What questions should I ask a newly referred patient with chronic obstructive pulmonary disease (COPD) during a pulmonary referral?

Essential Questions for New COPD Pulmonary Referral

When evaluating a newly referred COPD patient, your assessment should systematically address disease severity, treatment optimization needs, and identification of complications or alternative diagnoses that prompted the referral.

Core Assessment Areas

1. Confirm Diagnosis and Severity

• Spirometry confirmation: Verify post-bronchodilator FEV₁/FVC ratio and FEV₁ % predicted to classify severity (mild ≥80%, moderate 50-80%, severe 30-50%, very severe <30%) 1, 2
• Age at diagnosis: If patient is under 40 years old, specifically inquire about family history and consider alpha-1 antitrypsin deficiency screening 1
• Smoking history: Document pack-years (particularly note if <10 pack-years, which warrants early intervention) 1
• Rapid decline: Ask about rate of FEV₁ decline—a loss of 500 mL over 5 years indicates rapidly progressing disease requiring specialist management 1

2. Symptom Burden Assessment

Use the Modified Medical Research Council (mMRC) Dyspnea Scale 2, 3:

• Grade 0: Breathless only with strenuous exercise
• Grade 1: Short of breath when hurrying/walking uphill
• Grade 2: Walks slower than peers or stops for breath at own pace
• Grade 3: Stops for breath after 100m or few minutes
• Grade 4: Too breathless to leave house or breathless dressing

Additional symptom queries:

• Chronic cough and sputum production (volume, color, purulence) 4
• Frequency of wheezing and chest tightness 1
• Exercise tolerance and activities of daily living limitations 4

3. Exacerbation History

• Number of exacerbations in the past year (≥2 exacerbations or ≥1 hospitalization indicates high risk) 2
• Frequency of infections—if frequent, consider bronchiectasis 1
• Triggers for exacerbations
• Previous ICU admissions or need for mechanical ventilation

4. Complications and Comorbidities

Specifically assess for:

• Cor pulmonale: Peripheral edema, elevated jugular venous pressure, signs of right heart failure 1
• Depression: Directly screen, as it significantly impacts management 1
• Weight and nutrition: Document BMI (values <21 kg/m² associated with increased mortality) 2
• Cardiovascular disease, diabetes, osteoporosis and other comorbidities that affect prognosis 2

5. Current Treatment Evaluation

• Inhaler technique: Directly observe—poor technique is a common pitfall 1
• Current medications: Bronchodilators (LABA, LAMA), inhaled corticosteroids, oral corticosteroids
• Appropriateness of nebulizer use (if prescribed—many are inappropriate) 1
• Long-term oral corticosteroid use: If present, justify need or plan withdrawal 1
• Treatment adherence and understanding of regimen 1

6. Oxygen and Ventilation Needs

• Hypoxemia assessment: Ask about current oxygen use and cylinder consumption (>2 cylinders/week warrants formal assessment) 1
• Daytime symptoms of hypercapnia (headaches, confusion)
• Sleep-disordered breathing symptoms
• Note: Long-term oxygen therapy (LTOT) requires objective documentation of PaO₂ <7.3 kPa (55 mmHg) or SaO₂ ≤88% 1, 5

7. Functional Status and Social Circumstances

• Functional capacity: Ability to perform activities of daily living, employment status 1
• Social support availability: Living situation, caregiver support 1
• Travel plans: Particularly air travel (hazardous if PaO₂ <6.7 kPa) 1
• General condition and level of activity 1

8. Smoking Status

• Current smoking status
• Readiness to quit
• Previous cessation attempts and methods used 1

9. Red Flags Requiring Immediate Attention

• Symptoms disproportionate to lung function: Suggests alternative or additional diagnoses 1
• Bullous disease: Assess for recurrent pneumothoraces or isolated bullae (surgical candidates) 1
• Unexplained weight loss or hemoptysis: Consider lung cancer
• Unilateral symptoms: Think pneumothorax, pneumonia, pulmonary embolism 1

10. Rehabilitation and Advanced Care Planning

• Prior pulmonary rehabilitation: If not done and patient has moderate-to-severe disease, this is a priority referral 1
• Vaccination status: Influenza and pneumococcal vaccines 1, 5
• Advance directives: Discuss goals of care, particularly in severe disease 5

Common Pitfalls to Avoid

• Don't rely on peak flow alone—there is discordance between PEF and FEV₁ in COPD 1
• Don't assume all breathlessness is COPD—consider left ventricular failure, pulmonary embolism, anemia 1
• Don't overlook depression—it's common and treatable but often missed 1
• Don't prescribe LTOT without objective hypoxemia documentation 1, 5

This structured approach ensures you address the specific reasons for specialist referral 1 while comprehensively evaluating factors that impact mortality, morbidity, and quality of life.