 2 or chronic sputum production e. Weight loss, reduction in free-fat mass and anxiety are common problems in more advanced stages of the disease and are important prognostic factors 35, However they might be symptoms of other diseases e. Chapter 8 : CDC - Basics About COPD- Chronic Obstructive Pulmonary Disease (COPD) Management of Chronic Obstructive Pulmonary Disease (COPD) () The guideline describes the critical decision points in the Management of Chronic Obstructive Pulmonary Disease (COPD) and provides clear and comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DoD and VA Health Care systems. Chapter 9 : Respiratory Diseases Healthy People Chronic Obstructive Pulmonary Disease (COPD) as a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. Page 10