COPD as a Life-Limiting Illness: Implications for Advanced Practice Nurses

Donna M. Goodridge, RN, PhD

Disclosures

Topics in Advanced Practice Nursing eJournal. 2006;6(4) 

In This Article

Assessment of COPD Severity

APNs must have a clear understanding of the progression of COPD in order to determine the appropriate time to begin planning for end-of-life care. COPD is a chronic disease state characterized by airflow limitation that is not fully reversible, airway obstruction, systemic manifestations, and increasing frequency and severity of exacerbations.[17] Airflow limitation is typically progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases.[6] While smoking is the primary cause of COPD, other potential risk factors include environmental toxins, genetic predispositions, asthma comorbidity, low socioeconomic status, and cachexia.[18]

Symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors, are suggestive of COPD; diagnosis is confirmed by spirometry.[17] Table 1 describes the staging system for COPD severity, as outlined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006,[19] which takes into account forced expiratory volume in 1 second (FEV1), the ratio between FEV1 and forced vital capacity (FVC), sputum production, and cough.

These objective measures do not, however, necessarily capture all of the elements used to characterize the severity of the disease.[17,20,21] While FEV1 has been widely regarded as the best single correlate of mortality, Nishimura and colleagues[20] established that the degree of dyspnea was actually a better predictor of 5-year survival. The Modified Medical Research Council (MMRC) Scale[12] is widely used to assess the degree of dyspnea, and can be easily used in a clinical setting by APNs.

In grade 1, the patient is not troubled by breathlessness except on strenuous exercise; grade 2, the patient is short of breath when hurrying or walking up a slight hill; grade 3, the patient walks more slowly than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at his or her own pace; grade 4, the patient stops for breath after walking about 100 meters or after a few minutes on level ground; grade 5, the patient is too breathless to leave the house, or breathless when dressing and undressing.

The need for a comprehensive staging system that allows for more adequate categorization of patients with COPD provided the impetus for the development of the BODE Index.[22] The BODE Index (see Table 2 ) is a multidimensional 10-point grading system that assesses the respiratory and systemic expressions of COPD; it has found increasing acceptance in clinical practice.[22] The 4 variables that comprise the BODE Index are: (1) body mass index (BMI); (2) distance walked in 6 minutes (meters); (3) MMRC score; and (4) degree of airflow obstruction (FEV1 -- percentage of predicted). Higher scores on the BODE Index indicate higher risk of death. The hazard ratio of death from respiratory causes per 1-point increase in the BODE score was 1.62 (95% CI 1.48-1.77; P < .001). The BODE Index was found to be more effective than measurements of airflow limitations at predicting the risk of death among patients with COPD,[22] thus providing valuable information for clinical assessment.

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