The severity of airflow obstruction does not tell you how much your patient is affected by their COPD symptoms.
Evidence shows that the severity of an individual's lung obstruction doesn't necessarily reflect the effect that COPD has on their life. So it’s important that you use validated assessment tools to measure the impact of the condition.
This page will introduce you to a range of assessment tools that will help you to holistically assess your patient.
Breathlessness assessment
The Modified Medical Research Council Dyspnoea Scale grades the severity of dyspnoea (breathlessness) on a scale from 0 to 4, with higher scores indicating more severe breathlessness.
| Description | Grade |
|---|---|
| I only get breathless with strenuous exercise | 0 |
| I get short of breath when hurrying on level ground or walking up a slight hill | 1 |
| On level ground, I walk slower than people of my age because of breathlessness, or I have to stop for breath when walking at my own pace on the level | 2 |
| I stop for breath after walking about 100 yards or after a few minutes on level ground | 3 |
| I am too breathless to leave the house or I am breathless when dressing/undressing | 4 |
The Modified Borg Dyspnoea Scale allows your patient to rate their perceived exertion during activity.
Patient instruction:
“This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0 where your breathing is causing you no difficulty at all and progresses through to number 10 where your breathing difficulty is maximal. How much difficulty is your breathing causing you right now?”
|
Numeral |
Perceived exertion rating |
|---|---|
| 0 | No exertion |
| 0.5 | Noticeable |
| 1 | Very light |
| 2 | Light |
| 3 | Moderate |
| 4 | Somewhat difficult |
| 5 | Difficult |
| 6 | |
| 7 | Very difficult |
| 8 | |
| 9 | Almost maximal |
| 10 | Maximal |
The Borg RPE scale (R) ((C) Gunnar Borg, 1970, 1998, 2017). Scale printed with permission.
The BORG scale is often used in walking distance tests, such as the 6 minute walk test or shuttle test. These tests allow you to monitor your patient's breathlessness on exertion, their response to pulmonary rehabilitation and provide information about whether they need to be referred for oxygen assessment.
Another option for exercise testing is the One-Minute Sit to Stand Test. PCRS have produced a protocol for this test, which can be used in primary care. It can be easily conducted in a patient's home or a small clinic room, requires minimal equipment, is quick to perform, and provides valuable insights into your patient’s physiological response to exercise.
Visual Analogue Scale
A Visual Analogue Scale (VAS) is a tool used to measure the intensity of a patient's breathlessness. It consists of a horizontal line labelled from "No breathlessness" at one end to "Worst breathlessness imaginable" at the other, with numbers marked at regular intervals. Patients mark the point on the line that best represents their current level of breathlessness.
A numbered version of the VAS can make it easier for patients to indicate their level of breathlessness, especially for those who might find it challenging to mark an unnumbered line. It also allows for clear communication and documentation of the breathlessness
| No breathlessness | Maximum breathlessness | |||||||||
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Health status assessment
Health status assessments provide information about the impact that COPD is having on your patient's life and daily activities. They should be completed at diagnosis and every subsequent review, whether that be their annual review or a post exacerbation review.
The COPD Assessment Tool (CAT) is a questionnaire including eight items, each focusing on a different aspect of your patient's health related to COPD, such as cough, phlegm, chest tightness, breathlessness, activity limitation, confidence, sleep, and energy levels.
Each item is rated from 0 (no impact) to 5 (severe impact). The scores for all eight items are added together to give a total score between 0 and 40. Higher scores indicate a greater impact of COPD on your patient's health.
Please read the guide to the CAT before using it with your patients.
St George’s Respiratory Questionnaire (SGRQ) evaluates the frequency and severity of your patients symptoms: such as cough, sputum production, and breathlessness, the impact of breathlessness on physical activities and the social and psychological effects of the disease.
The GOLD ABE assessment tool
The GOLD guideline uses a combined 'ABE' approach to assess patients according to their level of symptoms and previous history of exacerbations. Symptoms are assessed using the mMRC or CAT scale. Exacerbations are assessed independently of symptoms to highlight their clinical importance.
Category A is defined by:
| Moderate or Severe Exacerbation History | Symptom Score |
|---|---|
| 0 or 1 (not leading to hospital admission | mMRC 0 or 1 or CAT <10 |
Category B is defined by:
| Moderate or Severe Exacerbation History | Symptom Score |
|---|---|
| 0 or 1 (not leading to hospital admission) | mMRC >=2 or CAT >=10 |
Category E (in GOLD 2024, category C and D groups were merged into a single group) is defined by:
| Moderate or Severe Exacerbation History | Symptom Score |
|---|---|
| >=2 or 1 leading to hospital admission |
mMRC 0 or 1 or CAT <10 mMRC >=2 or CAT >=10 |
Example: A patient with an FEV1 <30%, mMRC of 2, and three exacerbations in the past year would be classified as GOLD grade 4, group E.
In contrast, a patient with an FEV1 <30%, mMRC of 1, and zero exacerbations in the past year would be classified as GOLD grade 4, group A.
Mental health
Depression and anxiety in patients with COPD are common and are been associated with higher CAT scores. If your CAT or SGQ-C suggests your patient is low in mood, the Patient Health Questionnaire-9 can be used to gather more information about their mental health.
Nutritional assessment
Malnutrition and obesity in COPD can adversely affect health status.
NICE guidelines recommend that body mass index (BMI) is calculated in all patients with COPD. but this measurement can mask malnutrition and loss of muscle mass. Use of a validated screening tool such as The Malnutrition Universal Screening Tool ‘MUST’ which combines unintentional weight loss and the BMI measurement, increases accuracy.
It can also be utilised as a self-screening tool which can be sent to your patient to complete remotely.
Use in conjunction with the Managing Malnutrition in COPD pathway, which has patient education leaflets for all stages of nutritional status.