Part I: Identifying chronic obstructive pulmonary disease in patients with respiratory symptoms.

Chronic obstructive pulmonary disease (COPD) is a common and underdiagnosed disease that is a major cause of disability and death in the US and abroad. A more aggressive approach to managing COPD in primary care is critical to improving outcomes in patients with COPD. Since asthma is usually the main condition considered in the differential diagnosis of COPD, a thorough knowledge of the differences between asthma and COPD is particularly important. A careful history, a thorough physical examination, and the early use of spirometry may help identify patients earlier in the course of the disease. Smoking cessation remains a mainstay of COPD therapy. Other nonpharmacologic therapy includes avoidance of risk factors, patient education, pulmonary rehabilitation and, when necessary, oxygen therapy. Once COPD has been diagnosed, pharmacologic treatment depends on symptoms as well as the severity of disease. Therapy for mild disease includes smoking cessation and the use of short-acting bronchodilators as needed. Pharmacotherapy for moderate and severe disease typically includes one or more long-acting bronchodilators in addition to the treatment already described for mild disease. Inhaled corticosteroids are indicated in severe and very severe patients with recurrent exacerbations. Long-term oxygen therapy is indicated for all patients with documented hypoxemia. Patients with severe and very severe disease should receive pulmonary rehabilitation, and in patients with very severe disease, lung transplantation or other surgical treatment, such as lung volume reduction surgery or bullectomy, should be considered for appropriate patients.