Diagnosing COPD

All about Chronic Obstructive Pulmonary Disease (COPD)

COPD is characterised by chronic respiratory symptoms such as breathlessness, cough and sputum production
These symptoms are due to damage to the airways and/or alveoli that cause persistent, often progressive, fixed airﬂow obstruction
COPD is a chronic, progressive condition for which there is no cure
Patients with COPD are generally, but not always, over the age of 35
Many people with COPD experience exacerbations or ‘flare-ups’, in which their symptoms worsen, and they need additional treatment
1.7 million people are living with COPD, and around 600,000 are living undiagnosed across the UK
People from the poorest communities are five times more likely to die from COPD than those in the richest

COPD symptoms are managed by a combination of approaches, with the aim of:

Relieving symptoms
Improving lung function
Preventing exacerbations

Preventing exacerbations is crucial

Even one moderate exacerbation increases the risk of future multiple exacerbation events, starting a spiral of excessive disease progression and an increased risk of death.

- Gold, 2024

Clinical assessment - what to ask

COPD is diagnosed by combining clinical history and post bronchodilator spirometry results.

Obtaining a comprehensive clinical history is key to understanding your patient’s risk factors for COPD. It will also enable you to identify their symptoms, and how much they are affecting your patient’s quality of life.

Taking time to do this will help you plan treatment that will be the most effective for them, and thereby reduce their risk of an exacerbation.

Use the guide below to structure your clinical-history-taking. Alongside each question is the rationale for why that question is important, and some suggestions for additional actions you can take to support your diagnosis. The more detail you can gather at this stage, the easier your future management will be!

Questions to ask your patient	Why this question matters
How long have you been breathless for? What brings it on? Is it all of the time, or some of the time? What makes it worse?	Breathlessness in COPD is progressive over time, worse with exercise and persistent. Intermittent symptoms and night waking with symptoms, especially in younger patients, may be suggestive of asthma. See here for NICE's guide to clinical features differentiating COPD and asthma.
Do you cough and/or wheeze? Do you bring up sputum? How much/how often? What colour is it?	A cough in COPD may be continual or intermittent, productive or non-productive. Sputum colour can suggest infection (if green or brown) and any blood in the sputum (haemoptysis) which is worrying and will need further investigation.
Do you have frequent chest infections?	Many patients will have had exacerbations before they are diagnosed, because they have normalised their symptoms or don’t realise that they are significant. Look through your patient’s notes for evidence of repeated chest infections or episodes of ‘winter’ bronchitis. They may or may not have been prescribed antibiotics and/or steroids, or previous inhalers.
Are you a past or current smoker? Do/did you smoke roll ups, cigars, a pipe, a water pipe, marijuana? How many years have you smoked/did you smoke for? What quantity of tobacco do/did you smoke? Have you been exposed to passive smoking in your lifetime?	Tobacco smoking is the leading cause of COPD, responsible for about 90% of cases. Other forms of smoking like pipe, cigar, water pipe, and marijuana also increase the risk. Calculate your patient’s pack years, and also record the duration of their smoking time. The total number of years a person has smoked is also crucial as long-term smoking leads to cumulative damage to the lungs. Passive smoking can contribute to COPD.
Do you have acid reflux, or indigestion symptoms?	Gastro-oesophageal reflux disease (GORD) is common in people with COPD and has been associated with increased COPD exacerbation frequency.
Tell me about your work and hobbies (past and present)	Some occupations and activities are associated with a risk of developing COPD.
How do you heat your home?	Indoor pollutants from burning coal and wood can contribute to COPD.
Do you live/have you lived in an area of high outdoor pollution?	For people who have never smoked, air pollution is the leading known risk factor for COPD.
Has anyone in your family had COPD?	Smoking, and having a close relative with COPD, increases the risk of developing COPD. Genetic factors such as alpha-1-antitrypsin deficiency might make some people more susceptible.
Did you have any lung problems in your childhood?	Factors like maternal smoking and severe childhood respiratory infections can impair lung growth and increase the likelihood of developing COPD.

Patients with COPD have a higher risk of co-morbidities such as heart failure and lung cancer, in addition to other differential diagnoses. Review your patient's notes for the notes for clues for other causes of their symptoms, like asthma, atopy, pulmonary embolism or anxiety.

If you think COPD may be causing all or some of your patient's symptoms, you can now perform spirometry testing.

Spirometry

Spirometry is an objective diagnostic test which must be quality assured. It should only be performed and technically reported by an HCP who has undergone appropriate training.

The Association for Respiratory Technology and Physiology (ARTP) Spirometry National Register is a list of HCPs who have completed the ARTP Spirometry Certification. Joining the National Register is not mandatory, but it ensures that all HCPs have their skills assessed and are certified as competent.

For advice and support on choosing the right training for you, please see our training and development page.

Spirometry testing in COPD

Spirometry testing for COPD needs to be measured post-bronchodilator.

A post-bronchodilator FEV1/FVC fixed ratio of 0.70 is indicative of airway obstruction.

However, using this fixed ratio alone can be inaccurate in some groups. Since this ratio depends on age, height, and sex, it can lead to over-diagnosis in older people and under-diagnosis in the younger age group.

Therefore, it is important to use the Lower Limit of Normal (LLN) and/or Z scores. A Z-score shows how far a test result is from the mean/average. Any result less than -1.645 is below the LLN and is considered outside of the normal range.

The presence of airflow obstruction alongside a comprehensive clinical history, with signs and symptoms would support a diagnosis.

Want to know more? Listen to Christine Loveridge’ spirometry webinar.

Reversibility testing

Reversibility testing is not used for COPD diagnosis unless your clinical assessment has identified that your patient has features of asthma. You can also use peak flow monitoring to identify variability. Learn more about peak flow monitoring in COPD with this guide from PCRS.

Additional tests

Test	Rationale
Blood pressure	To establish baseline and identify hypertension.
Heart rate	To establish baseline and exclude arrythmia such as atrial fibrillation.
Peripheral oxygen saturations	To establish baseline and identify hypoxaemia.
Body mass index	Being overweight or underweight is prevalent in COPD and associated with increased mortality.
Chest x ray	A chest X-ray isn't used to diagnose COPD but is helpful to rule out other conditions like lung cancer, pulmonary fibrosis, bronchiectasis, skeletal issues, and cardiac diseases. It can show signs of COPD such as lung hyperinflation.
Blood tests: Full blood count BNP if indicated Alpha 1 antitrypsin	Identify anaemia or polycythaemia. Identify high eosinophils which might respond to an inhaled corticosteroid. or suggest asthma To identify cardiac failure as a cause of breathlessness. Identifying this deficiency allows for specific treatments, such as alpha-1 antitrypsin augmentation therapy (currently only available in clinical trial). Testing can help identify at-risk family members who may also benefit from early intervention and lifestyle modifications to prevent or manage COPD.
ECG	To identify a cardiac condition as a cause of breathlessness.
CT thorax - if indicated	To investigate symptoms that seem disproportionate to the spirometry results, explore signs suggesting other lung conditions like fibrosis or bronchiectasis, assess abnormalities found on chest X-rays, and determine suitability for lung volume reduction procedures.
Sputum culture – if sputum is purulent and persistent	To identify organisms which can be treated with antibiotics.

By combining your clinical assessment with objective tests, you will now be able to make a diagnosis of COPD and identify any other comorbidities.

Resources for your patient

A diagnosis of COPD can be distressing. Offer your patient our First steps to living with COPD booklet and signpost them to our Helpline, where our specialist nurse and healthcare advisors are available to talk things through with your patient, and explore any social and practical difficulties they might have.
Don’t forget our Helpline is here to support HCPs as well. Call and speak with our supportive respiratory nurse specialists if you have questions or worries about diagnosing, treating or supporting your patients with a lung condition.

Your next step is to classify the severity of your patient's airway obstruction.

Page last reviewed: 4 July 2024

Next review due: 4 July 2025

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