Management of COPD Based on CAT Score
The management of COPD should be guided by the CAT score, with patients having a CAT score ≥10 considered highly symptomatic and requiring more intensive treatment, while those with CAT <10 require less intensive management. 1
Understanding the CAT Score
The COPD Assessment Test (CAT) is a validated 8-item questionnaire that measures the impact of COPD symptoms on a patient's life. The items include:
- Cough
- Phlegm
- Chest tightness
- Breathlessness
- Limited activities
- Confidence leaving home
- Sleeplessness
- Energy
Each item is scored from 0-5, with a total score ranging from 0-40. Higher scores indicate greater symptom burden.
COPD Classification Using CAT
The CAT score is used alongside exacerbation history to classify patients into GOLD categories:
| Category | Symptoms | Exacerbation Risk |
|---|---|---|
| A | Low (CAT <10) | Low (0-1 per year, no hospitalizations) |
| B | High (CAT ≥10) | Low (0-1 per year, no hospitalizations) |
| C | Low (CAT <10) | High (≥2 per year or ≥1 hospitalization) |
| D | High (CAT ≥10) | High (≥2 per year or ≥1 hospitalization) |
Treatment Algorithm Based on CAT Score and GOLD Category
Group A (CAT <10, Low Exacerbation Risk)
- Start with a short-acting bronchodilator (SABA or SAMA) as needed
- Evaluate effect before continuing, stopping, or trying an alternative class 2
Group B (CAT ≥10, Low Exacerbation Risk)
- Start with a long-acting bronchodilator (LAMA or LABA)
- If symptoms persist, use LAMA+LABA combination 2
Group C (CAT <10, High Exacerbation Risk)
- Start with a LAMA
- Consider roflumilast if FEV1 <50% predicted with chronic bronchitis
- Escalate to LAMA+LABA or LABA+ICS if further exacerbations occur 2
Group D (CAT ≥10, High Exacerbation Risk)
- Start with LAMA or LAMA+LABA
- Consider LABA+ICS for patients with blood eosinophil counts suggesting steroid-responsive inflammation
- Escalate to triple therapy (LAMA+LABA+ICS) for persistent symptoms or exacerbations 2
Non-Pharmacological Management
Regardless of CAT score, all COPD patients should receive:
- Smoking cessation support (most important intervention for slowing disease progression)
- Annual influenza vaccination and pneumococcal vaccination
- Pulmonary rehabilitation (especially beneficial for those with CAT ≥10)
- Nutritional assessment and support as needed 2
Monitoring CAT Score Response to Treatment
- A decrease of 2 points in CAT score is considered clinically relevant improvement 3
- After pulmonary rehabilitation, mean improvement in CAT score is approximately 2.9 points 4
- CAT score remains improved at 6 months after pulmonary rehabilitation 5
Special Considerations
- Some patients may have discordant CAT and mMRC scores. A CAT score of 10 is most compatible with an mMRC score of 1 6
- When there is discordance between CAT and mMRC scores, it's recommended to use both tools to avoid misclassification of patients 6
- Non-respiratory CAT items (limited activities, confidence leaving home, sleeplessness, energy) significantly contribute to the total score and should not be overlooked 3
Management of Exacerbations
During exacerbations:
- Increase dose or frequency of bronchodilators
- Add antibiotics if increased sputum purulence is present
- Consider a short course of oral corticosteroids (0.4-0.6 mg/kg daily) if marked wheeze is present
- Consider hospitalization for severe exacerbations 2
Pitfalls to Avoid
- Underutilizing pulmonary rehabilitation despite proven benefits
- Inappropriate use of inhaled corticosteroids in patients without frequent exacerbations
- Failing to regularly assess and correct inhaler technique
- Not addressing comorbidities that contribute to symptoms and exacerbations
- Neglecting psychological symptoms which are highly prevalent in COPD 2
The CAT score provides a comprehensive assessment of COPD symptom burden and should be regularly monitored to guide treatment decisions and evaluate response to interventions.