When and how to assess your COPD patients


Key takeaways

  • Routinely assessing patients is key for an effective COPD treatment strategy
  • The frequency of routine assessment depends on the severity of your patient’s COPD
  • Consider a range of measurements and clinical factors during each assessment
  • Refer your patient for specialist advice if appropriate
  • Assess acute exacerbations and refer your patient to hospital if needed


You have a patient with confirmed COPD. You decide on the appropriate treatment strategy for your patient. But the story doesn’t end there. It is essential that each COPD patient is offered routine follow-up appointments to monitor progression and modify management.

Remember: Lung function may worsen over time even with the best available care 1

How often?

NICE recommend that COPD patients should be reviewed:

📅 At least once a year for COPD stages 1 to 3 2
📅 At least twice per year for COPD stage 4 2

Checking in

What to include in your routine assessment depends on the stage of your patient’s COPD. 2
Clinical assessment
Mild/moderate/severe (stage 1 to 3) Very severe (stage 4)
▪️ Smoking status and motivation to quit ▪️ Smoking status and motivation to quit
▪️ Adequacy of symptom control:
   ▫️ Breathlessness
   ▫️ Exercise tolerance
   ▫️ Estimated exacerbation frequency
▪️ Adequacy of symptom control:
   ▫️ Breathlessness
   ▫️ Exercise tolerance
   ▫️ Estimated exacerbation frequency
▪️ Need for pulmonary rehabilitation ▪️ Presence of cor pulmonale
▪️ Presence of complications ▪️ Need for long-term oxygen therapy
▪️ Effects of each drug treatment ▪️ Person with COPD's nutritional state
▪️ Inhaler technique ▪️ Presence of depression
▪️ Need for referral to specialist and therapy services ▪️ Inhaler technique
▪️ Need for social services and occupational therapy input
▪️ Need for referral to specialist and therapy services
▪️ Need for pulmonary rehabilitation
(NICE 2018) 2

Taking measurements

For all stages of COPD remember to measure: 2

📈 FEV1 and FVC
📈 BMI
📈 MRC dyspnoea score

For stage 4 patients also measure SaO2. Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression.

Assess the need for oxygen therapy if your patient has:
  • very severe airflow obstruction (FEV1 below 30% predicted)
  • cyanosis
  • polycythaemia
  • peripheral oedema
  • a raised jugular venous pressure
  • SaO2 of ≤92% breathing air
Refer to the full guideline for more details. 2

When measuring symptoms, use the COPD Assessment Test (CAT). 2, 3 Remember that your patient’s trends and changes over time are more valuable than single measurements.*1
 
Smoking is the most important causative factor for COPD and it is key to review your patient’s smoking status and discuss appropriate support and treatment if required. 4 1 in 4 smokers may successfully quit long term if you provide them with effective strategies. 1

When should you refer?

Referral is not restricted to people with severe COPD. If appropriate, you can refer your patient for specialist advice. 2 Reasons can vary, including onset of cor pulmonale, presence of dysfunctional breathing, and haemoptysis. A comprehensive list of reasons for referral can be found in the NICE guidelines.

NICE recommend that a loss of 500ml or more over five years from spirometric parameters demonstrates rapidly progressing disease. Consider referral for these patients to allow further investigation. 2

What about exacerbations?

If your patient has experienced an acute exacerbation, this may require you to change their treatment. While you do not need to diagnose exacerbations based on specific measurements, investigations can sometimes be helpful to ensure appropriate treatments are given. As a primary care professional, you can:

  • Record pulse oximetry if there are features of a severe exacerbation 2
  • Refer your patient to hospital for further investigation or treatment if required 2
  • Provide pharmacological management for example increased doses of short-acting bronchodilators 2
It can sometimes be tough to decide whether your patient can be treated at home or requires hospital referral. Consider the factors below to help you.

Factor Treat at home Treat in hospital
Able to cope at home Yes No
Breathlessness Mild Severe
General condition Good Poor/deteriorating
Level of activity Good Poor/confined to bed
Cyanosis
No Yes
Worsening peripheral oedema No Yes
Level of consciousness Normal Impaired
Already receiving long-term oxygen therapy No Yes
Social circumstances Good Living alone/not coping
Acute confusion No Yes
Rapid rate of onset No Yes
Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes) No Yes
SaO2 <90% No Yes
Changes on chest radiograph No Present
Arterial pH level ≥ 7.35
<7.35
Arterial PaO2 ≥ 7.35
<7 kPa

(NICE 2018) 2

Summary

Routine assessment can help you to identify any deterioration in COPD symptoms and to provide the most effective care for your patients. It better enables you to monitor trends and changes in your patient’s condition, support your patient in quitting smoking, as well as highlighting any need to refer your patient to specialist care or hospital treatment.



References
  1. Gold Initiative For The Diagnosis, Management, And Prevention of Chronic Obstructive Pulmonary Disease (2019 Report).
  2. https://www.nice.org.uk/guidance/ng115/chapter/Recommendations
  3. Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline Leidy N. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648-654. 
  4. Laniado-Laborin R. Smoking and chronic obstructive pulmonary disease (COPD). Parallel epidemics of the 21st century. Int J Environ Res Public Health. 2009. 

PM-GB-CPU-WCNT-190007 - March 2019

Rate this article

By sharing your feedback, you are helping us to provide you with more content that you find useful and relevant. Win-Win!

Enjoyed this article?

Stay up to date with relevant respiratory content and join the thousands of UK healthcare professionals subscribed to our updates

Sign up today!

Join the thousands of UK healthcare professionals subscribed to our updates.

Emails may contain promotional information from GSK and its group You can change your mind at anytime and unsubscribe from our mailing list. Please click here to see our privacy notice.

PM-GB-CAU-WCNT-190006
March 2019