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For Primary Care| Patient Scenarios

Patient Scenarios: GOLD COPD 2023

These scenarios are fictitious, but are similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. They are designed to highlight management approaches, and show some pitfalls to avoid.

The following case studies, written by Dr Kevin Gruffydd-Jones, relate to his article The 2023 GOLD report: what’s new for primary care? and GOLD's Global strategy for prevention, diagnosis, and management of COPD: 2023 report.

Case 1: Jean

Jean is a 60-year-old woman who has never smoked. She has a 6-month history of an unproductive cough, and has become more breathless on going upstairs during the last 3 months. She has experienced no weight loss, haemoptysis, hoarseness of voice, or chest pain on exertion. She is taking 50 mg of losartan per day to treat hypertension. 

On examination, her blood pressure is 135/75 mmHg, but a cardiovascular examination is otherwise normal. Examination of her chest reveals scattered wheezes only.

Questions for Reflection

  1. What other questions should you ask Jean? 
  2. What investigations should you carry out in primary care to elucidate the diagnosis?

How to Manage this Patient

Patient History

The absence of ‘red flags’ such as weight loss, haemoptysis, and chronic hoarse voice reduces the chances of lung cancer being present. The lack of chest pain on exercise reduces the likelihood of associated ischaemic heart disease, and there do not appear to be any signs of cardiac failure. Similarly, the absence of a chronic productive cough lessens the chance of bronchiectasis being present.

The main differential diagnosis lies between asthma and COPD, and questions should be asked regarding past or family history of these conditions (although late-onset asthma is likely to be nonatopic). Also, questions should be asked about the variability of symptoms—for example, worsening symptoms in response to specific triggers, with more severe symptoms in the early morning being more suggestive of asthma.

COPD is considered to be a smoking-related disease, but up to 30% of cases are thought to be unrelated to tobacco smoking in high-income countries like the UK. Therefore, questions should be asked regarding past and present occupations and exposure to indoor and outdoor environmental pollutants. In fact, Jean’s symptoms are more in keeping with COPD, and she discloses that she has a 30-year history of working in market gardening, during which time exposure to pesticides may have increased her risk of developing COPD.

As she is relatively young, it must be determined whether there is a family history of COPD; a positive reply will raise the possibility of hereditary alpha-1 antitrypsin deficiency.


A chest X-ray will help to rule out an alternative lung pathology (for example, lung cancer), which can present with the same symptoms. 

A full blood count can exclude anaemia as a cause of breathlessness and can detect eosinophilia, which will guide the need for ICS therapy (see Case 3).

Case 2: Stefan

Stefan is a 70-year-old retired refuse collector who has smoked 20 cigarettes per day for the past 40 years. He was diagnosed with COPD 1 year ago, and has been using salbutamol delivered via a metered-dose inhaler for relief of symptoms. However, in the last few months, he has become short of breath on exertion most days, and now has to stop several times while walking to and from the newsagents where he normally collects his newspaper. He has not experienced any attacks needing oral steroids or antibiotics.

Questions for Reflection

  1. What GOLD category does Stefan fit into?
  2. What management options should be considered for Stefan?

How to Manage this Patient

Stefan has frequent symptoms that affect his daily activities, but has experienced no exacerbations. Therefore, he falls into GOLD group B. 

Nonpharmacological management options should be considered first, as follows: 

  • Stefan should be assessed for an alternative pathology that may account for his worsening symptoms (for example, heart failure) 
  • any comorbidities should be treated (for example, heartburn) 
  • smoking cessation advice should be offered
  • the presence of hypoxaemia should be investigated using pulse oximetry
  • pulmonary rehabilitation should be considered (especially if his mMRC Dyspnoea Score is greater than or equal to 3)
  • his immunisation status for pneumococcal, influenza, and COVID-19 vaccines should be checked
  • his BMI should be calculated—if he is overweight, dietary advice should be provided; conversely, if his BMI is under 20 mg kg2, consider dietetic advice
  • he should also be asked about symptoms of anxiety or depression.
The GOLD report states that the pharmacological management of ‘group B’ patients should consist of regular dual LABA/LAMA therapy, with the choice of inhaler tailored to the individual patient.

Case 3: Vasily 

Vasily is a 73-year-old retired warehouseman, who smoked 30 cigarettes a day until 10 years ago when he was diagnosed with COPD. He also has borderline hypertension.

He has been using a LABA/LAMA combination dry-powder inhaler, but in the last year has had three severe episodes of breathlessness and productive cough. The latter has not really gone away.

Questions for Reflection

  1. What questions should you ask Vasily?
  2. How should this patient be managed? 

How to Manage this Patient

Vasily is experiencing frequent exacerbations, which have not fully resolved. This should raise the possibility of a significant comorbidity, such as lung cancer or bronchiectasis. Questions should be asked about haemoptysis, hoarse voice, and weight loss, and a chest X-ray should be arranged (and referral for a CT scan if bronchiectasis if suspected). 

In the absence of an alternative significant pathology, the following should be carried out:

  • optimise Vasily’s nonpharmacological therapy (see Case 2), including
    • discussing a written self-management plan in case of further exacerbations
    • rechecking adherence and inhaler technique
  • consider escalating LABA/LAMA therapy to triple LABA/LAMA/ICS therapy, especially if blood eosinophil count is greater than or equal to 100 cells/mcl
  • for patients with a blood eosinophil count lower than 100 cells/mcl, about whom there is diagnostic doubt, or whose symptoms have failed to respond to therapy, consider referral to secondary care.

Case 4: Bindi

Bindi is a 68-year-old retired teacher. An ex-smoker, she was diagnosed with COPD 15 years ago. She is on regular combination LABA/LAMA therapy and salbutamol as required. She comes to the surgery stating that she was looking after her grandchildren last week, one of whom was unwell with a ‘cold’. She has progressive shortness of breath, and has developed a worsening productive cough over the last few days.

Questions for Reflection

  1. How should you assess Bindi?
  2. You consider her fit to manage in primary care. How will you do this? 

How to Manage this Patient

Assessment should include history taking and an examination to exclude other causes of acute cough and dyspnoea, such as pneumonia, pneumothorax, and pulmonary embolism. Temperature, heart rate, respiratory rate, and pulse oximetry should be investigated. Testing for COVID-19 may also be appropriate according to the history. 

Hospital admission should be considered for an acute exacerbation of COPD if there are signs of respiratory distress (for example, a respiratory rate higher than 24 breaths per minute, indrawing of the intercostal muscles, a pulse rate in excess of 95 beats per minute, or an oxygen saturation of less than 90%), especially if there are significant comorbidities and/or contributory social circumstances.

Initial management in primary care should consist of increasing the frequency of delivery of short-acting bronchodilator therapy (for example, one or two puffs of a short-acting bronchodilator given via a large volume spacer every hour for two or three doses, then every 2–4 hours until symptoms improve).

Oral prednisolone (40 mg/day for 5 days) can reduce the duration of the exacerbation, and a 5-day course of oral antibiotics should be given if there is increase in sputum purulence and/or volume associated with the increase in dyspnoea. 

Follow up should be arranged soon after the onset of the acute attack, and a formal review within 4 weeks, to minimise the risk of further exacerbations.

GOLD=Global Initiative for Chronic Obstructive Lung Disease; COPD=chronic obstructive pulmonary disease; ICS=inhaled corticosteroid; mMRC=modified Medical Research Council; BMI=body mass index; LABA=long-acting beta2 agonist; LAMA=long-acting anti-muscarinic agent; CT=computed tomography