COPD GUIDELINES DIAGNOSIS >35 years of age Symptoms of cough, breathlessness, sputum, wheeze, Risk factor (SMOKING) Spirometry (post bronchodilator) FEV1/FVC = 0.7 ENCOURAGE PATIENTS TO BRING INHALERS IN FOR REVIEW CHECK IF OVER/UNDER ORDERING CHECK ADHERENCE CHECK INHALER TECHNIQUE CHECK AEROCHAMBER IS WASHED STEP DOWN HIGH DOSE ICS/LABA BEFORE STEPPING UP CHECK THE FOLLOWING INHALER TECHNIQUE: CAN THEY USE IT? ARE THEY USING IT? TRY ALTERNATIVE i.e. if initiated on LAMA but no symptom relief try LABA or vice versa. REFER TO PULMONARY REHAB IF MRC GRADE 3 AND ABOVE BMI OF THE PATIENT- An increase may explain breathlessness CO-MORBIDITIES ASTHMA COPD OVERLAP SYNDROME (ACOS): confirm diagnosis and treatment SMOKING CESSATION Offer: More Evidence Consider: Less Evidence Initial Treatment (NICE FEV1>80 or GOLD A) SABA OR SAMA SABA: VENTOLIN EVOHALER (SALBUTAMOL) SAMA: ATROVENT IPRATROPIUM Still symptomatic- regular treatment (NICE FEV1 > 50% or GOLD B) Offer LAMA (discontinue SAMA) OR LABA LAMA: TIOTRPOIUM (SPIRIVA) OR ACLIDINIUM (EKLIRA) LABA: FORMOTEROL (ATIMOS MODULITE OR EASYHALER DPI ) OR SALMETEROL SPIOLTO DUAKLIR ANORO ULTIBRO (Tiotropium/Olodaterol) (Aclidinium/Formoterol) (Umeclidinium/Vilanterol) (Glycopyrronium/Indacaterol) Still symptomatic Consider LAMA + LABA Still symptomatic AND MORE THAN 2 EXACERBATIONS PER YEAR (NICE <50% or GOLD B OR C) Consider Continuing LAMA+LABA OR Switch to LABA+ICS DuoResp Spiromax 320/9 DPI Fostair pmdi 200/6 or 100/6 Seretide Accuhaler 500 Symbicort Turbohaler 400/12 PERSISTENT EXACERBATIONS (NICE Persistent Breathlessness or GOLD D) Consider (LABA+ICS) AND LAMA (TRIPLE THERAPY) **NOTE** ICS not licensed as individual devices for COPD. Any addition of ICS must be given as a combination device with LABA so LABA/LAMA combination would not be appropriate
With acknowledgements to PrescQIPP NHS https://www.prescqipp.info/
EXACERBATION: RESCUE PACKS FOR COPD Definition of an exacerbation: 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. Reported Symptoms are worsening: Breathless ness Cough Increased sputum production Change in sputum colour Oral Corticosteroids: Increase Of Breathlessness PREDNISOLONE 30MG DAILY 7-14 DAYS IF WHEEZY Antibiotics: If Purulent Sputum, With Change In Colour(Green/Yellow) Amoxicillin 500mg TDS OR Doxycycline 200mg stat 100mg OD 5 DAY COURSE OR Clarithromycin 500mg BD WECCG Respiratory Winter Plan.pdf Patient information leaflet Recognising a flare-up or exacerbation with Action Plan CONSIDER REFERRAL FOR SPECIALIST ADVICE IF: Diagnostic uncertainty Wheezy despite adherence checked and inhaler optimisation & technique check Dysfunctional breathing or excessive cough Bronchiectasis Check Immune system Pneumococcal Antibodies PROVIDE: Smoking cessation advice Vaccines: influenza & pneumococcal recommended Oxygen Long Term (>15 hrs per day) www.britthoracic.org.uk Pulmonary Rehabilitation: (MRC grade 3 or more) Steroid treatment card: If using prolonged high doses of ICS MUCOLYTICS: Carbocisteine is the only oral mucolytic licensed for use in people with chronic obstructive pulmonary disease Only prescribe to treat phlegm Carbocisteine 750mg tds trialled for 4 weeks Discontinue if no effect If effective reduce to 750mg bd maintenance dose With acknowledgements to PrescQIPP NHS https://www.prescqipp.info/