Download Chronic Obstructive Pulmonary Disease

Care Guideline
Draft for Annual Review
Cycle 1/11/17
CARE OF THE ADULT COPD PATIENT
Target Audience:
The target audience for this clinical guideline is all MHS providers and staff including those
associated with our clinically integrated network. The secondary audience includes MHS clinical
support staff in these areas: Pharmacy, Nursing, Imaging, Lab, Care Management, Transitions of
Care, and Respiratory Therapy.
Scope/Patient Population:
This guideline applies to all adult patients in MultiCare’ s adult hospitals to include Tacoma
General, Allenmore, Good Samaritan, Auburn Medical Center and all of MultiCare Health
System’s primary care, specialty care and urgent care clinics.
The target patient population includes adults diagnosed with COPD and other patients who meet the
following definition provided by the Global Initiative for Chronic Obstructive Lung Disease.
Definition of COPD
Chronic Obstructive Pulmonary Disease a common preventable and treatable disease is
characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or
alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The
most common respiratory symptoms include dyspnea, cough and/or sputum production.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
Rationale:
Chronic Obstructive Pulmonary disease (COPD) is the fourth leading cause of death in the world
and represents an important health challenge that is both preventable and treatable.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) standard is the Universally
accepted measure for the diagnosis and grading of COPD, the 2017 GOLD standards were
reviewed in order to update currently available smart sets and order sets to serve providers and
adult patients in both the outpatient/ambulatory and inpatient arenas.
If the patients are engaged and involved with their care by use of tools, the outcomes will be
improved.
Objective
Goal Statement
Reduce the mortality rate associated with COPD
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Reduce the rates of both admission and readmission to healthcare facilities for COPD exacerbations
when avoidable. In turn, reduce the cost per hospital stay and maintain or decrease the length of
stay for patients admitted with COPD exacerbations.
Standardize and improve appropriate delivery of pharmacologic treatment and nonpharmacological treatment of COPD to include: Smoking cessation, Vaccinations, Short and long
acting Beta2-agonists and Anti-Cholinergics, Methylxanthines, inhaled corticosteroids, systemic
corticosteroids, Oxygen, COPD education including effective utilization of multi-dose inhalers, and
pulmonary rehabilitation for patients at all MultiCare entities by use standard order sets for
admission and discharge.
Recommendations:
DIAGNOSTIC ASSESSMENT
Clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or
sputum production, and a history of exposure to risk factors for the disease.
 Spirometry is required to make the diagnosis in this clinical context; the presence of a postbronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus
of COPD. Spirometry is unable to be tested during a hospital admission and needs to be ordered
in the ambulatory setting. Administration of spirometry may vary from clinic to clinic; the
person conducting the test should be signed off on the appropriate MultiCare competency.
 Spirometry testing done in the ambulatory setting has the following recommendations:
o Short acting bronchodilators or anticholinergic agent should not be used 4 hours
prior to testing
o Long acting bronchodilators should not be used 12 hours prior to testing
o No smoking greater than or equal to 1 hour prior to testing
o Post spirometry testing can be administered greater than or equal to 10 minutes and
up to 15 min for short acting bronchodilator and 30 minutes later for short acting
anticholinergic agents.
 The GOLD guidelines 2017 recommends the use of the revised ABCD assessment tool for
COPD which includes spirometry to note the severity of airflow limitation, a subjective
functional assessment of the patient’s symptoms using mMRC (modified British Medical
Research Council Questionnaire) or CAT (COPD Assessment Test) and assessment of recent
exacerbations and/or hospitalizations.
 Comorbidities occur frequently in COPD patients, including cardiovascular disease, skeletal
muscle dysfunction, metabolic syndrome, osteoporosis, depression, and lung cancer. Given that
they can occur in patients with mild, moderate and severe airflow limitation and influence
mortality and hospitalizations independently, comorbidities should be actively looked for, and
treated appropriately if present. Assessment of Co-Morbidities and risk for exacerbations are
documented by the health care provider while conducting the History & Physical on admission
whenever possible.
THERAPEUTIC OPTIONS
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In patients who smoke, smoking cessation is very important. Pharmacotherapy and nicotine
replacement reliably increase long-term smoking abstinence rates.
Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and
severity of exacerbations, and improve health status and exercise tolerance.
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To date, none of the existing medications for COPD has been shown conclusively to modify
the long-term decline in lung function. The patient severity should be assessed periodically to
determine if updates in treatment regime are needed.
Each pharmacological treatment regimen needs to be patient-specific, guided by severity of
symptoms, risk of exacerbations, drug availability, and the patient’s response. Inhaler technique
should be assessed frequently.
The need for supplemental oxygen if not already prescribed should be assessed and
effectiveness reassessed ongoing
In patients with chronic hypercapnia and history of hospitalization with acute respiratory
failure, long term noninvasive ventilation options could be considered
Influenza and pneumococcal vaccination should be offered to every COPD patient; they appear
to be more effective in older patients and those with more severe disease or cardiac
comorbidity.
All patients who get short of breath when walking on their own pace on level ground should be
offered rehabilitation; it can improve symptoms, quality of life, and physical and emotional
participation in everyday activities. Often rehab is prescribed to the most severe patients
instead of moderately severe where the most impact can be obtained.
COPD patients require nutritional support due to increased calorie expenditure and poor
tolerance to the energy required to take in sufficient nutrients. Nutritional support promotes
strength to respiratory muscle strength and increased activity tolerance.
Non-surgical bronchoscopic lung volume reduction techniques should not be used outside
clinical trials until more data are available.
Palliative Care is underutilized in the COPD patient. Palliative care encompasses approaches to
symptom management control as well as management of terminal illness when close to death.
Even with optimal medical treatment chronic breathlessness, fatigue, activity intolerance,
panic, anxiety and depression can be very distressing.
MANAGEMENT OF EXACERBATIONS
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Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually
the preferred bronchodilators for treatment of an exacerbation.
Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function
(FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure,
and length of hospital stay.
The need for supplemental oxygen if not already prescribed should be assessed and
effectiveness reassessed ongoing. ABGs should be considered. Noninvasive ventilation should
be the first mode of ventilation used in COPD patients with acute respiratory failure with no
contraindications
COPD exacerbations can often be prevented. Smoking cessation, influenza and pneumococcal
vaccination, knowledge of current therapy including inhaler technique, and treatment with
long-acting inhaled bronchodilators, with or without inhaled corticosteroids, and treatment with
a phosphodiesterase-4 inhibitor are all interventions that reduce the number of exacerbations
and hospitalizations
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Commented [AT1]: This is a copyrighted image. We
need to get permission to reference it.
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Evidence:
Reference Document
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary
disease, Updated 2017
List of Implementation Items and Patient Education:
MultiView Applications
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Order Sets and Smart Sets
1. Order set number for ED = 11293
2. Order set number for hospitalists = 11294
3. Order set number for inpatient discharge = 11268
4. EPIC Smart Text for After Visit Summary (AVS) Attachment B
Patient Education materials
1. Standard RED/YELLOW/GREEN format will be available through the MHS print shop. Form
#88-1667-9
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MultiCare Connect Tip Sheet
This Tip Sheet has been published following standard MHS change management protocols for
MultiCare Connect updates.
Metrics Plan:
AIM Statements
1. Increase the composite index score of the COPD NOREADMITS bundle to 70% by end of
year 2017.
2. Reduce COPD Readmissions to less than or equal to 16.61% by end of year 2017.
This team will launch at least one pilot to improve access to spirometry in 2017.
PDCA Plan:
The Medicine Collaborative will review this Guideline and all supporting deliverables on an annual
basis.
Point of Contact:
Medicine Collaborative (Current chair until delegated to other point of contact)
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Approval By:
MMA Clinical Quality & Compliance Committee
Urgent Care Collaborative
Emergency Department Provider Meeting
MultiCare Inpatient Specialist Meeting
Sound Inpatient Providers
Medical Imaging Northwest
Pharmacy and Therapeutic Committee
MHS Nurse Executive Committee
ESOC
Medicine Collaborative
Auburn Medical Executive Committee
TG/AH Medical Executive Committee
Good Samaritan Medical Executive Committee
Quality Steering Council
Original Date:
Revision Dates:
Reviewed with no Changes Dates:
Distribution: MultiCare Connected Care + MultiCare Health System
Date of Approval:
08/2014
08/2014
08/2014
08/2014
09/2014
07/2014
03/2014
09/2014
09/2014
05/2015
06/2015
07/2015
06/2015
06/2015
07/2015
08/2015
01/2015, 05/2015, 06/2015, 01/2017
Xx/xx
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COPD Discharge instructions
Medication Instructions:
o Take all medications as the physician prescribes.
o Do not stop taking these medications without contacting your provider.
o Oxygen is a medication; Do not change the amount unless told to do so by your doctor.
o Use metered dose inhaler with a spacer; rinse mouth after using an inhaler containing
steroids.
o Consult with your doctor before taking any over-the-counter medications or herbal
supplements.
o Get a flu shot each fall and talk to your doctor about the pneumonia shot.
Diet Instructions:
o Low Sodium (salt)/Low Fat diet
o Eat healthy foods such as fruits, vegetables, whole grains, and lean dairy and proteins.
o Eating many small meals throughout the day, rather than 2-3 large meals may lessen your
shortness of breath.
o Consult your doctor if you need to lose weight or need advice to keep weight on.
Special Instructions:
o DO NOT SMOKE and avoid second hand smoke. Your doctor recommends you attend
smoking cessation classes if you smoke.
o Avoid lung irritants, dust fumes, air pollution, and high humidity.
o Use nebulizer treatment or rescue inhaler when you are having shortness of breath,
wheezing, or more coughing than usual.
Activity Instructions:
o When you return home, pace yourself. Rest between activities. Do not allow yourself to
become fatigued.
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o
Exercise can help some of your symptoms and help you feel better. Talk to your doctor
about what exercise is best for you. Start slowly.
o If you become tired, short of breath, dizzy, or develop chest pain or fast heartbeat, stop the
activity, sit down and rest.
o Ask your doctor to see if Pulmonary Rehab is right for you.
Symptoms to Report to your doctor:
o Increased shortness of breath, wheezing or coughing.
o Loss of energy, not able to finish your usual activities.
o Increase or color change in mucus or if it has an odor.
o Feeling more tired than usual.
o Sore throat, fever, chills, or night sweats.
o Muscle aches and pains or headaches.
o Loss of appetite.
o Feeling as though you have a “chest cold”.
o Sudden weight gain with legs/feet swelling.
o Fast heart rate.
Call 911 IF:
o You have chest pain or feel as if you are going to faint.
o You are confused or cannot stay awake.
o You are coughing blood, have fever, or shaking chills.
o Cannot sleep because of your breathing or have severe shortness of breath even when
resting.
Follow Up Instructions:
o Your follow up appointment is *** at *** with ***
o Call your doctor if you start feeling worse before your appointment and ask for a same day
appointment.
o Talk to your doctor about any problems you have having with your medications including
any side affects you are experiencing, trouble using your inhalers, or if you are unable to
afford your medications.
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