Pulmonary function testingJanuary 3rd, 2016

Introduction
Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of death in the US and globally. Over 24 million Americans are affected by COPD, a group of conditions which includes emphysema, chronic bronchitis, and sometimes asthma. COPD is caused primarily by smoking (Todd et al., 2011). Respiratory symptoms include difficulty breathing, wheezing, coughing, and sputum production. COPD can and often does cause significant effects on other systems which contributes to its severity in certain patients (Huether & McCance, 2014). Chronic COPD can cause weight loss, depression and anxiety, osteoporosis, cardiovascular disease, and polycythemia (Todd et al., 2011). The purpose of this paper is to describe COPD diagnosis, management, and prevention strategies as outlined in the COPD guidelines of the Global Initiative for Chronic Obstructive Lung Disease. This paper will also illustrate implementation of these strategies using a specific case study.
COPD Diagnosis
According to Global Initiative for Chronic Obstructive Lung Disease (2011), a diagnosis of COPD is considered in any patient over 40 years of age who presents with: dyspnea that worsens over time or is persistent with exercise; intermittent chronic cough or chronic sputum production; or exposure to risk factors such as tobacco smoking or workplace dust and chemicals. Pulmonary function tests using spirometry are definitive for the clinical diagnosis of COPD. A post-bronchodilator FEV1/FVC of <0.70 confirms the presence of airflow obstruction (GOLD, 2011).
Management and Prevention Strategies
The first step in management and prevention of COPD is to assess and monitor the disease after it is diagnosed. Diagnosis of COPD is based on exposure to risk factors and the presence of airflow restriction, with or without symptoms. Patients with a chronic cough and sputum production with a history of risk factors for COPD should be tested, even if they do not present with other symptoms.
Spirometry (pulmonary function testing) is the gold standard for the diagnosis of COPD. Spirometry is a standardized and reproducible method of measuring airflow restriction. An FEV1/FVC of < 70% and a postbronchodilator FEV1 of < 80% of predicted is indicative of airflow limitation that is not fully reversible. Arterial blood gases (ABGs) should be done in all patients with an FEV1 of < 40% of predicted, or in patients with clinical signs of respiratory or heart failure (GOLD, 2011).
Once the patient is diagnosed and the acute episode is stabilized, the risk factors for that patient should be identified to prevent or reduce the severity of future episodes. These include counseling on smoking cessation, reducing exposure to dusts and chemicals in the workplace, and minimizing exposure to indoor and outdoor pollutants, including secondhand smoke (GOLD, 2011).
Health education is an effective way to help the COPD patient improve the ability to cope with illness. If the patient is a smoker, providing counseling on smoking cessation is another effective way to reduce acute episodes of COPD and stop its progression. Individual counseling and social support groups can also be useful. Several medications are currently available to help patients stop smoking, which can be valuable adjuncts to counseling (WHO, 2015). Patients who are subject to workplace exposure to industrial pollutants should be counseled on reducing risk by taking extra precautions, such as wearing protective masks while at work to prevent or minimize inhalation of dusts and noxious chemicals. Most patients with COPD can benefit from exercise programs designed to improve exercise tolerance and stamina, which will result in long-term reduction in symptoms (Sutherland & Cherniack 2011).
The existing medications for COPD treatment are designed to minimize symptoms and reduce acute episodes, but none of them prevent the decline in lung function over time. Inhaled bronchodilators are the main treatment for symptomatic management of COPD (Todd et al., 2011). They are administered either as needed for acute symptoms or on a daily basis. Long-acting bronchodilators, such as salmeterol and formoterol, and the anticholinergic tiotropium improve both lung function and dyspnea. Regular treatment with inhaled glucocorticoids are also frequently prescribed. Chronic treatment with systemic glucocorticoids should be avoided unless cases are severe enough to warrant it (Todd et al., 2011).
Administration of oxygen to chronic patients can improve daily life and increase survival. Patients with signs of airway infection, such as productive cough or fever, may need antibiotics. Finally, noninvasive positive pressure ventilation (NIPPV) in acute exacerbations can improve blood gases and reduce in-hospital mortality (WHO, 2015).
COPD Case Study
JR, a 38 year old female, has smoked since she was 18 years old, about one pack a day for the past 20 years, and has been unable to quit successfully. She visited her primary care physician with a complaint of a mild, occasionally productive cough for the past 4 months, which is worse when she is anywhere that allergens, such as dust, are present in the air. She has had shortness of breath during exercise over the previous few months. She also has a history of hypertension, for which she is taking lisinopril, metoprolol, and hydrochlorothiazide ( American Academy of Family Physicians, 2015).
Chest x-ray and spirometry are the initial diagnostic tests ordered for a patient suspected of having COPD. The chest x-ray can detect masses, infiltrates, or signs of obstructive airflow that would indicate COPD. However, a normal chest x-ray does not rule out COPD. Spirometry is also essential to evaluate any patient suspected of COPD.
JR’s spirometry results showed an FEV1/FVC of less than 70% and an FEV1 over 80% of predicted, so she has an obstructed airway consistent with mild COPD, as opposed to a restrictive process which would be consistent with asthma.
Her symptoms are mild, so counseling together with a medication to assist in quitting smoking would be beneficial. This patient would also benefit from the use of a short-acting bronchodilator, such as salbutamol or ipratropium, to help control her acute symptoms (AAFP, 2015).
Systemic beta blockers, ACE inhibitors, and thiazide diuretics are all safe and so she can continue to use these for control of her hypertension. Physicians are often concerned with the use of beta blockers in patients with COPD, due to the potential for bronchoconstriction, but some of the research contradicts this idea (Albouaini et al., 2011). This patient has a productive cough and a history of smoking, so mild COPD is the likely cause of her cough in this case (AAFP, 2015).
Conclusion
COPD is a condition commonly encountered in the clinic. APRNs should be well-versed in the diagnosis and management of these patients, as outlined in the Global Initiative for Chronic Obstructive Lung Disease. APRNs should have access to a spirometry laboratory and xrays in the clinic for proper diagnosis. Effective management of COPD can be done using a stepwise treatment approach, depending on the severity of the disease. An evidence-based approach along with chronic disease management can improve quality of life for many patients with COPD (Todd et al., 2011).