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COPD Early diagnosis

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COPD Early diagnosis

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Early detection and diagnosis: Reducing the burden of COPD

The development of COPD can be stopped. Early detection and healthy habits can prevent COPD development and can slow its progression. Early diagnosis allows for timely pharmaceutical and non-pharmacological therapies that are effective in avoiding airflow damage, thereby slowing the disease’s progression to greater severity and, ultimately, lowering mortality [1]. In this regard, it is critical to identify and remove the current barriers to early detection and diagnosis to COPD in Europe. Furthermore, research should focus on developing a better understanding of the disease’s natural course, with the goal of identifying biomarkers that can detect disease activity at an early stage.

Early detection through targeted lung health checks must become standard practice. By identifying COPD in its early stages, particularly among high-risk groups, we can significantly slow disease progression and improve quality of life for millions of Europeans.

Prof. Alessandro Vatrella, COPD project Medical Advisor

“In Italy, patients’ associations are advocating for the Government to implement screening programmes for people at-risk of COPD, similar to those already in place for the prevention of cardiovascular diseases.”

COPD Patient, Italy

“Many people do not know what COPD is and are embarrassed to go the doctor because they do not take their symptoms seriously.”

COPD Patient, The Netherlands

“Overall, there is a need for more research in all areas around COPD. Patients need more protection.”

COPD patient, France

“It is necessary to be screened more often. The disease does not give any signs. You need to be tested frequently and doctors should discuss and ask for details, especially from smokers, to look for symptoms.”

COPD patient, Poland

“Results were misinterpreted for so many years, spirometry was performed, there was increased expiratory resistance – no one determined the disorder as COPD.”

COPD patient, Poland

“The public authorities could do more to control air pollution.”

COPD patient, Finland

Living with COPD (Spanish)

Antonio, a COPD patient, shares his daily experiences with this condition. This video is part of a series where individuals with respiratory diseases discuss their challenges and hopes.

© Copyright by La Federación Española de Asociaciones de pacientes alérgicos y con Enfermedades Respiratorias, 2021.

Early diagnosis: Still missing the target

Early diagnosis was one of the goals identified by the EFA 2013 report to achieve patient-centred minimum standards of care for COPD. Early diagnosis of symptomatic individuals is crucial to prevent irreversible airflow limitation and lung tissue damage, which can significantly impact the patient’s outcome. Despite implementing some best practices, there has been no significant improvement in early diagnosis in the 19 countries surveyed over the last 10 years. Misdiagnosis or diagnosis of COPD at advanced stages can effectively reduce life expectancy and its quality.

Delayed diagnosis places a significant burden on patients and society (Agarwal, 2023). Patients with severe COPD (GOLD grades 3 and 4) and those with a history of severe acute exacerbations have a considerable reduction in life expectancy [2]. Conversely, patients diagnosed with mild stage COPD (GOLD grade 1) may not experience such reduction compared to healthy people [2]. Therefore, early, and correct diagnosis of symptomatic individuals, especially smokers with ongoing cough, continues to be a major issue. Individuals at-risk, including current and ex-smokers and passive smokers over 35, should receive spirometry testing as part of their regular health check-ups.

In this context, EFA also identified the need to increase healthcare professionals’ (HCPs) training, particularly among primary care practitioners and GPs, to administer spirometry and interpret the results. In fact, COPD is often poorly recognised. EFA-commissioned research revealed that patients who initially received a wrong diagnosis (16% of the sample) had to wait on average five years to receive the right one. Delayed diagnosis led to an increase in disease severity and the risk of adverse outcomes. In fact, 75% of patients who received an initial misdiagnosis went on to develop moderate to severe COPD (EFA, 2019).

Early interventions, particularly smoking cessation (see “Reduce exposure to cigarette smoking and vaping”), are associated with a subsequent absence of chronic symptoms [3].

Notably, early diagnosis of COPD is critical not only for managing the condition, but also for lung cancer surveillance. COPD patients, especially those with severe disease, have a higher risk of developing lung cancer. Thus, regular follow-ups should be considered in patients with COPD [4].

Policies aimed at promoting early diagnosis of COPD should focus on four dimensions:

  1. Spirometry screening programmes targeted at the at-risk population, ideally by enrolling them in a lung health plan;
  2. Wide availability of spirometry in primary care services;
  3. Awareness campaigns targeted to the general population to promote symptom recognition;
  4. Research on the physio pathological mechanisms of COPD and on new biomarkers for very early diagnosis, particularly among nonsmoker patients.
Raising Awareness and Effective Treatment for COPD (German)

This video addresses the high rate of undiagnosed COPD cases, emphasising the need for greater awareness among the general public and healthcare providers. Experts discuss comprehensive care strategies and the role of modern therapies for advanced cases.

© Copyright by Österreichische Lungenunion, 2024

Access to spirometry at primary care services

GPs do not routinely perform spirometry and/or are not trained to interpret the results

Diagnosis is largely made by pulmonary specialists

Spirometry is a simple medical test widely used for early diagnosis or to confirm the diagnosis of COPD in patients with respiratory symptoms and shortness of breath. It is the primary tool to screen the at-risk population. Although simple to use, spirometry is not widely available in primary care. According to national patient organisations participating in the EFA’s survey report, GPs frequently do not perform spirometry, are not trained to interpret the results, and do not receive incentives to do the test. Consequently, most diagnosis are made by pulmonary specialists. This may cause a delayed diagnosis due to long waiting lists for specialised visits. In Austria, only 50% of GPs receive reimbursement for spirometry, and they often delay referral of patients to pulmonary specialists because they do not recognise COPD symptoms. While spirometry is widely available in Iceland, GPs underuse it due to limited symptom recognition or lack of incentives. Furthermore, the workload of pulmonary specialists is increasing. In public hospitals in Turkey, a pulmonologist examines at least 50 patients per day.

The decreasing number of GPs observed in Europe since 2000 (Figure 9) is another barrier to early COPD diagnosis [5]. As a result, GPs must deal with an increasing number of patients and have less time to visit each one. Notably, such a decrease has a significant impact on less urbanised and rural areas. In this scenario, nurses and pharmacists could play a significant role in reducing workload in primary care, with active involvement in health promotion, case detection, as well as routine checks for chronically ill patients. Currently, nurses are undervalued in primary care. Their increased involvement would require specific training programmes, but it would have a relevant positive impact on healthcare systems. Data from a systematic review of 60 studies provides solid evidence for increased nurse engagement in general practice settings, particularly in the management of chronic diseases, including COPD [6]. According to the study, teams that include advanced-level nurses have better patient outcomes, higher patient satisfaction, and lower hospitalisation rates.

Figure 9. The share of generalist medical practitioners is dropping across most OECD countries

The dangers of undiagnosed COPD (Polish)

COPD affects 2 million Poles but is only diagnosed in 600,000. The disease can shorten life expectancy by 10-15 years if left untreated. Dr. Piotr Dąbrowiecki explains the key risk factors, symptoms, diagnosis methods, and treatments. Learn how to recognise symptoms, the role of spirometry and steps for effective prevention.

© Copyright by Academia NFZ, 2022

Podcast Date un Respiro: Early Diagnosis and Prevention of COPD (Spanish)

In this episode, healthcare professionals and patients discuss why COPD remains underdiagnosed despite affecting millions in Spain and explore how early diagnosis and prevention can make a difference.

© Copyright by La Federación Española de Asociaciones de pacientes alérgicos y con Enfermedades Respiratorias, 2022

Lack of lung health awareness and delayed symptom recognition

Delayed diagnosis is caused by a lack of awareness about symptoms and risk factors.

COPD is still considered as a self-inflected disease that only affects smokers. The smokers’ stigma tied to COPD may delay diagnosis and treatment.

The lack of awareness about lung health in general and COPD and its symptoms in particular is another barrier to early diagnosis. Smokers and elderly patients tend to think that coughing and shortness of breath are “normal”, and they may be embarrassed to talk about their symptoms. Case finding tools like questionnaires for patients can help to increase symptoms-awareness among patients. For example, the Dutch National Lung Alliance (LAN) and the Lung Foundation (LongFonds) have adopted a COPD screening eight item questionnaire to self-evaluate the individual risk of having COPD. Identifying and diagnosing asymptomatic individuals is even more challenging. It necessitates a proactive approach, including direct questions about symptoms, physical activity, possible minor unreported exacerbations, and previous personal and family lung disorders [3].

Healthcare authorities and scientific societies have demonstrated the effectiveness of national and regional plans in improving early diagnosis [7] [8] [9] [10]. In Denmark, training on adherence to guidelines, diagnosis, COPD staging, and treatment resulted in a 24% increase of spirometry recording by GPs [8]. In Italy, the region of Campania has developed the AGIRE programme as a training and awareness programme to build a synergy between GPs, pulmonary specialists, and regional healthcare authorities. The programme includes hands-on training for GPs to improve identification of patients with COPD at a very early stage and to simplify access to specialist centres to start treatment. In Sweden, the National Board of Health and Welfare, which is the national authority in charge of social and health services, published national guidelines with recommendations for early diagnosis. Nevertheless, an assessment of adherence to recommendations highlighted regional differences in terms of access to diagnosis [10]. In this context, training of primary care physicians can improve early detection and recognition of COPD and the ability of interpreting spirometry results [7] [8].

Best Practice 1
Lung Foundation (LongFonds) The Netherlands – Risco test

A COPD screening ten item questionnaire available at:
https://www.longfonds.nl/doe-nu-de-copd-risicotest

The aim of the COPD risk test is to rapidly and easily identify people who have greater risk of developing COPD. It is based on a self-administered questionnaire available online. The test looks at the symptoms and behaviours but does not make a diagnosis. In case of an increased risk, the results prompt the individual to make an appointment with the GP for diagnosis and provide a help line and useful information.

The COPD risk test was developed from research in the United States and Europe among thousands of people considering a large number of factors related to COPD. A research in the Netherlands subsequently validated the test.

Early detection of COPD: Lung screening for population at-risk

Screening for people at-risk is not implemented

Screening the at-risk population for COPD increases the chances of early case detection, thereby enabling timely diagnosis and treatment, ultimately resulting in reduced costs and mortality [11]. The GOLD strategy recommends spirometry screening for individuals at-risk, such as smokers and those with recurrent chest infections, and it boasts a high case detection rate [1]. Health authorities should enforce simple spirometry screening, open to all individuals at-risk, given spirometry’s high case detection potential [12]. This strategy has proven successful for other diseases (e.g., mammography screening for breast cancer, EEG for cardiovascular diseases, and blood tests for diabetes). Nevertheless, despite encouraging evidence and low costs of the test, community-based COPD screening remains underused [12].

None of the countries surveyed have implemented official screening programmes for COPD, which are instead organised ad hoc, on a voluntary basis by patient associations and medical societies. As pointed out by the Turkish association, physicians do not have specific indications regarding spirometry in at-risk patients over the age of 40, and the decision relies only with them. In Portugal, despite the existence of a legal framework to promote early COPD diagnosis, neither the government nor the doctors seem aware of the importance of early diagnosis (especially compared to other chronic diseases). In Spain, screening is organised locally by hospitals, therefore, these initiatives are unable to reach a wide audience. While screening programmes for COPD have not been implemented, some pilot lung cancer screenings using CT scans have been successfully launched in the UK (LHC, University of Manchester national trial), in Belgium and in the Netherlands (NELSON trial). Lung cancer screening programmes were effective also for early detection of other pulmonary conditions (LHC, University of Manchester national trial).

Box 12
Who should be screened for COPD?
  • Smokers, ex-smokers and long-term passive smokers
  • People who cough often
  • People who experience shortness of breath when walking quickly
  • People receiving treatment for other lung conditions.

Modified from European Lung Foundation (ELF) https://europeanlung.org/

Research: What is ahead?

Promising ongoing research supports the impact of early detection of individuals at-risk of developing COPD, with a focus on symptomatic smokers. On the contrary, identification of at-risk patients among non-smokers is still a difficult challenge.

Thus, COPD often goes undiagnosed in non-smokers. Notably, in some populations (e.g., among Latin Americans) non-smokers can reach 30% of all COPD patients. Childhood asthma, a history of respiratory infections, and early exposure to tobacco smoke are all predictors of COPD development [3]. Furthermore, Agusti and Faner (2019) have linked the onset of COPD to lung abnormal function development (also known as lung function trajectories) [13]. Throughout life, a variety of environmental and genetic variables may disrupt the normal evolution of the lung function trajectory. More research is needed to better understand the biological mechanisms underlying different abnormal lung function trajectories, including why some children can recover lung function while others do not, and to identify and validate appropriate biomarkers for use in clinical practice to improve the diagnosis of COPD.

Box 13
Call for researchers: Diagnose COPD before irreversible airflow limitation.

Diagnosis of COPD relies almost entirely on post-bronchodilator spirometry and no new technique has been developed in decades. Unfortunately, spirometry is underused and frequently misinterpreted.
Most importantly, spirometry is not sensitive enough to detect early alterations of lung function, which may be treated.

We urge for a wider definition of COPD that includes persons who have airflow restriction determined by more sensitive pulmonary function tests or pathological abnormalities revealed by imaging methods.

Modified from: Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission [14]

Living with COPD: Prevention, Diagnosis and Treatment (Polish)

Follow the daily challenges of patients with COPD and learn more from healthcare specialists about available medical treatments and the need to improve prevention.

© Copyright by Polska Federacja Stowarzyszeń Chorych na Astmę i Choroby Alergiczne i Przewlekłe Obturacyjne Choroby Płuc (2024)

Conclusion: Early diagnosis can reduce the burden of COPD

Early diagnosis is a priority to reduce the burden of COPD, prevent its progression, and reduce exacerbations and mortality. Being able to identify COPD cases at a very early stage would also change the sense of helplessness commonly associated with COPD diagnosis. Regrettably, people often receive a diagnosis of COPD too late, once it has negatively impacted their quality of life and life expectancy. Healthcare professionals and national and local authorities should collaborate to address this issue.

Access to diagnosis should be promoted by increasing the availability of simple medical testing such as spirometry in primary care and community-based settings, including pharmacists and community nurses. Training healthcare professionals to perform and interpret spirometry results effectively reduces misdiagnosis. In addition, increasing awareness among healthcare professionals and the public on COPD is crucial to improve symptom recognition and a proactive approach to case finding. Local and national healthcare authorities should also consider actively screening the at-risk population as integral parts of a general programme to promote lung health. All these measures combined can effectively improve the diagnosis of COPD in individuals at-risk, increase life expectancy, and reduce hospitalisations and the related societal costs. Furthermore, the identification of biomarkers of early COPD risk would change the approach to COPD by enabling active prevention.

Recommendations

Reducing COPD Progression through Early Detection and Awareness

Reducing the progression of COPD requires proactive measures, including early detection through lung health checks and targeted awareness actions.

 

At national level:
  1. Raise awareness of COPD symptoms and risk factors: Conduct public awareness initiatives to promote COPD symptom recognition (i.e., dyspnoea, “shortness of breath”, chronic cough) while educating about risk-factors. These initiatives should be carried out in collaboration with civil society, particularly patients and healthcare professionals’ associations.
  2. Strengthen primary care for COPD diagnosis: Ensure that COPD diagnosis is widely accessible by strengthening capacity of primary care as the frontline in managing COPD. This involves training and incentivising general practitioners to routinely perform spirometry testing and enhancing the role of nurses in running lung health check-ups.
  3. Provide lung health checks for at-risk groups: Offer lung health checks for early detection of COPD in people who are symptomatic or at higher risk. Targeted groups include current and former smokers, patients with related comorbidities (i.e., asthma, Alpha-1, cardiovascular symptoms, osteoporosis) and those exposed to risk factors, such as chemicals, gas, fumes, and urban pollution.

 

At European level:
  1. Earmark EU funding for COPD research: Allocate EU funds to support research on the lung function trajectories that may predict the development of chronic lung diseases, including the identification of new biomarkers for very early diagnosis, particularly among non-smoking patients.
  2. Promote studies on the cost-effectiveness of early detection: Support health economic studies on the cost-effectiveness of early COPD detection across European regions and pilot screening programmes anchored in primary care.
  3. Expand digital networks for early COPD detection: Invest in expanding and reinforcing digital networks to support early COPD detection. This includes harnessing the full potential of EU-wide registries, medical devices, machine learning technologies and the European Health Data Space.
  4. Adopt a WHO Europe Lung Health Agenda: Advocate for the adoption of a comprehensive and multistakeholder WHO Europe Lung Health Agenda to improve COPD prevention and care across the region.
References

1. GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2024 Report). 2024.↩

2. Chen C-Z, Shih C-Y, Hsiue T-R, Tsai S-H, Liao X-M, Yu C-H, et al. Life expectancy (LE) and loss-of-LE for patients with chronic obstructive pulmonary disease. Respir Med. 2020;172:106132.↩

3. Laucho-Contreras ME, Cohen-Todd M. Early diagnosis of COPD: myth or a true perspective. European Respiratory Review. 2020;29.↩

4. Sekine Y, Katsura H, Koh E, Hiroshima K, Fujisawa T. Early detection of COPD is important for lung cancer surveillance. European Respiratory Journal. 2012;39:1230–40.↩

5. OECD. Realising the Potential of Primary Health Care. 2020.↩

6. Matthys E, Remmen R, Van Bogaert P. An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care? BMC Fam Pract. 2017;18:110.↩

7. Chavannes N, Schermer T, Akkermans R, Jacobs JE, Graaf G van de, Bollen R, et al. Impact of spirometry on GPs’ diagnostic differentiation and decision-making. Respiratory Medicine. 2004;98:1124–30.↩

8. Ulrik CS, Hansen EF, Jensen MS, Rasmussen FV, Dollerup J, Hansen G, et al. Management of COPD in general practice in Denmark–participating in an educational program substantially improves adherence to guidelines. Int J Chron Obstruct Pulmon Dis. 2010;5:73–9.↩

9. Vasankari T, Pietinalho A, Lertola K, Junnila SY, Liippo K. Use of spirometry and recording of smoking habits of COPD patients increased in primary health care during national COPD programme. BMC Fam Pract. 2011;12:97.↩

10. Socialstyrelsen. Performance assessment of asthma and COPD healthcare. Adherence to National Guidelines 2018. 2018.↩

11. Axelsson M, Backman H, Nwaru BI, Stridsman C, Vanfleteren L, Hedman L, et al. Underdiagnosis and misclassification of COPD in Sweden – A Nordic Epilung study. Respir Med. 2023;217:107347.↩

12. Agarwal D. COPD generates substantial cost for health systems. Lancet Glob Health. 2023;11:e1138–9.↩

13. Agusti A, Faner R. Lung function trajectories in health and disease. Lancet Respir Med. 2019;7:358–64.↩

14. Stolz D, Mkorombindo T, Schumann DM, Agusti A, Ash SY, Bafadhel M, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet. 2022;400:921–72.↩

 

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About
What is copd
Burden of copd
Cost of COPD
Disease awareness
COPD Prevention
COPD Early Diagnosis
COPD Care Acces
Quality of Life with COPD
Digital Health for COPD
The Impact of COVID-19 on COPD Care
Recommendations