for Health Care Providers
Chronic Obstructive Pulmonary Disease (COPD)
Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.
- COPD comprises emphysema, chronic bronchitis, or a combination of the two.
- COPD is a common cause of morbidity in HIV-infected veterans.
- Multimodal treatment may decrease symptoms and slow progression.
- For smokers, smoking cessation should be emphasized.
- Drug-drug interactions between PIs and inhaled corticosteroids may affect treatment.
- A general term that applies to individuals with emphysema, chronic bronchitis, or as is common clinically, a combination of the two.
- Characterized by airflow limitation that is not fully reversible.
- Usually progressive; it is associated with abnormal inflammatory response of the lung to irritants.
- Preventable and treatable.
- Diagnostically defined as a post-bronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio of <0.70, and lack of alternative explanation for the symptoms and airflow obstruction.
Veterans with HIV*
- COPD is the fourth leading cause of chronic morbidity and mortality in the United States.
- More than 100,000 people in the United States die each year of complications from COPD.
- Underdiagnosed: Approximately 50% of patients with COPD have not been diagnosed.
- Smoking is estimated to be responsible for approximately 75% of COPD deaths.
- Only 15-20% of individuals with a significant smoking history are ever diagnosed with COPD. This reflects underdiagnosis as well as variability in susceptibility of smokers to the disease.
- HIV-infected subjects were 50-60% more likely than HIV-uninfected subjects to have COPD in a prospective observational study done at VA medical centers.
- After adjustment for age, race, ethnicity, pack-years of smoking, and history of intravenous drug and alcohol abuse, HIV infection has been identified as an independent risk factor for COPD.
Types of COPD
|* Irreversible airflow obstruction = post-bronchodilator FEV1/FVC <70%|
|Physical examination||Note: Physical examination has low sensitivity and specificity.
|Pulmonary function tests (PFTs), including spirometry||PFTs and spirometry are the diagnostic tests of choice. Order:
Consider arterial blood gas (ABG) test for patients with <50% of predicted FEV1, severe symptoms, and documented or suspected hypoxemia (O2 saturation by pulse oximetry <88%)
Consider bronchodilator reversibility testing for diagnosis of airway obstruction, particularly if history of asthma symptoms; may see partial but not full reversibility in COPD
Repeat spirometry if there is an increase in symptoms, or a complication
|Differential diagnosis (keep in mind that patients may have multiple conditions affecting pulmonary function, eg, COPD plus congestive heart failure)||Asthma (see Asthma)
Smoking Cessation: Prevention and Treatment
- Smoking cessation is the single most effective and cost-efficient intervention for most people to reduce the risk of developing COPD and limit its progression.
- Brief, 3-minute periods of counseling from a provider to urge a smoker to quit result in smoking cessation rates of 5-10%.
- For all smokers, try to incorporate the 5 A's of brief cessation counseling at each visit:
- Ask about tobacco use
- Advise to quit
- Assess willingness to make a quit attempt within the next 30 days
- Assist patients in quitting if they are ready
- Arrange follow-up
See Smoking Cessation for more information.
Stable Chronic COPD
Goals: prevent progression, relieve symptoms, improve exercise tolerance, improve health status, prevent and treat complications, prevent and treat exacerbations, reduce mortality
Remember: Counsel for smoking cessation at all stages!
|* There are important interactions between some inhaled corticosteroids and certain ARVs. See Table 3: Potential ARV Interactions.|
|II: Moderate||Short-acting bronchodilator, plus:
|III: Severe||Each of the above, plus:
|IV: Very Severe||Each of the above, plus:
|Respiratory Failure||PaO2<60 mmHg with or without PaCO2>50 mmHg||Same as "IV: Very Severe" above|
- Pulmonary rehabilitation (stage II and greater) - refer to Pulmonary or Physical Therapy, depending on facility practice
- Lung volume reduction (stage IV) - refer to Thoracic Surgery
Acute Exacerbations of COPD
This refers to acute increases in symptoms beyond normal daily variation, including 1 or more of the following symptoms:
- Cough:↑ severity and frequency
- Sputum production:↑ in volume or changes in character
Among patients with an acute exacerbation of COPD and a PaCO2 of >50 mmHg, the 6-month mortality rate is 33%.
Precipitants include bacterial or viral infection (50-60%), air pollution exposure (10%), and temperature changes.
In patients with COPD and advanced HIV infection, consider evaluation for respiratory opportunistic infections (eg, P jiroveci pneumonia) in the setting of an exacerbation.
|Beta-adrenergic agonists (albuterol, levalbuterol, pirbuterol)|
|Anticholinergic bronchodilators (ipratropium, glycopyrrolate)|
|Noninvasive positive pressure ventilation (NIPPV) in hospitalized patients|
ARVs and inhaled corticosteroids
ARVs and theophylline
- Crothers K. Chronic obstructive pulmonary disease in patients who have HIV infection. Clin Chest Med. 2007 Sep;28(3):575-87, vi.
- Crothers K, Butt A, Gibert C, et al. Increased COPD among HIV-positive compared to HIV-negative veterans. Chest. 2006 Nov;130(5):1326-33.
- Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007 Sep 15;176(6):532-55.
- VA/DoD Clinical Practice Guideline Working Group. Management of Chronic Obstructive Pulmonary Disease. Washington, D.C.: Department of Veterans Affairs, Office of Quality and Performance; 2007.