How to Detect COPD Early in Primary Care?

What to Focus on When Taking a Medical History

• Exposure to risk factors:
  • smoking (active and passive exposure) − cigarettes, pipes, cigars, marijuana;
  • substances from the work environment − chemical vapors, combustion products, fine dust particles, e.g., from diesel engines;
  • smog.
• Presence of COPD in family medical history.

Symptoms

• Any chronic sputum production.
• Persistent or intermittent cough (dry and productive).
• Dyspnea (exertional, resting).
• Nonspecific fatigue.
• Prolonged colds in autumn/winter.
• Weight loss.

Subtle Changes in Patient Behavior

• Is it possible that the usual time for a routine walk (e.g., to a bus stop) has lengthened?
• Do you use the elevator more often, whereas you used to choose walking?
• Do you walk on flat ground more slowly than people of comparable age?
• Do you need to make stops while walking quickly on flat ground?
• Can you walk up a slight hill without shortness of breath?

Differential Diagnosis

COPD

• Development of the disease is common in middle and older age.
• Symptoms are progressive.
• History of exposure to tobacco smoke or other harmful substances.

Bronchial Asthma

• Onset of the disease at a younger age.
• Symptoms vary significantly from day to day and are often worse in the evening or early morning.
• Diagnosis is supported by the concurrent occurrence of allergies, rhinitis, or eczema, or a family history of asthma.

Congestive Heart Failure

• Findings on chest X-ray (heart enlargement, pulmonary edema).
• Functional tests indicate restrictive ventilatory disorder.

Bronchiectasis

• Large volume of expectorated sputum, often purulent.
• Usually, G-negative pathogens or atypical mycobacteria in cultures.
• Dilation of the bronchi and thickening of their walls observable on X-ray or HRCT.

Obliterative Bronchiolitis

• Onset at a younger age in non-smokers.
• History may include concurrent rheumatoid arthritis or acute exposure to smoke, or possibly bone marrow or lung transplantation.
• Areas of decreased density observable on lung HRCT.

Diagnostic Procedure for Suspected COPD

Physical Examination

Physical signs are usually present only in more severe bronchial obstruction. Expiratory wheezing and crackles can also be present in other diagnoses (bronchial asthma, sarcoidosis, pulmonary embolism, left-sided heart failure, infectious bronchiolitis, etc.). Pulmonary emphysema is often accompanied by diffusely weakened alveolar breathing with hyperresonant percussion.

Functional Tests

A general practitioner can perform an initial spirometry (code 25211). If the FEV₁/FVC ratio is < 70%, the patient should be referred for a detailed functional assessment in a pulmonary clinic to confirm or exclude the suspected diagnosis.

Exercise Tests

The gold standard remains spiroergometry. The 6-minute walk test (6MWT), the incremental shuttle walk test (ISWT), the endurance shuttle walk test (ESWT), or the 1-minute sit-to-stand test (1STS) are also used.

Imaging Methods

Chest X-rays are usually not diagnostic except for obvious bullous emphysema, but they are valuable in differential diagnosis. Typical radiographic changes associated with COPD include hyperinflation signs − flattened diaphragms on lateral views, increased retrosternal space, increased lung transparency, rapid decrease in pulmonary vascular markings, and widened intercostal spaces.

Blood Gas Analysis

Arterial (or capillary) blood gases should be tested if hemoglobin saturation (SpO₂) is < 92%.

Alpha-1-Antitrypsin Deficiency Testing

If COPD develops before the age of 50, congenital alpha-1-antitrypsin (AAT) deficiency should be excluded with a simple biochemical blood test.

Organization of Care

• The diagnosis of COPD, including its staging, is confirmed by a pulmonologist.
• Treatment of COPD is typically based on cooperation between the general practitioner and the pulmonologist.
• The recommended frequency of follow-ups is once every 3–6 months for stable individuals, or at shorter intervals for unstable individuals.
• Follow-ups should include updating the medical history, smoking cessation intervention (if smoking persists), physical and spirometry examination, hemoglobin oxygen saturation measurement using pulse oximetry, assessment of compliance with inhalation therapy and inhalation technique, monitoring of associated therapy and side effects of treatment.
• The severity of symptoms can be assessed using the COPD Assessment Test (available, e.g., at: www.catestonline.org/content/dam/global/catestonline/questionnaires/Czech_CAT_combined.pdf).

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Source: Koblížek V.. Zatloukal J., Konštacký S. Chronic Obstructive Pulmonary Disease. 2019 Update. Recommended diagnostic and therapeutic procedures for general practitioners. Society of General Practice CLS JEP, Prague, 2019.