COPD: Challenges in Primary Care

Introduction

Chronic obstructive pulmonary disease is a progressive disease characterized by persistent airflow limitation [1] that it is estimated to be the third leading cause of death worldwide [2]. The challenges for Primary Care (PC) are known to be immense and among them include, primary prevention with reduction of risk factors, secondary prevention with early detection and monitoring of COPD and tertiary prevention to improve health status, decrease disease progression and reduce exacerbations rate [1,3].

Prevention

In PC, general preventive strategies are influenced by time, cost, availability and practice capacity that makes it a challenge to manage behavioral risk factors [4]. Undoubtedly, cigarette smoking is by far the most important risk factor for COPD [1]. Fletcher and Peto demonstrated that smoking cessation abated the lung function decline that is characteristic of COPD [5]. Effective smoking cessation interventions in primary care are based on an awareness of which strategies have been shown to work and on making the most of available resources [6,7]. To that direction the International Primary Care Respiratory Group (IPCRG) has published a practical guidance for PC [6]. Despite that it is well known that smoking cessation in PC is feasible [6,7], physicians are not always prepared to deliver effective interventions for smoking cessation to their patients [8]. Furthermore, education and awareness to patients that pharmacological treatment as well as behavioural support for smoking cessation is available at a PC clinic is needed [9]. However, the preventive role of PC regarding COPD should not be limited to smoking. The Copenhagen City Heart Study highlighted that moderate to high levels of regular physical activity are associated with reduced lung function decline and COPD risk among smokers [10]. Additionally, a systematic review by the PRO active consortium showed that the physical activity level in COPD is consistently associated with mortality and exacerbations, yet there is poor evidence about determinants of physical activity [11]. Therefore, it is obvious that health-care providers should promote physical activity. Moreover data indicate that an increase in consumption of vegetables, fruit and (although with less evidence) fibre may contribute to the prevention of COPD [12].

When designing prevention strategies for COPD, a variety of risk factors should be considered; host factors (i.e; atopy), perinatal factors (i.e; maternal smoking, maternal exposure to air pollution), childhood exposures (i.e; respiratory tract infections, indoor-outdoor air pollution, obesity) and adult exposures (i.e; occupational, indooroutdoor air pollution) [13]. Therefore efforts to prevent COPD should also focus on optimization of lung health in the early years of life, before birth, and possibly even before conception [13]. Provider education, raising community awareness and the support and capacity building may improve the uptake of lifestyle modification interventions [4].

Challenging Mis and Under Diagnosis- The Role of Spirometry

The PLATINO [14] and the IBEPROC [15] study showed that 88.7% and 78.2% respectively, of patients with COPD had not been diagnosed while in the USA, more than 50% of patients with COPD have been either undiagnosed or misdiagnosed [16]. Patients with COPD may experience respiratory symptoms that are often disregarded by patients who do not always report them to their PC physicians [17].

Misdiagnosis of COPD and asthma is common [18]. Tinkelman et al. have developed a symptom-based questionnaire to differentiate between asthma and COPD that could potentially be used extensively in PC in the future [19]. Spirometry is an important tool for the accurate diagnosis of COPD [1,3] and lack of routine spirometry [20] is a key cause of this misdiagnosis. The DIDASCO study illustrated a high accuracy with the use of a portable spirometer when PC physicians received training in performance and interpretation [21]. Despite that, spirometry is still underused in PC [22,23] due to barriers such as, lack of access to calibrated spirometers and inadequate training and interpretation skills [22-24]. However it is promising to assure the quality of spirometry in PC settings [25] and solutions to overlap technical interpretation barriers have been extensively proposed [23]. Some examples are [23] basic training, operators that practice performing the man oeuvre to reinforce and improve skills, automatic feedback and technical error messages from the machine, use of IPCRG opinion sheets for spirometry [26],financial incentives for PC physicians to offset the cost of training, etc [23]. Increased use of spirometry in PC is a significant challenge as it is expected not only to increase rate of detection of COPD but also reporting to smokers their lung age (the age of the average healthy individual who would perform similar to them on spirometry), which is found to be effective to significantly improve the likelihood of someone to quit smoking [27].

Mass Population Screening or Case Finding?

The use of spirometry in mass population screening remains controversial and is not recommended however, its use in targeted case identification is more feasible [1]. Although when case-finding using full diagnostic spirometry is not possible in the PC setting in patients with symptoms, there are other approaches that could be useful. Such approaches are the use of questionnaires [28-31] designed to assess the risk for COPD and/or micro-spirometers such as copd-6 [32] PiKo-6 [33,34] as initial screening tools. All these studies [32-34] on microspirometry demonstrated a high negative predictive value meaning that they predict with a range of 91-98% accuracy level that the patient does not have COPD. In this direction, IPCRG has developed an algorithm driving GPs towards an effective case-finding (Figure 1) [23]. More studies are needed to confirm their role in PC.

    

    

    Figure 1:  An approach to COPD case-identification in primary care [23].
*Patients aged 30 and over if high risk (e.g. family history of COPD,
occupational or environmental risk, smoker since childhood). The possibility
of COPD should be considered in all patients with a long-term history of
exposure to risk factors, all those with a clinical history suggestive of COPD,
and all those with a positive questionnaire result. Multiple protocols for
investigating the possibility of COPD in at-risk patients are appropriate in
primary care, depending on the setting and resources available. Where a full
spirometry service is readily available, immediate diagnostic spirometry might
be appropriate. In other settings, opportunistic case-identification spirometry
may enable the primary care health professional to identify those who require
further investigation. Regardless of the initial steps taken to rule out COPD,
patients with abnormal findings on spirometry or symptom questionnaire will
require full diagnostic spirometry, performed to internationally acceptable
standards. Diagnostic spirometry must include post-bronchodilator testing.
    
    

    

    

    Figure 2:  CCQ based treatment algorithm [39].
    
    

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Citation: Tsiligianni I. COPD: Challenges in Primary Care. Austin J Pulm Respir Med 2015;2(2): 1025. ISSN:2381-9022

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