Most diagnoses of COPD are made in the primary care setting. Try these 6 questions to see what you know about the essentials of the differential diagnosis.
Most patients with chronic obstructive pulmonary disease (COPD) are diagnosed by a primary care physician. But diagnosis is not always straightforward. Clinical features of COPD can be highly variable so a considered and comprehensive differential diagnosis is important.
Which factors account for most COPD diagnoses? Which tools are most accurate for differentiating COPD from asthma and from asthma/COPD overlap? How is COPD progression best monitored?
Try the 6 questions that follow here, based on a recent review in JAMA, to find out what you know about assessment for the fourth leading cause of death in the US.
Answer: B. Primary care clinicians. PCPs make the diagnosis for most patients with COPD and manage patient care for about 80% of the roughly 30 million adults in the United States known to have the condition. COPD accounts for 3.2% of physician office visits annually and is the fourth leading cause of death. About 6% of the US population self-reports a diagnosis.
Answer: A. Tobacco smoke. More than 75% of COPD diagnoses in the United States are related to tobacco smoke. Implicated in about 25% of patients with COPD who never smoked are smoke from wood and other fuels used for cooking and heating and occupational dust and chemical fume exposures.
Answer: C. Spirometry. Incompletely reversible obstruction is the hallmark of COPD. If obstruction is present on spirometry, a short-acting bronchodilator should be administered and the patient retested in 15 minutes to establish the diagnosis. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend using a fixed ratio of 0.7 of the forced expiratory volume in the first second of the forced vital capacity (FEV1/FVC) to establish a diagnosis of obstruction.
5. True or False: Physical examination may be used to assess signs of lung hyperinflation in advanced COPD.
Answer: A. True. Physical examination also may help rule out alternative diagnoses related to nonpulmonary organ involvement. Adventitious breath sounds (eg, wheezing and rhonchi) may indicate an acute exacerbation rather than stable COPD. Rales may suggest pulmonary fibrosis or congestive heart failure. Auscultation of prolonged air flow at the trachea during a maximal forced effort may be useful in early diagnosis of obstruction or when spirometry is not available.
Answer: C. ADO and BODE indexes. The age, dyspnea, airflow obstruction (ADO) index predicts risk of mortality by incorporating age, mMRC dyspnea scale, and FEV1, measures that are easily accessible in a primary care setting. The body mass, obstruction, dyspnea, exercise (BODE) index predicts mortality by incorporating the negative prognostic implications of a body mass index of 21 or lower, FEV1, mMRC, and the 6-minutewalk test. Assessing risk of future acute exacerbations and death helps in setting patient expectations and planning treatment.