0 Chronic obstructive pulmonary disease Implementing NICE guidance June 2010 NICE clinical guideline 101
What this presentation covers Background Scope Key priorities for implementation Discussion Find out more
Background Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment An estimated 3 million people have chronic pulmonary disease (COPD) in the UK, though many remain undiagnosed COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term
Scope The scope for the guideline update was to examine: a) Diagnosis and severity classification: spirometry and post-bronchodilator values multidimensional severity assessment indices (for example, the BODE index) a) Management of stable COPD and prevention of disease progression long-acting bronchodilators: beta 2 agonists and anticholinergics (tiotropium, formoterol fumarate, salmeterol) as monotherapy and in combination, both with and without inhaled corticosteroids mucolytic therapy (carbocisteine and mecysteine hydrochloride) BODE = body mass index, airflow obstruction, dyspnoea and exercise tolerance
Definition of COPD Airflow obstruction is defined as reduced FEV 1 /FVC ratio (< 0.7) It is no longer necessary to have an FEV 1 < 80% predicted for definition of airflow obstruction If FEV 1 is 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough FEV 1 = forced expiratory volume in 1 second FVC = forced vital capacity
Diagnose 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 [2004]
Diagnose COPD: 2 The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry [new 2010] All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results [2004]
Diagnose COPD: 3 Assess severity of airflow obstruction using reduction in FEV 1 NICE clinical guideline 12 (2004) ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101 (2010) Postbronchodilator FEV 1 /FVC FEV 1 % predicted Postbronchodilator Postbronchodilator Postbronchodilator < 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)* < 0.7 50 79% Mild Moderate Stage 2 (moderate) Stage 2 (moderate) < 0.7 30 49% Moderate Severe Stage 3 (severe) Stage 3 (severe) < 0.7 < 30% Severe Very severe Stage 4 (very severe)** * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV 1 < 50% with respiratory failure Stage 4 (very severe)** [new 2010]
Stop smoking Encouraging patients with COPD to stop smoking is one of the most important components of their management All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity Record a smoking history, including pack years smoked Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [2010] [2004]
Promote effective inhaled therapy In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: if FEV 1 50% predicted: either LABA or LAMA if FEV 1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV 1 [new 2010] ICS = inhaled corticosteroid LABA = long-acting beta 2 agonist LAMA = long-acting muscarinic agonist
Use of inhaled therapies Breathlessness and exercise limitation SABA or SAMA as required* Exacerbations or persistent breathlessness FEV 1 50% FEV 1 < 50% LABA LAMA Discontinue SAMA 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 Discontinue SAMA Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness Offer Consider LABA + ICS in a combination inhaler Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler * SABAs (as required) may continue at all stages
Provide pulmonary rehabilitation Make available to all appropriate people, including those recently hospitalised for an acute exacerbation Tailor multi-component, multidisciplinary interventions to individual patient s needs Pulmonary rehabilitation An individually tailored multidisciplinary programme of care to optimise patients physical and social performance and autonomy Hold at times that suit patients, and in buildings with good access Offer to all patients who consider themselves functionally disabled by COPD [new 2010]
Use non-invasive ventilation (NIV) Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy NIV should be delivered by staff trained in its application, experienced in its use and aware of its limitations When starting NIV, make a clear plan covering what to do in the event of deterioration and agree ceilings of therapy [2004]
Managing exacerbations Minimise impact of exacerbations by: - giving self-management advice on responding promptly to symptoms of exacerbation - starting appropriate treatment with oral steroids and/or antibiotics - use of non-invasive ventilation when indicated - use of hospital-at-home or assisted-discharge schemes The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations [2004]
Multidisciplinary working COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists Consider referral to specialist departments (not just respiratory physicians) Specialist department Physiotherapy Dietetic advice Occupational therapy Social services Multidisciplinary palliative care teams Who might benefit? People with excessive sputum People with BMI that is high, low or changing over time People needing help with daily living activities People disabled by COPD People with end-stage COPD (and their families and carers) [2004]
Discussion How can we improve identification and diagnosis of people over 35 who have a risk factor? How does our use of spirometry compare with the recommendations? How will our prescribing practice need to change? What pulmonary rehabilitation services are available? How do we minimise the risk of exacerbations for our patients?
Find out more Visit www.nice.org.uk/cg101 for: the guideline the quick reference guide Understanding NICE guidance costing report audit support NICE is developing a Quality Standard for COPD which will be published in 2011