What questionnaires are used in the management of Chronic Obstructive Pulmonary Disease (COPD)?

Questionnaires Used in COPD Management

The primary questionnaires recommended for routine COPD assessment are the modified Medical Research Council (mMRC) dyspnea scale, the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ), with mMRC and CAT being the most widely endorsed by international guidelines. 1, 2, 3

Core Symptom Assessment Tools

Modified Medical Research Council (mMRC) Dyspnea Scale

• The mMRC is a simple 5-point scale (0-4) that specifically measures breathlessness severity 1, 3
• A threshold of mMRC ≥2 separates "less breathlessness" from "more breathlessness" and identifies patients requiring more intensive treatment 1, 2, 3
• The scale grades dyspnea from Grade 0 (breathless only with strenuous exercise) to Grade 4 (too breathless to leave the house or breathless when dressing) 1
• mMRC scores ≥2 predict increased mortality in COPD patients 1

COPD Assessment Test (CAT)

• The CAT is an 8-item comprehensive questionnaire that assesses the full impact of COPD beyond just dyspnea, including cough, sputum, chest tightness, activity limitation, sleep, and energy 1, 3, 4
• A CAT score ≥10 indicates significant symptom burden and is the standard threshold for identifying high-symptom patients 1, 2, 3
• The CAT is responsive to exacerbations, with scores rising significantly during acute events and correlating with exacerbation severity and duration 5
• CAT scores correlate with lung function changes during exacerbations (rho = -0.20, P = 0.032) 5

Clinical COPD Questionnaire (CCQ)

• The CCQ is recommended by GOLD guidelines as an alternative comprehensive assessment tool with a threshold of ≥1 for high symptoms 1, 4
• The CCQ has been validated across chronic respiratory diseases, not just COPD 6
• The minimum important difference for the CCQ is -0.4 at the individual patient level 6
• The CCQ shows strong correlation with other quality-of-life measures (r = 0.53 with CAT, -0.64 with CRQ) 6

Comprehensive Health Status Questionnaires

St. George's Respiratory Questionnaire (SGRQ)

• The SGRQ is a comprehensive disease-specific questionnaire with domains covering symptoms, activity, and psychosocial impact 1, 7
• SGRQ scores ≥25 are uncommon in healthy persons and indicate significant disease impact 1
• The SGRQ has established thresholds for clinical significance and demonstrates improvement after pulmonary rehabilitation 1
• While highly validated, the SGRQ is too complex for routine clinical practice but valuable for research and specialized assessments 1

Chronic Respiratory Questionnaire (CRQ)

• The CRQ measures four domains: dyspnea, fatigue, emotion, and mastery 1, 7
• The CRQ has both operator-administered and self-administered versions available 1
• Like the SGRQ, the CRQ is too lengthy for routine clinical use but demonstrates beneficial changes after pulmonary rehabilitation 1

Multidimensional Prognostic Indices

BODE Index

• The BODE index combines Body mass index, airflow Obstruction (FEV1), Dyspnea (mMRC), and Exercise capacity (6-minute walk distance) 1, 2
• The BODE index is particularly recommended in Spanish and French guidelines for comprehensive assessment and mortality prediction 2
• This composite index provides superior prognostic accuracy compared to FEV1 alone 1

BODEx Index

• The BODEx substitutes exercise capacity with exacerbation history, making it more practical for patients with COPD stages I-II 2
• This modification eliminates the need for 6-minute walk testing while maintaining prognostic value 2

Practical Implementation Algorithm

For routine clinical assessment, follow this sequence:

1. Use mMRC or CAT for initial symptom assessment - mMRC if focusing primarily on breathlessness, CAT for comprehensive symptom evaluation 1, 3, 4

2. Apply the threshold of mMRC ≥2 or CAT ≥10 to identify high-symptom patients requiring intensified therapy 1, 2, 3

3. Document exacerbation history - the number of exacerbations in the past year is the best predictor of future events 1, 2, 3

4. For moderate to severe COPD, consider BODE or BODEx for more comprehensive risk stratification and mortality prediction 2

5. Reserve SGRQ and CRQ for specialized assessments, pulmonary rehabilitation programs, or research settings 1

Critical Pitfalls to Avoid

• Do not rely solely on spirometry (FEV1) to assess disease impact - lung function correlates poorly with symptom burden and quality of life 4, 8
• Patients often underreport symptoms because they unconsciously reduce activities to avoid dyspnea; structured questionnaires capture this hidden burden 7
• Baseline CAT scores are significantly higher in frequent exacerbators (19.5 vs 16.8, P = 0.025), making it useful for risk stratification 5
• Quality-of-life questionnaires from 1995 were not yet validated for routine clinical practice at that time, but current tools (CAT, CCQ, mMRC) now have robust validation 1