How I would manage a woman with COPD who is symptomatic but at low risk of an exacerbation: a primary care perspective from the UK

Abstract

This 61 year-old lady with an established history of COPD (dyspnoea in the context of a 20-40 pack year smoking history and obstructive spirometry that persists despite bronchodilation) has become more breathless over recent months. Further management will depend on a thorough assessment of the cause of her current breathlessness and the effect of her symptoms on everyday activities. What is causing her breathlessness?77% of people with COPD have at least one other long-term condition -most commonly cardiac in origin -that can cause breathlessness.1 They are also at higher risk of lung cancer 2 as a result of their smoking history. I would therefore ask about a history of increasing persistent cough, haemoptysis, ankle swelling, palpitations, chest pain and paroxysmal nocturnal dyspnoea. An electrocardiogram and chest X-ray will look for evidence of cardiac and other pulmonary disease, and a full blood count will exclude anaemia. Recent dramatic decline in pulmonary function can be assessed by up-to-date spirometry.If we accept that her problems are due to the COPD then her current burdensome symptoms need attention. Assessment of current symptomsI would want to understand what symptoms are really causing her trouble: what can she not do that she wants to do? A tool such as the COPD Assessment Tool (CAT) can look at specifics such as the effect of COPD on sleep, isolation and exercise; a score of 10 or more indicates a high impact of symptoms.3 She has retired recently and was looking forward to time in her garden and with her grandchildren. That does not seem to have happened as anticipated, maybe causing depression, which is 2-3 times commoner in people with long-term conditions than in those with good physical health. What is she hoping to achieve? An holistic assessment such as thiswith involvement of, and shared understanding with, the patientallows an individualised management plan to be formulated with a greater likelihood of success. 5As part of this assessment, future risk needs to be considered; this is most closely related to exacerbation frequency. The DOSE score is a validated primary care-friendly tool that can predict risk of exacerbation 6 (see Table 1). In this case her moderate reduction in FEV 1 , current (albeit recent) non-smoking status, and rare exacerbations, means that she is at low risk despite her high symptom-based modified MRC Dyspnoea score of 3. It would, however, be important to record future exacerbations to allow on-going risk assessment. Clinical scenarioA 61 year-old lady is concerned about her increasing breathlessness. When she retired last year from her job as a secretary she was looking forward to gardening, and joining in activities with her grandchildren. She has discovered that anything more than gentle exercise makes her breathless and she has to stop for rest. COPD was first diagnosed 10 years ago and spirometry last year recorded an FEV1/FVC ratio of 0.45 and a post-bronchodilator FEV1 of 55% predicted. After nearly 40 years of smoking between 10 and 20 cigarettes a...