Primary Care management

Chronic obstructive pulmonary disease

Implementing NICE Guidance and Quality Standards

NICE clinical guideline 101

Additional information can be found at www.copdeducation.org.uk

On behalf of the Southampton COPD Group

NICE Quality outcome - spiro

• People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation.

Definition of COPD

• Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)

• It is no longer necessary to have an FEV1 < 80% predicted for definition of airflow obstruction

• If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough

FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity

Diagnose COPD: 1

• 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: 2

• Assess severity of airflow obstruction using reduction in FEV1

NICE clinical guideline 12

(2004)

ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101

(2010)

Post-bronchodilator

FEV1/FVC

FEV1 % predicted

Post-bronchodilator

Post-bronchodilator

Post-bronchodilator

< 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)**

Stage 4 (very severe)**

* Symptoms should be present to diagnose COPD in people with mild airflow obstruction** Or FEV1 < 50% with respiratory failure

[new 2010]

Asthma or COPD

• To help resolve cases where diagnostic doubt occurs, or both COPD and asthma are present, the following findings should be used to help identify asthma:

• 1. a large (> 400 ml) response to bronchodilators

• 2. a large (> 400 ml) response to 30 mg oral prednisolone daily for 2 weeks

• 3. Serial peak flow measurements showing 20% or greater diurnal or day-to-day variability. (NICE 2010)

Basic SpirometryPatients with normal lungs empty most of their volume in the first second of expiration

Patients with COPD have problems in expiration so it takes much longer to empty their lungs

NormalCOPD

The inspiratory parts of the flow loops look similar

The expiratory parts of the flow loop are very different however with sudden loss of expiratory flow seen in COPD

The Flow Volume LoopIn

spira

tion

Exp

iratio

n

Other tests to confirm the diagnosis in the new patient

CXR – excludes other conditions

BMI – Big predictor in mortality terms but only in moderate and severe disease

FBC - Polycythaemia Anaemia

“It has generally been assumed that individuals with the lowest FEV1 were also progressing the fastest as they had ‘‘clearly’’ lost more function than individuals with more normal lung function. However, evidence is accumulating that this assumption is in error, making it essential to distinguish between severity and activity”

JØRGEN VESTBO 2010

What is the decline in mls/yr ?

TORCH UPLIFT

Gold II 60 49

Gold III 56 41

Gold IV 34 31

NICE outcomes - therapy

• People with COPD have a current individualised comprehensive management plan

• People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan

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 FEV1 ≥ 50% predicted: either LABA or LAMA

• if FEV1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA

• Offer LAMA & LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS,

• Triple therapy not dependent on FEV1

• Inhaler technique and ability ro activate the device

ICS = inhaled corticosteroidLABA = long-acting beta2 agonist

LAMA = long-acting muscarinic agonist[new 2010]

Use of inhaled therapies

SABA or SAMA as required*Breathlessness and exercise limitation

Exacerbations or persistent breathlessness

Persistent exacerbations or breathlessness

LABA LAMADiscontinue

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

LAMADiscontinue

SAMA________

Offer LAMA in preference to regular SAMA

four times a day

FEV1 ≥ 50% FEV1 < 50%

LABA + ICS in a combination

inhaler________

Consider LABA + LAMA if ICS

declined or not tolerated

LAMA + LABA + ICS

in a combination inhaler

Offer Consider* SABAs (as required) may continue at all stages

Nice outcome - smoking

• People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support.

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]

Intervention Stop Smoking

Nice Outcomes - oxygen

• People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.

• People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service.

• People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD

Long term oxygen therapy –who?

•FEV1 < 30% predicted

•Cyanosis

•Polycythaemia.

•Peripheral oedema.

•Raised jugular venous pressure.

•Oxygen saturations < 92% on air.

Nebulisers

• Mainstay of therapy should be by a conventional inhaled route.

• Majority of patients get little added benefit from nebulisers.

• Consider nebulisers if:• Patient lacks dexterity to use

inhalers.• Patient has cognitive

impairment.• Patient has severe COPD and is

still symptomatic despite high dose inhaled bronchodilator therapy.

Nice outcome - rehab

• People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.

Provide pulmonary rehabilitation

Pulmonary rehabilitation

An individually tailored multidisciplinary programme of care to optimise patients’ physical and social performance and autonomy

Tailor multi-component, multidisciplinary interventions to individual patient’s needs

Hold at times that suit patients, and in buildings with good access

Offer to all patients who consider themselves functionally disabled by COPD

Make available to all appropriate people, including those recently hospitalised for an acute exacerbation

[new 2010]

What does it achieve ?

• Pulmonary rehabilitation

• Reduces the number of hospital days

• Reduces health-care utilization

• Increases exercise tolerance

• Reduces need for 02

• Reduces exacerbation frequency

NICE outcome - exacerbations

• People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.

• People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported- discharge scheme with appropriate community support.

• People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non-invasive ventilation delivered by appropriately trained staff in a dedicated setting.

• People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge.

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

• The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations

[2004]

Treat at home or in hospital?

Characteristics Home Hospital

Cyanosis No Yes

Peripheral Oedema

No Yes

Consciousness Normal Impaired

LTOT? No Yes

Social Good Alone/Not coping

Confusion No Yes

Rapid Onset No Yes

CVD or DM No Yes

SaO2 >90% <90%

Exacerbations Aetiology

• 50% of exacerbation caused by viruses (Rhinovirus and influenza viruses are the most common)

• 50% of exacerbations caused by bacteria (H. Influenzae, S. pneumoniae and M. catarrhalis)

• Up to 20% have both

• Consider co morbidities as a cause of an exacerbation if no obvious infective symptoms or signs e.g CFF and PE

Antibiotics

• All exacerbations should be treated with antibiotics.

• Either doxycycline 200mg BD 2/7 then doxycycline 200mg OD 5/7

• If treatment fails or recent course of doxycycline then try

• Azithromycin 500mg OD 3-5/7

Prednisolone

• 30mg OD for one week

• If improves then stop – no tailing off

• If not improving then use 30mg for another week

• Do not continue beyond 2 weeks

End of life outcome

•People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs.