Furnace House SurgeryFurnace House SurgeryChronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease

ProtocolProtocol

Date: 13Date: 13thth April 2005 April 2005Review Date: April 2006Review Date: April 2006Acknowledgement: Sarah HicksAcknowledgement: Sarah Hicks

Aims and objectives of this protocolAims and objectives of this protocol..

• to improve COPD care in this Practice • to reduce emergency admissions to hospital due to

COPD • to improve quality of life in COPD patients • to improve patient education • to encourage patients to take responsibility for their own

COPD management

Definition of COPDDefinition of COPD

• A collection of conditions that share the features of chronic obstruction of expiratory flow, e.g. chronic bronchitis, emphysema, chronic obstructive airways disease, chronic airflow obstruction and some cases of chronic asthma which have resulted in irreversible lung destruction.

• slow progressive condition characterised by marked airways obstruction that does not change markedly over time.

Each patient will have varying proportions ofEach patient will have varying proportions of::

• Chronic bronchitis with increased and airway wall inflammation;

• small or peripheral airways disease increased mucus, airway wall thickening, scarring and narrowing

• emphysema permanent destruction of the alveoli, airspaces distal to the terminal bronchiole. On lung expansion, elastic recoil is reduced and pressure to drive expiration is lost. There is also a drop in intraluminal pressure needed to maintain airway patency during forced exhalation (demonstrated by lip pursing).

PresentationPresentation

• smoked for at least 20 pack years • Usually present in the fifth decade with a productive

cough or an acute respiratory complaint.

• By the sixth or seventh decade, exertional dyspnoea is

usually a feature and intervals between acute

exacerbations become shorter • earlier stages, slow, laboured expiration, plus wheezing

on forced expiration may be apparent • Can result in hyperventilation and a gradual increase in

the anteroposterior diameter of the chest.

CausesCauses

The underlying causes of COPD yet to be fully elucidated but include:

• cigarette smoking, with other types of tobacco smoking also being

strong risk factors

• heavy exposure to occupational dusts and chemicals (vapours, irritants and fumes)

• indoor and outdoor air pollution.

• Alpha-1 Antitrypsin Deficiency (very small minority)

Disease classificationDisease classification

severity of disease rather than presumed underlying causes. The objective measure used for this and monitoring progression of the disease is Forced Expiratory Volume in one second (FEV 1).

Severity of Airflow Obstruction FEV1% predicted

• Mild 50 – 80• Moderate 30 – 49• Severe <30

Making a DiagnosisMaking a Diagnosis

Think of a diagnosis of COPD for patients who are:• Over 35 years• Smokers or ex-smokers• No relevant pathology on chest XRay• Have any of these symptoms

– exertional breathlessness– chronic cough– regular sputum productions– frequent winter bronchitis– wheeze

Perform spirometry if COPD seems likely.

At the time of their initial diagnosticAt the time of their initial diagnosticevaluation, prior to spirometry, all patientsevaluation, prior to spirometry, all patients

should have:should have:

• a chest radiograph to exclude other pathologies• a full blood count to identify anaemia or polycythaemia• body mass index (BMI) calculated.

• An Alpha-1 Antitrypsin test if there is early onset of symptoms, minimal smoking history or family history.

FEV1 (%) and the smoking effectsFEV1 (%) and the smoking effects

The COPD ClinicThe COPD Clinic

• Attendance at this clinic is initially instigated via the doctor but follow-up appointments will be generated by either the clinic nurse or the administrating assistant at a period suitable to the patient needs.

• The clinic will provide assessment of patient general health, in relation to their COPD, and spirometry testing for the purpose of an

aid to either early diagnosis or management of the patients disease.

• The patient should be given the ‘Lung Function Test’ Patient Information Leaflet (can be located in ‘Patient Information Leaflets’

in Global Server) at least 1 week prior to any spirometry tests

Initial Clinic Appointment.Initial Clinic Appointment.

The following will take place at an initial clinic appointment:

• Spirometry to confirm diagnosis• Assessment of smoking status and desire to quit

If applicable• Adequacy of symptom control:

– Breathlessness– Exercise tolerance– Estimated exacerbation frequency

• Inhaler technique• Body Mass Index• Pulse oximetry (SaO2)• Flu / Pneumonia immunisation status cont.

• Depression Assessment

• Dyspnoea Score

• COPD Information Leaflet

• Referral back to GP for regular 6 monthly follow-up if spirometry confirms COPD diagnosis

Annual Clinic ReviewAnnual Clinic Review

The following will take place at a each follow-up clinic appointment:• Patient education about COPD, effects of smoking and the disease

progression• Smoking status, encouragement to stop and their desire to quit (Referral to

Smoking Cessation Service if patient agreeable)• Adequacy of symptom control• Presence of complications• Effects of drug treatment• Inhaler technique• FEV1 and FVC• Pulse oximetry (SaO2)• BMI and nutritional state• Dyspnoea Score• Need for social services or occupational therapy input • Need for referral to specialist and therapy services• Need for long-term oxygen therapy• Flu / Pneumonia immunisation status

If applicable

• Bronchodilator reversibility test

• Steroid reversibility test • Depression Assessment

C onsider COPD

Request ches t xray

R efer to COPD c linic for assessment(Appointment needs to be 6 weeks pos t exacerbation / ches t infect ion)

Give Lung Funct ion Test Information Leaf let (on Global Server)

COPD (Chest) Clinic1st appointment

Lung Function Test + Reversibil ity to Salbutamol

Normal Lung Function ResultsInform GP

N o follow -up appointmentat Chest Clinic

Advise to return to GP if symtomsreturn / worsen

Ask GP to apply Read Code forremoval off COPD / Asthma register

COPDRead Code C OPD

Inform GPGive COPD Information leaflet

Lifesty le advise inc luding smoking statusand importance of exercise

Refer back to GP for appropriate medication

AsthmaRead Code Asthma(if not on regis ter)

Inform GPRefer back to GP for

appropriate m edicat ion

Give Information about condit ionGP rev iew 3 monthly unt il stable

then 6 monthlyAnnual review at as thma c linic

Abnormal Lung Function Tes ts results

6 monthly review by GP

Annual COPD ClinicSteroid revers ibility avalable (GP to indicate)

Pat ient knowlegde and educationSm ok ing and exerc ise s tatus

Inhaler techniquePulse oximetry

Check spirometryBody mass IndexD yspnoea score

Signs of depressionIm munisation status

Mult idisc iplinary / spec ialis t input needed

Over 35 Years of age+ smokers or ex-smokers

+have any of the following symptoms- Exertional breathlessness

-Chronic cough-R egular sputum production-Frequent W inter bronchitis

-W heeze+ No c linical features of asthm a

Reversibility tests: Reversibility tests: differentiation of COPD from asthmadifferentiation of COPD from asthma

• Reversibility tests involve measuring spirometry before and after treatment and can help distinguish between COPD and asthma. Tests may include reversibility to bronchodilators (beta2 agonists or anticholinergics) or inhaled / oral steroids.

• Significant reversibility is defined as a rise in FEV1 that is both greater than 200ml and 15% of the pre-test value.

• Substantial reversibility (>400ml) indicates asthma.

Pharmological Management of COPDPharmological Management of COPD

AsymptomaticMaintain present treatment

AsymptomaticMaintain present treatment

NBMucolytics can be used at any stage to relieve chronic sputum production and reduce exacerbations

e.g. Mecysteine Hydrochloride (Visclair)

AsymptomaticMaintain present treatment

2 Month Assessment or exacerbation

SymptomaticAdd Theophylline slow release

Discontinue if no benefit af ter 4 weeks

SymptomaticAdd Inhaled Corticosteroid

Fluticasone (Flixotide) or Budesenide (Pulmicort)or Consider combined treatment e.g.Salmeterol + Fluticasone (Seretide)

Formeterol + Budesonide (Symbicort)Discontinue if no benefit af ter 4 weeks

Beta 2 Agonist or AnticholenergicSalbutamol Atrovent

2 Month Assessment or exacerbation

SymptomaticAdd Long Acting beta2Agonist = Salmeterol (Serevent) / Formeterol( Oxis )

orLong Acting Anticholenergic = Tiotropium (Spiriva)

2 month Assessment or exacerbation

MucolyticsMucolytics

Mucolytic drug therapy should be considered in patients

• with a chronic cough productive of sputum.

• Mucolytic therapy should be continued if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production).

Exacerbation in Primary CareExacerbation in Primary Care

Investigation

• sending sputum samples for culture is not recommended in routine practice

• pulse oximetry is of value if there are clinical features of a severe

exacerbation.

Cont.Cont.

• usually managed by taking increased doses of shortacting

bronchodilators and these drugs may be given using different delivery systems.

NB. Only if a patient is hypercapnic or acidotic should the nebuliser be

driven by compressed air, not oxygen (to avoid worsening

hypercapnia). The driving gas for nebulised therapy should

always be specified in the prescription.

cont. Exacerbations:cont. Exacerbations:Systemic CorticosteroidsSystemic Corticosteroids

• oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in breathlessness which interferes with daily activities.

• Prednisolone 30 mg orally should be prescribed for 7 to 14 days. It

is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged

therapy.

• Osteoporosis prophylaxis should be considered in patients requiring frequent courses of oral corticosteroids.

• Patients should be made aware of the optimum duration of

treatment and the adverse effects of prolonged therapy.

Cont. Exacerbations:Cont. Exacerbations:AntibioticsAntibiotics

• Antibiotics should be used to treat exacerbations of COPD

associated with a history of more purulent sputum.

• Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia.

• Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline. When initiating empirical antibiotic treatment, prescribers should always take account of any guidance issued by their local microbiologists.

Cont. Exacerbations:Cont. Exacerbations:Oxygen therapy during exacerbations of COPDOxygen therapy during exacerbations of COPD

• The oxygen saturation should be measured in patients with an

exacerbation of COPD

If necessary, oxygen should be given to keep the SaO2 greater than 90% but not above 93%.

MRC Dyspnoea ScoreMRC Dyspnoea Score

MRC Dyspnoea Score

Grade Degree of breathlessness related to Activities

1. Not troubled by breathlessness except on strenuous exercise2. Short of breath when hurrying on the level or walking up a slight hill3. Walks slower than contemporaries on the level because of

breathlessness, or has to stop for breath when walking at own pace4. Stops for breath after walking about 100m or after a fw minutes on the

level5. Too breathless to leave the house, or breathless when dressing or

undressing

Reference:

Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance ofrespiratory symptoms and the diagnosis of chronic bronchitis in a workingpopulation. British Medical Journal 2:257–66.

DepressionDepressionHealthcare professionals should be alert to the presence of depression in

patients with moderate to severe COPD. The presence of anxiety and depression should be considered in patients:

• who are hypoxic (SaO2 less than 92%)• who have severe dyspnoea• who have been seen at or admitted to a hospital with an exacerbation of COPD.

The presence of anxiety and depression in patients with COPD can be identified using validated assessment tools.

Patients found to be depressed or anxious should be treated with conventional pharmacotherapy.

For antidepressant treatment to be successful, it needs to be supplemented by spending time with the patient explaining why depression needs to be treated alongside the physical disorder.

See depression scoreRef. Birchell et al (1989) The Depression Scoring Instrument (DSI): J Affect Disorder 16 269-281

ReferencesReferences

• Chronic Obstructive Pulmonary Disease: National clinical guideline for management of Chronic Obstructive Pulmonary Disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): 1-232

• Chronic Obstructive Pulmonary Disease. A Boyter et al. Pharmaceutical Journal (vol 261) 5.9.98 

• First UK Guidelines for Management of Chronic Obstructive Pulmonary Disease. Pharmaceutical Journal (Vol 259) 13.12.97 

• NICE Guidelines (2004). Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 12. National Collaborating Centre for Chronic Conditions. London. http://www.nice.org.uk/pdf/CG012_niceguidelines.pdf

• Ref: British Thoracic Society. Guidelines for the Management of COPD. Thorax 1997;52 Suppl 5:51-28

• The Management of Chronic Obstructive Pulmonary Disease. MeReC 9(10) November 1998.