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. 2024 Jan 5;13(2):303. doi: 10.3390/jcm13020303

Table 1.

Follow-up activities in patients with COPD coordinated between the different care settings. Adapted from SEMERGEN, SEPAR, semFYC, SEMG, SEFAC, GRAP. Referral criteria in COPD. Continuity of care. IMC 2023 [6].

Clinical Evaluation
Disease control (symptoms and exacerbations) Clinical Control Questionnaire for COPD

  • - Patient’s status compared to the previous visit

  • - Exacerbations in the last 3 months

  • - Excessive use of rescue medication

  • - Evaluation of sputum (Murray Scale)

  • - Exercise in the last week

  • - Dyspnoea degree and cause (mMRC Scale)
Patient’s quality of life CAT Test
Assessment of body mass index (BMI) Both obesity (BMI > 30 kg/m2) and malnutrition (BMI < 18.5 kg/m2) are associated with a worse prognosis in COPD.
Monitoring the appearance or presence of what it calls “treatable features” associated with COPD Alpha-1 antitrypsin deficiency, dyspnea, chronic bronchitis, severe emphysema and pulmonary hyperinflation, chronic bronchial infection, bronchiectasis, precapillary pulmonary hypertension, chronic respiratory insufficiency, cachexia.
Complementary tests
Lung function Forced spirometry
Determination of blood pressure, heart rate, and oxygen saturation In the case of chronic respiratory failure (arterial blood gas: PaO2 < 60 mmHg and/or PaCO2 > 45 mmHg), consider continuous home oxygen therapy or non-invasive ventilation.
Treatment
Treatment adherence and evaluation (response and adverse effects) Follow-up with the TAI questionnaire and record of medication withdrawn from the electronic prescription.
Inhaler technique review Every 2 months to check patient’s satisfaction and ensure appropriate.
Review of vaccination status Influenza, SARS-CoV-2, pneumococcal, herpes zoster and tetanus, diphtheria, and pertussis (Tdap).
Health education
Nutritional status
Recommendation for regular physical activity adapted to the clinical situation Calculation of the level of physical activity using the brief CGPPAQ-EGPPAQ2 questionnaire (Spanish version of the Brief Physical Activity Assessment Tool) and assessment of sedentary time (hours/day).
Persistence of active smoking Address smoking cessation, and if not achieved, refer to the Smoking Cessation Service.

BMI, body mass index; CAT, COPD assessment test; COPD, chronic obstructive pulmonary disease; mMRC, modified Medical Research Council; PaCO2, partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen; TAI, test of adherence to inhalers.