B-QuiCK: COPD

B-QuiCK: COPD

Diagnosis

Consider COPD in any patient aged over 40 years with:

• A significant history of exposure to cigarette smoke, dust, fumes or gas, or recurrent respiratory infections; AND
• Typical symptoms, e.g. persistent dyspnoea that worsens with exercise, chronic cough, sputum production, chest tightness, wheezing, fatigue

Non-respiratory symptoms, e.g. weight loss, reduction in muscle mass, anorexia, anxiety and depression more likely in severe disease

Take a history to identify risk factors and symptoms

Ask about:

• Noxious exposures
• Previous respiratory conditions and other relevant medical history, e.g. maternal smoking history during pregnancy
• Family history of chronic respiratory conditions, including COPD
• Symptom onset pattern
• History of prior hospitalisations for respiratory symptoms (or unrecognised exacerbations)
• Co-morbidities
• Impact of symptoms on their life
• Opportunities to reduce exposure to risk factors or triggers
• Family and social support available

Quantify symptom impact using validated assessment tools

• Use the Modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT) to assess the patient’s level of breathlessness and impact of symptoms
  • Consider initiating treatment in patients with a mMRC score ≥ 2 or a CAT score ≥ 10

Perform a physical examination

• Physical signs may be observed in patients with more advanced disease, e.g. hyperinflation of the chest, hyperresonance to chest percussion, reduced chest expansion, soft breath sounds on auscultation, prolonged expiratory phase
• Other signs can be more obvious during an acute exacerbation, e.g. tachypnoea and tachycardia, accessory muscle use and cyanosis

Spirometry is essential to establish a diagnosis

Perform if resources available or refer to a respiratory service (also refer if uncertainty about results)

• A post-bronchodilator FEV₁ < 80% of predicted value and a FEV₁/FVC < 0.7 confirms persistent airflow limitation (click here for further information)
• Symptom burden and spirometry results (i.e. airflow obstruction) may not correlate in all patients
• If already prescribed, a long-acting bronchodilator is adequate for post-bronchodilator spirometry (i.e. patients do not need to withhold this prior to testing)
• Spirometry results do not predict treatment response

Arrange relevant laboratory investigations and imaging

• Full blood count – baseline blood eosinophil level, secondary polycythaemia
• Pulse oximetry – baseline oxygen blood saturation level
• Brain natriuretic peptide (BNP) – if symptoms and signs of heart failure
• Electrocardiogram (ECG)
• Chest X-ray (not routinely required)
  • For Community Referred Radiology National Clinical Criteria, click here
• Alpha-1 antitrypsin serology – younger patients, if symptom severity inconsistent with reported exposure history, or persistently abnormal liver function tests

Differential diagnoses to consider and rule out

• Asthma, bronchiectasis, heart failure, respiratory infection, pulmonary embolism (particularly small recurrent emboli), interstitial lung disease, lung cancer and tuberculosis (click here for details)

Management

Non-pharmacological interventions underpin COPD management

• Smoking cessation—the most important factor to improve symptoms and slow disease progression
• Increase physical activity and reduce sedentary behaviour
• Maintenance of healthy weight
• Identify and optimise treatment of co-morbidities
• Offer pulmonary rehabilitation. A list of providers is available here.
• Respiratory physiotherapy, e.g. breathing techniques, breathlessness strategies or managing chronic sputum production (see local HealthPathways for available services)
• Develop a written COPD action plan. An example is available here.
• Recommend immunisations – annual influenza, COVID-19 (six-monthly or annually depending on risk) and appropriate pneumococcal immunisation (PCV13 and 23PPV)*
  • Consider vaccination for pertussis, respiratory syncytial virus (RSV) and herpes zoster (shingles), if appropriate

* These immunisations are recommended for people with COPD, however, not all are funded for this group. For further information, see the Immunisation Handbook.

Pharmacological treatment

• Introduce medicines in a stepwise approach based on the patient’s condition (incorporating results of mMRC, CAT and spirometry)
• Improvement in dyspnoea can take up to six weeks to become apparent
• Assess changes in exacerbation frequency over 6 – 12 months
• Consider patient preferences, available devices, complexity of the treatment regimen and potential adverse effects when escalating treatment

Click here for current funded medicines/inhalers for COPD treatment in New Zealand

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Figure 1. Suggested stepwise treatment for patients with COPD.

Red pathway indicates prompt treatment escalation (recommended)

* SAMA and a LAMA should not be used concurrently

† A LABA + LAMA (single inhaler combination) is preferred, however, current Special Authority criteria for a LABA + LAMA single inhaler requires patients to be stabilised on LAMA treatment first

‡ A LABA + LAMA + ICS (single inhaler combination) is preferred — Special Authority criteria for a LABA + LAMA + ICS single inhaler requires patients to be on ICS + LABA or LABA + LAMA combination treatment, or multiple inhaler triple treatment (i.e. ICS + LAMA + LABA) first

CAT = COPD Assessment Test; COPD = chronic obstructive pulmonary disease, ICS = inhaled corticosteroid; LABA = long-acting beta₂-agonist; LAMA = long-acting muscarinic antagonist; mMRC = Modified Medical Research Council Dyspnea Scale; SABA = short-acting beta₂-agonist; SAMA = short-acting muscarinic antagonist.

Withdrawal of ICS treatment

• Consider if the patient:
  • Shows no evidence of benefit, i.e. no improvement in symptoms or fewer exacerbations
  • Develops pneumonia or other ICS-related adverse effects
  • Is clinically stable for 12 months and has had no exacerbations in that time
• Request a blood eosinophil level - withdrawal may not be appropriate if ≥ 0.3 x 10⁹/L
• Arrange follow-up four-to-six weeks after ICS withdrawal to assess for worsening of symptoms or CAT score

Regular follow-up is crucial to optimise treatment

• If stable, review annually, or more regularly if more severe disease or co-morbidities
• At every follow-up, discuss:
  • Treatment adherence – check inhaler technique and non-pharmacological interventions before adjusting treatment
  • Symptom control (e.g. CAT score)
  • Exacerbations – frequency and severity
  • Smoking cessation support (if applicable)
  • Vaccinations – check if due for influenza, pneumococcal or COVID-19
• Additional investigations may be required at some follow-up appointments, e.g. oxygen saturation, repeat spirometry
• Consider a chest X-ray and referral for non-acute respiratory assessment and chest CT if substantial deterioration since last review
• Review co-morbidities, focusing on improving overall clinical status – the “treatable traits” approach
• Initiate early discussions regarding advance care plans where appropriate
• If the treatment regimen is modified, arrange a follow-up to evaluate the response after six weeks

A template for a four-step COPD consultation is available in Appendix 2 of the New Zealand COPD Guidelines: 2025 Update.

Managing COPD exacerbations in primary care

• Develop an exacerbation plan with the patient and regularly review this as part of ongoing follow-up; ensure they know how to recognise and respond to an exacerbation
  • Click here for exacerbations features
• Rule out other causes of symptoms and identify potential complications
• Acute referral to hospital should be considered in the following situations:
  • Insufficient or no response to medical management
  • A sudden worsening of symptoms
  • Confusion or drowsiness
  • Cyanosis and peripheral oedema
  • Low oxygen saturation (SpO₂ < 85 – 90%)
  • Co-morbidities, e.g. heart failure, newly occurring arrhythmias
  • Living circumstances are not appropriate, e.g. limited home support, lack of telephone, transport or distance to hospital

Pharmacological management of COPD exacerbations

• A SABA is recommended first-line in patients experiencing an exacerbation
• Advise patients to continue maintenance bronchodilator (and ICS) treatment during an exacerbation
• Prescribe antibiotics if clinical features are suggestive of bacterial infection; click here for antibiotic options
• Consider a short course of oral corticosteroids in moderate to severe exacerbations
  • Prescribe 40 mg prednisone, once daily, for five days

Arrange post exacerbation follow-up

• Full recovery from an exacerbation may take up to six weeks
• Review overall COPD management, including current medicines, inhaler technique, adherence and non-pharmacological interventions, after every exacerbation
• Refer for pulmonary rehabilitation, unless completed in last 12 months or contraindicated (e.g. recent cardiac event, unstable angina or medical condition that restricts movement such as severe arthritis)
• Consider spirometry to reassess lung function