Assessment in Diagnosis of COPD

A 62 year old man with a 60 pack year cigarette smoking history presents with a chief complaint of progressive dyspnea on exertion and a chronic productive cough over the past eight years. Significant contributing history include two episodes of being seen in urgent care in the past year for "bronchitis" and being told he should follow up with primary care. 

When considering the diagnosis of COPD, which of the following is the most important diagnostic parameter? 

A. patient report of progressive dyspnea and chronic productive cough

B. 60-pack year cigarette smoking history

C. FEV1 to FEC ratio of less than 0.7 post bronchodilator

D. FEV1 of less than 50 % of predicted

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 62-year-old man with a 60 pack year cigarette smoking history presents with a chief complaint of progressive dyspnea on exertion and a chronic productive cough over the past 8 years. Significant contributing history include two episodes of being seen in urgent care in the past year for “bronchitis” and being told he should follow up with primary care. When considering the diagnosis of COPD, which of the following is the most important diagnostic parameter?

A. Patient report of progressive dyspnea and chronic productive cough

B. 60 pack-year cigarette smoking history

C. FEV1 to FEC ratio of less than 0.7 post bronchodilator

D. FEV1 of less than 50 % of predicted

And the correct answer is C. FEV1 to FEC ratio of less than 0.7 post bronchodilator.

Where should we start with this question? First determine what kind of a question it is. Given we're provided with some information on this patient's risk factors and persistent symptoms. We're being asked what would support a working diagnosis. Um, and of course we're being asked specifically about the working diagnosis of COPD. This would actually be then an assessment question because it's being asked what you would do for gathering additional information or looking at the information that you already have. First, some background information. COPD is a preventable and treatable disease. The pulmonary component is characterized by airflow limitation that is not fully reversible. And you know it's important to remember what is the full name of the disease, chronic obstructive pulmonary disease. And therefore, even with treatment the airway obstruction is not fully reversible. And that's in contrast to asthma which is characterized by airflow limitation that is generally reversible or more reversible than it is with COPD.

In COPD airflow limitation is usually progressive. And remember when we look at COPD it really is a disease of air trapping where particularly in earlier disease people have a lot of difficulty getting air out and eventually they have difficulty getting air into as well. The pathophysiology of COPD involves inflammation and narrowing of the peripheral airways that leads to characteristic decreases in lung function. The loss of small airways in addition to airway narrowing is really a significant contributor to airflow limitation and the air trapping that I just mentioned. Of course, the most common risk factor that we see in North America for COPD development is tobacco use. In addition, biomass fuel exposure through burning of wood, coal, and kerosene are also major contributors to the disease development in select exposed population. 

There are also some genetic components that can be contributors. And one very important point to remember with COPD, whereas tobacco use is the biggest risk factor or the most common risk factor, not everybody who smokes develops COPD. A great resource to learn more about COPD is at goldcopd.org. So I'll just spell that out. GOLDCOPD one word dot org. And that's the global initiative looking at COPD. The information there is great. It's open access. It is based on best evidence and there are annual updates on this wonderful resource. The clinical presentation of COPD typically includes symptoms of recurring dyspnea, chronic cough and persistent sputum production which particularly occur in the absence of respiratory tract infection. This might account for in this particular patient the two episodes of  “bronchitis” that led to urgent care visits and these chronic symptoms arise from the pathophysiology of the disease. Airway inflammation, smooth muscle constriction and airflow limitations. 

Now years back there was more of a tendency to almost like take COPD and divide it into two different diseases. Chronic bronchitis and empyema. Chronic bronchitis being more in airway disease. Empyema being more in alveolar disease. That was then. This is now. There is a recognition that virtually everybody who develops what we now call COPD has both an airway and an alveolar component to this. A working diagnosis of COPD should be considered in any patient with COPD symptoms such as we have here the progressive dyspnea, the chronic cough or sputum production and or the history of risk factors. COPD is characterized by a decrease in the ratio of FEV1 or forced expiratory volume at 1 second to FVC or force vital capacity ratio. Force vital capacity reflects the total amount of air pushed out of the lungs with full exhalation. Well, the FEV1 or the forced expiratory volume at 1 second reflects the amount of air volume that can be forcefully exhaled at 1 second. And remember, the lungs, no matter how hard somebody works, the lungs can never be 100% emptied out of air. But the FEV1 and the FEC are two very important parameters in looking at pulmonary function tests. The FEV1 to FEC ratio is considered to be the most sensitive indicator of early airflow limitation and the presence of post bronco dilator FEV1 to FEC ratio of less than 70% or .7 confirms persistent airflow obstruction.

The degree of spirometry abnormality generally reflects the severity of COPD. However, it is incredibly important to remember that symptoms often do not correlate well with objective measures and or patients often deny symptoms yet they meet diagnostic criteria of COPD. One part that often happens with people, particularly with earlier COPD, they get so used to not being able to breathe well that they don't notice what's going on. And the patient in this question, he's had symptoms for eight years. Eight years. So this didn't just happen yesterday. So he has probably adapted quite a bit to this. A standardized question such as a COPD assessment test, the CAT, is a very helpful adjunct in symptom assessment. The goals of treating COPD are to reduce the symptoms, reduce frequency and severity of COPD exacerbations, improve exercise tolerance, and overall health status. In another podcast, I've covered first line pharmacologic intervention and information on the overall goals of COPD care. 

So, let's go back with that as background information and take another look at the question and possible answers. A 62-year-old man with a 60 pack year cigarette smoking history presents with a chief complaint of progressive dyspnea and a chronic productive cough over the past 8 years. Significant contributing history include two episodes of being seen in urgent care in the past year for “bronchitis” and being told he should follow up with primary care. When considering the diagnosis of COPD, which of the following is the most important diagnostic parameter? 

Now, before we go any further, one of the things I want to point out to you here is that “bronchitis” diagnosis, you know that that was a COPD exacerbation, right? because we never assign the diagnosis of quote acute bronchitis to a person with lower airway disease. All right, so back to the answers here. 

A. patient report of progressive dyspnea and chronic productive cough. Well, these symptoms correlated with his cigarette smoking history are highly suggestive of COPD. The diagnosis of COPD is made by measurable parameters. Please keep that in mind. In other words, we need to look at the PFTs. Measurable parameters. And just to reiterate this, there are many C meds used in COPD like the llama lava inhalers that insurance will not pay for unless there are documented abnormalities on PFTS in the patient's record. I can't say that strongly enough. Right. At the same time, it's so important to listen to the patient because this is what brought this patient in. Please note, he's had symptoms like this for 8 years and COPD is characterized by progressive worsening of symptoms over time. Last, but certainly not least, there are a number of other diseases that can cause progressive dyspnea and chronic cough. So this is non-specific for the report of COPD.

B. 60-pack year cigarette smoking history. Again not the correct answer but coupled with a symptomatology. This is highly suggestive of COPD. But I also want to remind you there uh likely is even in tobacco user some kind of an underlying genetic component to the development of COPD that's not fully understood. That's a complicated way of saying there are people with 60 pack cigarette smoking histories who might have a chronic cough and even some shortness of breath. But you check this spirometry and it's actually within acceptable parameters. Therefore, do not qualify for a COPD diagnosis.

Option C. FEV1 to FEC ratio of less than 0.7 post bronchodilator. This is of course the correct answer. The gold COPD guidelines state that spirometry demonstrating persistent airflow limitation is required to establish the diagnosis of COPD. And the defining diagnostic criteria is just what we have here the post bronco dilator FEV1 to FEC ratio of less than .7 because this helps confirm persistent airflow obstruction distinguishing COPD from other causes of respiratory symptoms like asthma, heart failure, deconditioning. General rule on boards, remember this. Whenever possible, you want an objective measure in a diagnosis, a test, something you can look at results that would be in the record. That's going to be helpful. And that's usually when we get into diagnostic criteria for a variety of different conditions. In this case, we're talking about COPD, but also you do need even with asthma diagnostic criteria for asthma includes measurable abnormality in lower airway function. 

D. An FEV1 of less than 50% of predicted. This is incorrect. FEV1 is used to help classify COPD severity. In addition, FEV1 use is part of ongoing COPD monitoring and it measures lower airway obstruction. FEV1 should be done once the COPD diagnosis is made with every single COPD related visit. Key takeaway in COPD symptoms and smoking history suggest COPD post bronco dilator FEV1 to FEC ratio of less than .7 confirms the diagnosis of COPD. FEV1 helps with staging and monitoring COPD.

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