JOINT CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) MANAGEMENT GUIDELINES

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1 JOINT CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) MANAGEMENT GUIDELINES Authors Dr Ian Benton Respiratory Consultant COCH Penny Rideal Respiratory Nurse COCH Kirti Burgul Respiratory Pharmacist COCH Pam Abbott Prescribing Support Pharmacist Date Issued 4/10/12 Review Date 4/10/14

2 Joint Guidelines for Chronic Obstructive Pulmonary Disease (COPD) Contents Page Diagnosing COPD 2 COPD algorithm: use of inhaled therapies 3 Follow up and review of patients with COPD in 4 primary care Managing Exacerbations of COPD 5 Referral for specialist advice 6 Appendix 1 7 References 8

3 Diagnosing Chronic Obstructive Pulmonary Disease - COPD Consider a diagnosis of COPD for people who are: over 35, and smokers or ex-smokers, and have any of these symptoms: - exertional breathlessness - chronic cough - regular sputum production - frequent winter bronchitis - wheeze and do not have clinical features of asthma Perform initial diagnostic evaluation if COPD seems likely: o post-bronchodilator spirometry -record absolute and percentage of predicted values (if >400ml response consider asthma) o chest X-ray to exclude other diagnoses o full blood count to identify anaemia or polycythaemia o body mass index (BMI) calculation Assess severity of airflow destruction NICE clinical guideline 101 (2010) Post-bronchodilator FEV 1 /FVC FEV 1 % predicted Post-bronchodilator <0.7 80% Stage 1 Mild * < % Stage 2 - Moderate < % Stage 3 - Severe <0.7 <30% Stage 4 Very Severe ** * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV 1 <50% with respiratory failure Consider alternative diagnoses in older people without typical symptoms of COPD and FEV1/ FVC ratio < 0.7, and younger people with symptoms of COPD and FEV1/ FVC ratio 0.7 Spirometric reversibility testing is not usually necessary as part of the diagnostic process or to plan initial If no doubt, diagnose COPD and start treatment If still in doubt, make a provisional diagnosis and start empirical treatment Reassess diagnosis in view of response to treatment: o Clinically significant COPD is not present if FEV1 and FEV1/ FVC ratio return to normal with drug o Refer for more detailed investigations if needed For all people with diagnosed COPD o Highlight the diagnosis of COPD in the notes and computer database (using Read codes) o Record the results of spirometric tests at diagnosis absolute and percentage of predicted values FEV 1 Forced expiratory volume in 1 second FVC Forced vital capacity

4 COPD algorithm: use of inhaled therapies 1 At all steps in the algorithm, BEFORE considering medication changes ask about: Smoking status encourage to stop and offer help at every opportunity Check inhaler technique Adherence to medication Screen for anxiety and depression HAD score Breathlessness and/or exercise limitations Exacerbations or persistent breathlessness REVIEW SABA* or SAMA as required FEV 1 50% FEV 1 <50% LABA Exclude diagnosis of asthma if LABA without ICS LAMA** Offer LAMA in preference to regular SAMA four times a day LABA+ICS in a combination inhaler Consider LABA+LAMA if ICS declined or not tolerated LAMA** Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness REVIEW LABA+ICS in a combination inhaler Consider LABA+LAMA if ICS declined or not tolerated REVIEW LAMA+LABA+ICS If poor symptom control at any stage consider referral consider offer * SABA as required may continue at all stages ** Discontinue SAMA When initiating high dose ICS (>800 microgram beclometasone or equivalent per day) or reviewing existing patients Discuss the risk of pneumonia Issue a steroid card Consider bone protection SABA=short-acting beta 2agonist; SAMA=short-acting muscarinic antagonist; LABA=long-acting beta 2agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid: HAD score = Hospital Anxiety & Depression score

5 Follow-up and review of patients with COPD in primary care Review people with mild, moderate or severe COPD at least once a year and those with very severe COPD at least twice a year. Cover the assessments and measurements as below: Ask about the following factors where COPD is suspected: weight loss effort intolerance ankle swelling fatigue haemoptysis chest pain occupational hazards waking at night For all stages of disease assess: Smoking status and desire to quit Inhaler technique and compliance Adherence to medication Adequacy of symptom control: o Breathlessness o exercise tolerance o estimated exacerbation frequency Presence of complications including cor pulmonale Effects of each drug treatment Check annual flu and pneumococcal vaccinations up to date Presence of anxiety or depression - HAD score if appropriate Need for pulmonary rehabilitation Need for social services and occupational services Need for referral to specialist and services Need for LTOT Discuss advanced care planning Measure: FEV 1 and FVC BMI check diet & exercise MRC dyspnoea score 2 Oxygen saturation of arterial blood if SpO 2 92% breathing air

6 Managing Exacerbations of COPD Definition of an exacerbation An exacerbation is a sustained worsening of the patient s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production, and change in sputum colour. The change in these symptoms often necessitates a change in medication. Initial Management Increase frequency of bronchodilator use after reviewing inhaler technique Oral antibiotics if purulent sputum or clinical signs of pneumonia (refer to current Management of Infection guidelines for Primary Care ) Prednisolone 30 mg daily for 7-14 days unless contraindicated (no advantage in prolonging ) Decide where to manage (see table below) Home Investigations Sputum culture not normally recommended Pulse oximetry assess in context to patients normal SpO 2 values Further management Arrange appropriate review Establish on optimal Arrange multidisciplinary assessment if necessary Give clear instructions Factors to consider when deciding where to manage patient Factor Able to cope at home Favours treatment at home Favours treatment in hospital Breathlessness Mild Severe General Condition Level of activity Good Good Cyanosis Worsening peripheral oedema Level of consciousness Already receiving LTOT Social circumstances Acute confusion Rapid rate of onset Significant comorbidity (particularly cardiac and insulin dependent diabetes) rmal Good Poor Deteriorating Poor/confined to bed Impaired Living alone / not coping SpO 2 < 92% Changes on the chest radiograph Arterial ph level Present 7.35 < 7.35 Arterial Pao 2 7kPa <7 kpa Hospital Investigations and management refer to NICE CG101 Further management Arrange appropriate review Establish on optimal Arrange multidisciplinary assessment if necessary Assess need for rescue pack medication Give clear instructions

7 Referral for specialist advice It is recommended that referrals for specialist advice are made when clinically indicated. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled patients. Reason Diagnostic uncertainty Onset of cor pulmonale Assessment for oxygen Assessment for long-term nebuliser Assessment for oral corticosteroid Bullous lung disease A rapid decline in FEV 1 Assessment for pulmonary rehabilitation Assessment for lung volume reduction surgery Assessment for lung transplantation Dysfunctional breathing Aged under 40 years or a family history of alpha 1 antitrypsin deficiency Purpose Confirm diagnosis and optimise Confirm diagnosis and optimise Optimise and measure blood gases Optimise and exclude inappropriate prescriptions Justify need for long-term treatment or supervise withdrawal Identify candidates for pulmonary rehabilitation Encourage early intervention Identify candidates Identify candidates for surgery Identify candidates for surgery Confirm diagnosis, optimise pharmaco and access other therapists. Identify alpha 1 antitrypsin deficiency, consider and screen family Symptoms disproportionate to lung function deficit Haemoptysis Reconsider diagnosis If carcinoma of the bronchus suspected refer urgently

8 Appendix 1 MRC (Medical Research Council) dyspnoea scale 2 The Modified Medical Research Council Dyspnea Scale, or MRC, uses a simple grading system to assess a patient's level of dyspnoea -- shortness of breath. Spirometry objectively measures airflow limitation but may not correlate with the impact of dyspnoea on exercise performance. MRC Dyspnoea Scale Grade Description of Breathlessness 1 t troubled by breathlessness except on strenuous exercise. 2 I get short of breath when hurrying on level ground or walking up a slight hill. 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on level ground. 5 Too breathless to leave the house, or breathless when dressing or undressing Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2:

9 References: 1. National Institute for Health & Clinical Excellence (NICE) - Chronic obstructive pulmonary disease in adults in primary and secondary care (2010 update) accessed June National Institute for Health & Clinical Excellence (NICE). MRC dyspnoea scale accessed June tationserviceforpatientswithcopd/mrc_dyspnoea_scale.jsp

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