C3. Assessing the severity of COPD

Spirometry is the most reproducible, standardised and objective way of measuring airflow limitation, and FEV1 is the variable most closely associated with prognosis (Peto 1983). The grades of severity according to FEV1 and the likely symptoms and complications are shown in Box 4. However, it should be noted that some patients with an FEV1 >80% pre­dicted, although within the normal range, may have airflow limitation (FEV1/FVC ratio <70%).

A Spanish cohort study of 611 COPD patients found that the British Thoracic Society classification (which is very similar to Box 4) had the optimal sensitivity and specificity against the criterion of all cause and respiratory mortality over 5 years (Esteban 2009). There were also significant differences in health-related quality of life (HRQoL) between different stages of the disease [evidence level III-2].

Exacerbations are an important complication of COPD (see X: Manage eXacerbations). The future risk of exacerbations should be assessed in patients with COPD. Exacerbations are more frequent with increased severity of COPD. The most important risk factor for exacerbations is a history of past exacerbations; other factors include gastro-oesophageal reflux, poorer quality of life and elevated white cell count (Hurst 2010). A systematic literature review that included data from 76 studies confirmed that a past history of exacerbations is the most important predictor of future exacerbation risk (Hurst 2022) [evidence level I].

Box 4: Classification of severity of chronic obstructive pulmonary disease (COPD)




Typical Symptoms Few symptoms Breathless walking on level ground Breathless on minimal exertion
Breathless on moderate exertion Increasing limitation of daily activities Daily activities severely curtailed
Cough and sputum production Recurrent chest infections Exacerbations of increasing frequency and severity
Little or no effect on daily activities Exacerbations requiring oral corticosteroids and/or antibiotics
Typical Lung Function FEV1 ≈ 60-80% predicted FEV1 ≈ 40-59% predicted FEV1 < 40% predicted
FEV1=forced expiratory volume in one second. PaO₂=partial pressure of oxygen, arterial. PaCO₂=partial pressure of carbon dioxide, arterial.

Box 4 adapted from Lung Foundation Australia’s Stepwise Management of Stable COPD available at https://lungfoundation.com.au/resources/?search=stepwise&condition=9