Clinical Review

Chronic Obstructive Pulmonary Disease: Epidemiology, Clinical Presentation, and Evaluation

Journal of Clinical Outcomes Management. 2017 April;24(4)

References

1. Rennard SI. COPD: overview of definitions, epidemiology, and factors influencing its development. Chest 1998;113(4 Suppl):235S–41S.

2. National Center for Health Statistics. Health, United States, 2015: with special feature on racial and ethnic health disparities. Hyattsville, MD; 2016.

3. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2000;160:1683–9.

4. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available at http://goldcopd.org.

5. Vestbo J, Hurd SS, Rodriguez-Roisin R. The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD) – why and what? Clin Respir J 2012;6:208–14.

6. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. American Thoracic Society. Am J Respir Crit Care Med 1995;152(5 Pt 2):S77–121.

7. Siafakas N, Vermeire P, Pride Na, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). Eur Respir J 1995;8:1398–420.

8. Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932–46.

9. Swanney MP, Ruppel G, Enright PL, et al. Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax 2008;63:1046–51.

10. Bestall J, Paul E, Garrod R, et al. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999;54:581–6.

11. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013;187:347–65.

12. Pauwels RA, Buist AS, Calverley PM, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001;163:1256–76.

13. Dirksen A, Christensen H, Evald T, et al. Bronchodilator and corticosteroid reversibility in ambulatory patients with airways obstruction. Danish Med Bull 1991;38:486–9.

14. Sin DD, Miravitlles M, Mannino DM, et al. What is asthma-COPD overlap syndrome? Towards a consensus definition from a round table discussion. Eur Respir J 2016;48:664–73.

15. Hansen EF, Phanareth K, Laursen LC, et al. Reversible and irreversible airflow obstruction as predictor of overall mortality in asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999;159(4 Pt 1):1267–71.

16. Ford ES, Croft JB, Mannino DM, et al. COPD surveillance—United States, 1999-2011. Chest 2013;144:284–305.

17. Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-94. Series 1: programs and collection procedures. Vital and health statistics Ser 1, Programs and collection procedures. 1994:1–407.

18. Martinez CH, Mannino DM, Jaimes FA, et al. Undiagnosed Obstructive lung disease in the United States. Associated factors and long-term mortality. Ann Am Thorac Soc 2015;12:1788–95.

19. Tilert T, Dillon C, Paulose-Ram R, et al. Estimating the U.S. prevalence of chronic obstructive pulmonary disease using pre- and post-bronchodilator spirometry: the National Health and Nutrition Examination Survey (NHANES) 2007-2010. Respir Res 2013;14:103.

20. Prentice HA, Mannino DM, Caldwell GG, Bush HM. Significant bronchodilator responsiveness and “reversibility” in a population sample. COPD 2010;7:323–30.

21. Chang JT, Moran MB, Cugell DW, Webster JR. COPD in the elderly: a reversible cause of functional impairment. Chest 1995;108:736–40.

22. Ulrik C, Backer V. Nonreversible airflow obstruction in life-long nonsmokers with moderate to severe asthma. Eur Respir J 1999;14:892–6.

23. Hing E, Hall MJ, Ashman JJ, Xu J. National hospital ambulatory medical care survey: 2007 outpatient department summary. Natl Health Stat Report 2010;28:1–32.

24. Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Natl Health Stat Report 2010;26:1–31.

25. Kozak LJ, DeFrances CJ, Hall MJ. National hospital discharge survey: 2004 annual summary with detailed diagnosis and procedure data. Vital and health statistics Series 13, Data from the National Health Survey. 2006(162):1–209.

26. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2013;61:1–117.

27. Mannino DM, Brown C, Giovino GA. Obstructive lung disease deaths in the United States from 1979 through 1993. An analysis using multiple-cause mortality data. Am J Respir Crit Care Med 1997;156(3 Pt 1):814–8.

28. Camilli AE, Robbins DR, Lebowitz MD. Death certificate reporting of confirmed airways obstructive disease. Am J Epidemiol 1991;133:795–800.

29. Miller JD, Foster T, Boulanger L, et al. Direct Costs of COPD in the U.S.: An Analysis of Medical Expenditure Panel Survey (MEPS) Data. COPD 2005;2:311–8.

30. Ford ES, Murphy LB, Khavjou O, et al. Total and state-specific medical and absenteeism costs of COPD among adults aged >/= 18 years in the United States for 2010 and projections through 2020. Chest 2015;147:31–45.

31. Mannino DM. Counting costs in COPD: what do the numbers mean? Chest 2015;147:3–5.

32. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2197–223.

33. Murray CJ, Abraham J, Ali MK, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013;310:591–606.

34. Lopez AD, Murray CC. The global burden of disease 1990–2020. Nat Med 1998;4:1241–3.

35. Cohen SB-Z, Paré PD, Man SFP, Sin DD. The growing burden of chronic obstructive pulmonary disease and lung cancer in women. Am J Respir Crit Care Med 2007;176:113–20.

36. Han MK, Postma D, Mannino DM, et al. Gender and chronic obstructive pulmonary disease: why it matters. Am J Respir Crit Care Med. 2007;176:1179–84.

37. Tanoue LT. Cigarette smoking and women’s respiratory health. Clin Chest Med 2000;21:47–65, viii.

38. Silverman EK, Weiss ST, Drazen JM, et al. Gender-related differences in severe, early-onset chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000;162:2152–8.

39. Carter R, Nicotra B, Huber G. Differing effects of airway obstruction on physical work capacity and ventilation in men and women with COPD. Chest 1994;106:1730–9.

40. Foreman MG, Zhang L, Murphy J, et al. Early-onset chronic obstructive pulmonary disease is associated with female sex, maternal factors, and African American race in the COPDGene Study. Am J Respir Crit Care Med 2011;184:414–20.

41. Sørheim I-C, Johannessen A, Gulsvik A, et al. Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax 2010;65:480–5.

42. Kanner RE, Connett JE, Altose MD, Buist AS, Lee WW, Tashkin DP, et al. Gender difference in airway hyperresponsiveness in smokers with mild COPD. The Lung Health Study. Am J Respir Crit Care Med 1994;150:956–61.

43. De Marco R, Locatelli F, Sunyer J, Burney P. Differences in incidence of reported asthma related to age in men and women: a retrospective analysis of the data of the European Respiratory Health Survey. Am J Respir Crit Care Med 2000;162:68–74.

44. Moorman JE, Moorman J, Mannino DM. Increasing US asthma mortality rates: who is really dying? J Asthma 2001;38:65–71.

45. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma—United States, 1960–1995. MMWR CDC Surveill Summ 1998;47:1–27.

46. Snider GL. Molecular epidemiology: a key to better understanding of chronic obstructive lung disease. Monaldi Arch Chest Dis 1995;50:3–6.

47. Hogg JC. Chronic bronchitis: the role of viruses. Semin Respir Infect 2000;15:32–40.

48. Kraft M, Cassell GH, Henson JE, et al. Detection of Mycoplasma pneumoniae in the airways of adults with chronic asthma. Am J Respir Crit Care Med 1998;158:998–1001.

49. Hegele RG, Hayashi S, Hogg JC, Paré PD. Mechanisms of airway narrowing and hyperresponsiveness in viral respiratory trad infections. Am J Respir Crit Care Med 1995;151:1659–65.

50. Blanc PD, Iribarren C, Trupin L, et al. Occupational exposures and the risk of COPD: dusty trades revisited. Thorax 2009;64:6–12.

51. Becklake MR. Occupational exposures: evidence for a causal association with chronic obstructive pulmonary disease. Am Rev Respi Dis 1989;140(3 Pt 2):S85–S91.

52. Po JYT, FitzGerald JM, Carlsten C. Respiratory disease associated with solid biomass fuel exposure in rural women and children: systematic review and meta-analysis. Thorax 2011;66:232–9.

53. Mannino DM, Buist AS. Global burden of COPD: risk factors, prevalence, and future trends. Lancet 2007;370:765–73.

54. Trupin L, Earnest G, San Pedro M, et al. The occupational burden of chronic obstructive pulmonary disease. Eur Respir J 2003;22:462–9.

55. Andersen ZJ, Hvidberg M, Jensen SS, et al. Chronic obstructive pulmonary disease and long-term exposure to traffic-related air pollution. Am J Respir Crit Care Med 2011;183:455–61.

56. Agusti À, Soriano JB. COPD as a systemic disease. COPD 2008;5:133–8.

57. Eisner MD, Blanc PD, Yelin EH, et al. COPD as a systemic disease: impact on physical functional limitations. Am J Med 2008;121:789–96.

58. Cekerevac I, Lazic Z, Petrovic M, Novkovic L. COPD and depression. Eur Respir J 2012;40(Suppl 56).

59. Fromer L. Diagnosing and treating COPD: understanding the challenges and finding solutions. Int J Gen Med 2011;4:729–39.

60. Cavaillès A, Brinchault-Rabin G, Dixmier A, et al. Comorbidities of COPD. Eur Respir Rev 2013;22:454–75.

61. Barnes PJ. Gold 2017: A new report. Chest 2017;151:245–6.

62. Choo C. Combination therapy options in Stable COPD. US Pharm 2010;35:31–7.

Evaluation

The evaluation of a patient with suspected COPD is oriented toward establishing the correct diagnosis and, once this has occurred, determining the extent of the impairment such that therapy can be appropriately targeted.

The differential diagnosis of COPD is listed in Table 2 . While some of the other diagnoses listed are rare in the United States (eg, diffuse panbronchiolitis, obliterative bronchiolitis), others, such as asthma and congestive heart failure, are quite common. In addition, in underdeveloped regions of the world, bronchiectasis and tuberculosis continue to be very important and prevalent diseases.

Components in the evaluation of COPD are listed in Table 3 . Every patient with suspected COPD should undergo a thorough history and physical examination. The history should pay particular attention to the following: exposure to risk factors; past history of asthma or allergic disease; family history of COPD; presence of comorbid diseases; effect of disease on the patient’s life, including ability to work and mental health status; and possibilities for reducing risk factors, especially smoking cessation [4]. The physical examination is rarely diagnostic in COPD because most physical abnormalities do not occur until the advanced stages of the disease. Physical examination findings in

patients with advanced disease include wheezing, prolonged expiration, decreased breath sounds, and an increased anterior-posterior diameter of the chest.

Pulmonary function testing is a critical part of the evaluation of suspected COPD. Whereas most patients with COPD can be managed by a primary care physician, patients with moderate or severe COPD should be evaluated by a specialist [4].

Once the diagnosis of moderate or severe COPD has been established, further testing, including chest radiograph, arterial blood gas determination, screening for α1-antitrypsin deficiency, 6-minute walk testing or exercise oxymetry may be indicated based on the patient’s history and/or clinical findings. Data from computed tomography scans are useful in some advanced cases.

Prognosis of COPD is often influenced by presence of various comorbidities including extrapulmonary, such as osteoporosis, metabolic syndrome, and depression that may be seen as parts of multimorbidity associated with aging [60,61]. Therefore, it is advised to look for comorbidities in COPD patients with any severity of airflow obstruction and treat them accordingly [4].

Therapy for COPD targets reducing risk factors, improving symptoms, and decreasing the risk of exacerbations [10]. Interventions include smoking cessation, vaccinations, decreasing exposures to occupational and environmental pollutants, pulmonary rehabilitation, bronchodilators, and corticosteroids. Select patients with advanced COPD may benefit from other interventions, such as surgical reduction of lung size, lung transplant, the phosphodiesterase inhibitor roflumilast and chronic treatment with antibiotics such as macrolides.

Conclusion

COPD is a common disease that is a leading cause of morbidity and mortality, both in the United States and worldwide. Most cases of COPD are attributable to smoking. Although its incidence among men has plateaued, it continues to increase among women. COPD, particularly in its early stages, is under-diagnosed in the United States. An increased awareness among physicians of the prevalence of mild COPD and the importance of spirometry in diagnosing the disease is important in combating the disease.