Download Chronic Obstructive Pulmonary Disease (COPD)

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Care Process Model
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M A N A G E M E N T 8O F
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Chronic Obstructive Pulmonary Disease (COPD)
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This care process model (CPM) was developed by multidisciplinary clinical
experts from Intermountain Healthcare, based on
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guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)GOL, the American College of Physicians, and
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the American Thoracic Society (ATS), and others.ACP The CPM recommends screening, diagnosis, and treatment processes to improve
Early Termination
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care and outcomes for patients with chronic obstructive pulmonary disease
(COPD). Related
tools, such as forms, reference tables,
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and patient education materials, support implementation of the recommended
care processes.
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Why Focus ON copd?
• Spirometry is underutilized. Despite being simple and inexpensive and required
for COPD diagnosis, spirometry testing is underutilized to evaluate and diagnose
COPD. Though appropriate use has improved from 34.7% in 2008 to 41.4% in
2011 in SelectHealth patients, it is still below the regional and national averages,
and well below the national 90th percentile (see Figure 1).
52.70%
Select
Health
2008
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41.44%
43.85%
42.56%
Select
Health
2011
Mountain
regional
average
2011
National
average
2011
Algorithm and
Supporting Notes.................... 2
Spirometry and other tests..... 4
Oxygen Therapy........................... 6
Smoking Cessation...................... 7
Pharmacological Therapy........ 8
Exacerbation Management.....10
Figure 1. Percentage of appropriate spirometry testing
34.65%
4
What’s iNside?
• It’s common and underdiagnosed. More than 12 million adults are diagnosed
with COPD, and researchers estimate that another 12 million may have COPD
but not realize it, indicating that the disease may be underdiagnosed.NHL
The percentage of patients
over 40 who received
appropriate spirometry
testing for diagnosis and
evaluation of COPD.
3
National
90th
percentile
2011
• COPD prevalence continues to grow. COPD is the 4th leading cause of death
in the U.S. The World Health Organization (WHO) estimated that more than 3
million people died of COPD in 2005.WHO It is the only chronic illness for which
prevalence is projected to increase in the coming decades.HAL
• Good care improves outcomes and reduces costs. A study of 37,089 COPD
patients in the U.S. showed that severe exacerbations requiring hospitalization
were associated with significantly higher COPD-related healthcare costs than
lower severity exacerbations treated in outpatient or ED settings. Improved
symptom management and reduction in exacerbations would reduce the cost
burden of COPD and improve the patient’s quality of life.DAL, REA
What’s new?
• Recommended use of ACP/ATS criteria for diagnosis of COPDACP (pages 2–3)
• Emphasis on spirometry for COPD diagnosis (pages 1–4)
• New GOLD definition of COPD (page 3)
• Use of home oximetry (page 6 sidebar)
• New class of medications (phosphodiesterase-4 inhibitors) (pages 8 and 9)
• Palliative care guidelines (page 11)
Ongoing Treatment and
Follow up.....................................11
References and Resources.......12
Goals
• Present an evidence-based,
standardized approach for care
of COPD
• Increase use of spirometry
for diagnosis
• Decrease hospitalizations
and readmissions
• Provide tools to assist in the
management of COPD
–– PFT and oxygen therapy order forms
–– Patient education recommendations
–– Web and other resources
Indicates an Intermountain measure
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
F e b rua ry 2 013
ALGORITHM
1. SCREEN patients over 40 with COPD risk factors OR chronic respiratory symptoms (a)
Evaluate symptoms for
differential diagnosis (b)
Refer for pre- and postbronchodilator testing; see
Asthma CPM
Suspect
asthma
Suspect COPD (c)
2. TEST using spirometry (d) to evaluate and confirm COPD diagnosis
Meet COPD diagnostic criteria?ACP
Evaluate other
causes of symptoms;
refer if needed (e, f)
no
FEV1/FVC ratio < lower limit of normal %
based on patient’s age, sex, height, ethnicity
(usually ratio <70%; see pages 4 and 5)
3. EVALUATE comorbidities and treat concurrently (f, g)
4. CLASSIFY severity (based on FEV1 and symptoms) and TREAT (h)
STAGE 1: MILD
• FEV1 >80%
• Cough and sputum may be
present
STAGE 2: MODERATE
• FEV1 50% to 80%
• Dyspnea on exertion
• Cough and sputum sometimes
present
STAGE 1:
Core
treatment
STAGE 3: SEVERE
• FEV1 30% to 50%
• Increased dyspnea, reduced
exercise capacity
• Fatigue, exacerbations
•Smoking cessation (see page 7)
•Influenza and pneumococcal vaccines (see the Immunizations topic
on intermountain.net)
•Avoidance of inhalation exposures
•Consideration of alpha-1 antitrypsin deficiency test (f)
STAGE 2–4:
Core
treatment
plus
STAGE 4: VERY SEVERE
• FEV1 <30%
• Chronic respiratory failure
• Life-threatening exacerbations
•Evaluation for oxygen therapy (see page 6)
•Exacerbation prevention and management (see page 10)
•Medications: Inhaled short-acting beta2-agonists (SABA) as needed
(see pages 8 and 9)
•Pulmonary rehabilitation (see page 11)
•Consideration of:
–– Pulmonary consult
–– Arterial blood gas (ABG) and other tests (f)
–– Action plan or care plan
•First-line medications: (see pages 8 and 9)
–– Inhaled SABA
–– Anticholinergics
•Second-line:
–– SABA plus short-acting anticholinergic
–– Long-acting beta2-agonists (LABA)
–– LABA plus corticosteroid
–– Phosphodiesterase 4 (PDE4) inhibitor
5. FOLLOW UP every 3 to 12 months (see page 11)
Indicates an Intermountain measure
2 ©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Fe b rua ry 2 013
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
(d) Basic spirometry for COPD diagnosis (see pages 4 and 5)
(a) COPD risk factors and symptoms
Risk
factors
•• Tobacco smoking history (by far the most
significant risk factor)
•• History of other inhalation exposures (e.g.,
occupational dusts or chemicals, indoor or outdoor air
pollution, passive exposure to smoking)
•• Familial or genetic tendency for COPD (e.g.,
alpha-1 antitrypsin deficiency; alpha-1 antitrypsin
deficiency is a relatively rare, but underdiagnosed
genetic risk factor for COPD)
Symptoms
• Dyspnea: progressive, worse with exercise or during
respiratory infections*
• Chronic, persistent cough: present intermittently or daily
• Chronic sputum production
Note: Airflow limitation in mild COPD may produce
no symptoms. Conversely, chronic cough and sputum
production often precede the development of airflow
limitation by many years, although not everyone with
cough and sputum develops COPD.
*Ask patients about their degree of breathlessness with certain activities, such as
walking stairs or slight inclines, walking with others, dressing, and undressing to
understand the severity of a patient’s symptoms.
(b) Differential diagnosis of COPD versus asthma
FVC (Forced Vital Capacity): The total amount of air a patient can
forcibly blow out after a full inspiration (assesses lung capacity).
FEV1: The amount of air a patient can forcibly blow out in the 1st second.
FEV1/FVC ratio: The ratio of FEV1 to FVC. Lower limit of normal varies by
age. Reduced ratio required for the diagnosis of COPD.
(e) Other diseases that present with signs
and symptoms of COPD
• Asthma
• Sleep apnea
• Cardiac dysfunction
• Metabolic disorders
(e.g., congestive heart failure)
• Chronic lung infections
(e.g., tuberculosis, bronchiectasis)
(e.g., thyroid disease)
• Chronic cough from GERD
or post nasal drip
(f) Other tests to consider
Test
Consider for…
Alpha-1
antitrypsin
Emphysema in a patient under 40; emphysema
with minimal smoking history; unexplained
chronic liver disease or panniculitis; consider for all
patients with emphysema
Arterial blood
gases (ABGs)
Smoker; FEV1 <50% (Stage 3 or 4 COPD);
if you’re ordering oxygen
Brain natriuretic
peptide (BNP)
Suspected heart failure or cor pulmonale
Note: May be normal in obesity despite volume
overload; may be elevated in PE, right heart failure,
or pulmonary hypertension
History / Risk Factor
COPD
Asthma
Smoker (or ex-smoker)
Nearly always
Possibly
Symptoms before age 35
Rare
Common: persistent
and progressive
Common
Variable
Chest x-ray (CXR)
Symptoms out of proportion to risk factor exposure
Chronic productive cough
Common
Uncommon
DEXA
Chronic sputum production
Common
Uncommon
Moderate to severe COPD; screening for
osteoporosis; when considering steroid use
Echocardiogram
Uncommon
Common
Suspected pulmonary artery hypertension or
congestive heart failure; dyspnea without apparent
cause; undiagnosed edema; elevated BNP
Uncommon
Uncommon
Common
Common
Low-dose CT
Uncommon
Common
Current or former smokers 55 to 74 years old with
at least 30 pack-years smoking history, no history of
lung cancerALA
Nocturnal
oximetry
Moderate to severe COPD with no obstructive sleep
apnea (OSA)
Breathlessness
Waking at night with cough,
breathlessness, or wheeze
Allergic rhinitis
History of eczema
Significant variability of
symptoms for day to day
(c) COPD definition
(g) COPD comorbidities
GOLD’s definition of COPD
GOL
“COPD, a common preventable and treatable disease, is characterized
by persistent airflow limitation that is usually progressive and associated
with an enhanced chronic inflammatory response in the airways and
the lung to noxious particles or gases. Exacerbations and comorbidities
contribute to the overall severity in individual patients.”
Emphysema and chronic bronchitis
Emphysema and chronic bronchitis are the major components of COPD.
• Emphysema is a pathological term describing the destruction of the
gas-exchanging surfaces of the lung (alveoli).
• Chronic bronchitis is a clinical term for the presence of cough and
sputum production for at least 3 months in each of 2 consecutive years.
New GOLD criteria deemphasizes the use of this distinct terminology.
These disease states may overlap, and the treatment approach is the same
for both in patients with risk factors for COPD and airflow limitation.
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Comorbidities need to be treated in conjunction with COPD treatment:
• Congestive heart failure
• Skeletal muscle wasting
• Ischemic heart disease
• Cachexia
• Depression
• Obstructive sleep apnea (OSA)
• Lung cancer
• Diabetes mellitus
• Osteoporosis
• Metabolic syndrome
(h) COPD treatment goals
Treatment is based on COPD severity. Treatment goals include:
• Relieve symptoms
• Improve exercise tolerance
• Prevent and manage exacerbations (see page 10)
• Slow the progression of the disease
• Reduce morbidity and mortality
Reducing therapy after symptoms are controlled may not be possible.
Further deterioration of lung function usually requires introduction of more
treatments to limit the impact of the changes.
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MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
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Information on spirometry testing10
for
patients with COPD can be found on
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goldcopd.org. (Search for “spirometry.”)
Why spirometry?
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You can find normal ranges for spirometry
results on the CDC website: cdc.gov/niosh/
topics/spirometry/nhanes.html. Results are
organized by age, ethnicity, and gender.
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Spirometry is required for diagnosing COPD, as well as for diagnosing asthma,
pulmonary fibrosis, and cystic fibrosis.
Spirometry should be performed for any patients
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with chronic symptoms suggestive of COPD or for patients over 40 with risk factors
for COPD, especially a smoking4 history. (See algorithm and notes on pages 2 and 3.)
MI
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NO
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Reference ranges for 2
spirometry results
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Spirometry and Other Tests
Guide to Spirometry
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Criteria for diagnosis and severity assessment
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Basic spirometry tests for evaluation
and diagnosis of COPD are described in table d
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on page 3. The following results are used for diagnosis and severity classification:
• Diagnosis: Along with the evaluation of symptoms, the diagnosis is confirmed with
an FEV1/FVC ratio of less than about 70% (varies based on patient’s age, sex, height,
ethnicity; see sidebar to link to values).
• Severity classification: Along with severity of symptoms, the FEV1 percent of
predicted helps classify severity (see sidebar to link to values).
The flow patterns shown below are consistent with mild, moderate, and severe COPD,
based on the definitions in the algorithm on page 2.
Figure 2. Sample loops based on severity of obstruction
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Normal: FEV1/FVC ratio >0.70;
FEV1 >80% of predicted
Mild obstruction: FEV1/FVC ratio <0.70;
FEV1 >80% of predicted
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NO
L
A
IL
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SEV
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Moderate obstruction: FEV1/FVC ratio <0.70;
FEV1 50 to 80% of predicted
R
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Flow (L/sec)
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Severe obstruction: FEV1/FVC ratio <0.70;
FEV1 <50% of predicted
In-office testing versus referral to pulmonary function lab
Physicians can perform spirometry in their offices if they have the necessary equipment
and training to perform high-quality studies and correctly interpret results. Otherwise,
patients should be referred to a pulmonary function testing lab. See the sidebar for
guidance on in-office spirometry testing.
TABLE 1. In-office spirometry versus pulmonary function lab testing
Perform in office:
Refer to pulmonary lab:
•• If you have the necessary equipment and training
•• If you suspect asthma
•• If you suspect other comorbidities
•• If there are interstitial changes on CXR
•• For patients with moderate to severe disease
•• When a BODE index score is desired*
to perform high-quality studies and correctly
interpret results
•• For uncomplicated patients without significant
suspected comorbidities
•• For patients with mild disease
•• When calculation of mortality risk is not desired
*The BODE index score is part of a COPD spirometry protocol that includes post-bronchodilator spirometry and a
6-minute walk test (see table 3 and figure 3 on next page). A BODE index score >7 predicts increased mortality.CEL1
4 ©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Fe b rua ry 2 013
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Additional pulmonary function tests
Ordering PFTs
Additional pulmonary function tests (PFTs) may be useful in situations where the
diagnosis of COPD or shortness of breath is unclear, to evaluate for combined
restrictive lung disease along with COPD, or to further assess COPD severity level
and mortality risk.
Intermountain’s Pulmonary Function
Testing (PFT) Orders form can be used
to order PFT labs. This form includes
appointment information, indications for
testing, and a list of possible tests and
protocols. You can access and print the
form from the COPD topic page at
intermountainphysician.org/
ClinicalPrograms
TABLE 2. Other pulmonary function tests
Pre- and postbronchodilator
spirometry
Used to differentiate between COPD and asthma and to further evaluate COPD. In general, an
improvement of 15% or more in FEV1/FVC ratio after use of a bronchodilator is suggestive of
asthma.
COPD
spirometry
protocol
Includes post-bronchodilator spirometry, a 6-minute walk test (see sidebar), and calculation of
the BODE index score (see table 3 and figure 3 below).CEL1 The BODE has been shown to be better
than the FEV1 alone at predicting the risk of death among patients with COPD (see figure 2),
which may be useful in counseling patients about disease progression and palliative care.
Full PFTs
Pulmonary Function Testing (PFT) Orders
DOB:
Phone:
Patient Name:
Ordering Physician:
Lab location:
APPOINTMENT INFO
Description/when it may be useful:
Phone:
FAX:
Phone:
__ FAX:
__ Time:
Appointment date:
Instructions:
 Don’t drink caffeine or use bronchodilators for at least 12 hours before your test
 Don’t smoke for at least 2 hours before your test (preferably 24 hours)
 Don’t eat a heavy meal or do vigorous exercise for at least 2 hours before your test
 Wear loose fitting clothes and remove back braces
 Other:
 ASSESSMENT (diagnostic
evaluation)
REASONS FOR TESTING
Test
 Asymptomatic, but suspected
diagnosis
 Symptomatic
 Baseline for screening after
acute illness (e.g., pneumonia)
 Baseline for preoperative
 Baseline for pre-chemotherapy
 Baseline for pre-bone marrow
transplant
 Baseline for pre-employment
 Baseline for insurance
 Baseline for athletics
 MONITORING
 Routine follow-up — no specific indication
 Follow up for treatment titration/adjustment
 Follow up for symptom/function exacerbation
 DRUG REACTIONS
 Amiodarone
 General chemotherapy for cancer
 Bleomycin
 Methotrexate
 Radiation reaction
 DISEASE/SYMPTOM/MANIFESTATION
 Cough
 Dyspnea
 Asthma/reactive airways disease
 Chronic bronchitis
 Pulmonary emphysema
 Cystic fibrosis
 Bronchiectasis
 Heart failure
 Interstitial lung disease
 Sarcoidosis
 Pulmonary vascular disease (e.g., thromboembolism,
pulmonary arterial hypertension)
 Central airway obstruction (e.g., goiter, tracheal/vocal
cord abnormality)
Select specific test(s) or protocol(s) below:
Most common tests and protocols:
 SPIROMETRY  Screening (pre-bronchodilator only)  Post-bronchodilator if indicated*
 COPD protocol: Includes spirometry with bronchodilator, 6-min walk, B.O.D.E. Index
 Full PFTs: Includes spirometry with bronchodilator if indicated*; DLCO; TLC by body plethysmography
if FVC and TLC sb is reduced; 6-min walk
Includes spirometry with bronchodilator if indicated, DLCO (diffusion capacity), total lung capacity
by body plethysmography (if appropriate), and 6-minute walk test. Consider for restrictive disease
or other suspected comorbidities.
 Asthma protocol: Includes spirometry with bronchodilator
Other specialty tests:
 Diffusing capacity: Single-breath carbon monoxide diffusing capacity (DLCO)
 LUNG VOLUMES
 Single breath Gas Dilution (with DLCO)
 Body box (plethysmography)
 Multiple breath N2 washout (with right to left shunt estimation)
 VO2 max
 6-min walk
*Indications for bronchodilator testing:
 Obstruction
 Cough
 Other symptoms of asthma/COPD
 MUSCLE STRENGTH
 MIP/MEP  MVV (maximum voluntary ventilation)
 BRONCHOPROVOCATION
 Eucapnic voluntary hyperventilation (EVH)
 Methacholine challenge
 Exercise
 Mannitol inhalation test
 EXERCISE TESTING
 Maximum exercise ABG Arterial line
 Walking saturation
Other disease-based and specialty protocols:
 Amiodarone protocol: Includes spirometry (bronchodilator if indicated*), DLCO
 Bone marrow transplant protocol: Includes spirometry (bronchodilator if indicated*), DLCO
 Diabetes (inhaled insulin) protocol: Includes spirometry, DLCO
 Heart transplant protocol: Includes spirometry with bronchodilator, DLCO, room air ABGs
 Neuromuscular disorder protocol: Includes spirometry (bronchodilator if indicated*), MIP/MEP/MVV, sitting and supine VC
 Occupational exposure protocol: MIP/MEP/MVV, R/a ABGS, spirometry with bronchodilator, DLCO, lung volumes
Date:
Ordering Physician Signature:
For more information or additional copies of this form, go to intermountainphysician.org/clinicalprograms.
©2007-2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 COPD101 – 02/13
DLCO
Low diffusion capacity for carbon monoxide (DLCO) can indicate interstitial lung disease and may
also occur in the presence of emphysema.
Lung volume
Measures total lung capacity (TLC), which is not measured by spirometry. Lung volumes can
be measured by a gas dilution technique or by body plethysmography. Lung volume tests can
be helpful when a patient has severe airflow obstruction and a reduction in FVC. A normal or
increased TLC would exclude an associated restrictive process.
Maximum voluntary ventilation (MVV) measures prolonged, rapid breathing for 12 to 15 seconds
to evaluate respiratory muscle function; used to evaluate muscle weakness.
MIP and MEP
Maximum inspiratory pressure (MIP) measures the amount of pressure generated at the mouth
during a forced inspiration. Maximum expiratory pressure (MEP) measures the amount of pressure
generated at the mouth during a forced expiration.
ABG
Arterial blood gas (ABG) evaluates gas exchange and is a more sensitive test than pulse
oximetry at determining hypoxemia. ABGs should be considered in COPD patients with FEV1
<50% of predicted.
D: Dyspnea
Points on the BODE index
1
2
3
>21
<21
>65% of
predicted
50–64% of
predicted
36–49% of
predicted
<35% of
predicted
0–1
2
3
4
0 — Not troubled by breathlessness except with strenuous
exercise
1 — Troubled by shortness of breath when hurrying on the
level or walking up a slight hill
2 — Walks slower than people of the same age on the level
because of breathlessness or has to stop for breath
when walking at own pace on the level
3 — Stops for breath after walking about 100 yards or after
a few minutes on the level
4 — Too breathless to leave the house or breathless when
dressing or undressing
E: Exercise
(6-minute
walk)
>350
min
250–349
min
The patient walks as far as possible for
6 minutes, typically along a long, flat,
hallway. At the end of 6 minutes, the
distance covered is recorded, along with
dyspnea levels and pulse oximetry
(if appropriate).
1.0
0
150–249
min
Quartile 1 = Score 0-2
Probability of Survival
O: Obstruction
(FEV1 % of
pred)
This test helps assess the submaximal
level of functional capacity (which mimics
most activities of daily living).
Figure 3. Probability of survival based on BODE index score
TABLE 3: Calculating the BODE index score
B: BMI
Order 50261
The 6-minute walk test
MVV
Variable
*50261*
0.8
Quartile 2 = Score 3-4
Quartile 3 = Score 5-6
0.6
0.4
Quartile 4 = Score 7-10
0.2
P<0.001
0.0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
Months
From: Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction,
dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl
J Med 2004; 350: 1005-1012. Copyright ©2004 Massachusetts Medical Society.
All rights reserved. Reprinted with permission.
<149
min
TOTAL BODE index score
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
5
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Exercise oximetry
protocol
1. Walk with patient for 200 to 400 feet or
until he/she exhibits symptoms. Do not
push patient beyond his/her normal level
of exertion.
2. Measure pulse oximetry continuously —
before, during, and after walking.
3. Observe the patient closely for level of
discomfort (e.g., can patient speak while
he/she walks?). Ask:“Is this how fast
you usually walk? Are you feeling out
of breath?”
Consider a trial of oxygen therapy if the
patient desaturates while walking at his/her
normal level of exertion.
OXYGEN Therapy
Long-term oxygen therapy improves survival and quality of life in patients with COPD
and resting hypoxemia. It also decreases pulmonary hypertension and polycythemia
and enhances neuropsychiatric function.NOC,REP,TAR
Oximetry testing
Oximetry is an important tool for assessing symptoms and the need for oxygen
therapy. Resting oximetry should be performed at every office visit. If results are
uncertain, consider exercise and/or nocturnal oximetry. The algorithm below outlines
a testing protocol, including qualifying criteria for oxygen therapy.
Resting office oximetry
O2 sat 89% to 94%;
PO2 55 to 59 mm Hg;
disproportionate symptoms
or a smoker*
O2 sat <89% OR
PO2 <55 mm Hg
Oxygen
therapy*
Follow-up and Monitoring
Physicians should follow up to
re-evaluate continued need for
oxygen therapy 60 to 90 days after
initial prescription, and then annually.
Most patients will continue to meet
prescribing criteria indefinitely.
Studies on home oximetry monitoring
show that patients often desaturate
below 90% on their set O2 flow rate.
Home oximetry monitoring and adjustment
in O2 flow rate may be helpful for COPD
management. Intermountain experts
recommend that patients consider
purchasing an oximeter if they travel
frequently to higher altitudes or
experience frequent exacerbations.
F e b rua ry 2 013
O2 sat
<89% OR
PO2 <55
mm Hg
O2 sat >94% OR
PO2 >59 mm Hg
Reevaluate
at next
office visit
Exercise oximetry
(Also consider nocturnal
oximetry, especially if
concerned about sleep apnea)
*NOTE: In smokers, carbon monoxide can affect the O2 SAT measured with pulse oximetry (SpO2). SpO2
consistently overestimates saturation in the presence of COHb. Therefore, if the patient has smoked within 5
hours of the test, the O2 SAT may be erroneously elevated. In this case, if symptoms warrant, order an ABG.
Also consider obtaining a multiple wavelength oximeter that measures oxyhemoglobin directly.
Oxygen prescription and delivery systems
An oxygen prescription should include:
• Qualifying diagnoses
• Qualifying results from pulse oximetry or PO2 testing
• Recommended flow rate
• Duration of need (days)
• Recommended delivery system
No single oxygen delivery system is right for all patients. Modalities should be matched
to the patient’s need for oxygen at rest, during exercise, and/or at night. Since patient
compliance with the initial oxygen prescription may be an issue, discuss the need for
therapy and for continual compliance with the patient. Address common concerns and
preferences regarding mobility, travel, safety, etc.
TABLE 4. Portability characteristics of commonly used oxygen
systems and tanks
Duration of use at 2 liters/min
System / Tank
Height / weight
Continuous flow*
Pulsed flow*
Compressed
or home-filled
tanks
E-tank
25 inches / 10.2 lbs
5 hours
10 to 20 hours
D-tank
16.5 inches / 6.4 lbs
3 hours
6 to 12 hours
C-tank
10.7 inches / 3.8 lbs
1.5 hours
3 to 6 hours
Liquid O2
Helios
11 inches / 3.6 lbs
n/a
6 to 10 hours
Helios marathon
15 inches / 5.6 lbs
5.5 hours
12 to 20 hours
26 inches / 17 lbs
1 hour
2.5 to 4 hours
Portable concentrator
*A pulsed oxygen conserver delivers oxygen to a patient only during inspiration — rather than continuously. The
benefit is that oxygen supply can last 2 to 5 times longer, depending on the patient’s inspiratory/expiratory ratio and
rate. This allows patients to carry smaller tanks. However, not all patients can use a pulsed oxygen system. Medically
fragile patients, for example, may not be able to generate adequate inspiratory force.
6 ©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Fe b rua ry 2 013
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Smoking cessation
Smoking cessation is the most important component of effective COPD treatment.
Encourage COPD patients to stop smoking immediately and help them find a way.
Nicotine replacement therapy (NRT)
SelectHealth patients can receive up to 10 weeks of NRT at no cost if they:
• Have a pharmacy benefit.
Smoking cessation
resource
Intermountain’s Quitting Tobacco
smoking cessation booklet is available
at intermountainphysician.org/
ClinicalPrograms on the COPD
topic page.
• Enroll in Quit for Life® (see right sidebar). NRT for Quit for Life is provided
through the mail.
• Undergo a nicotine dependency assessment and be recommended for NRT by a
smoking cessation specialist at Quit for Life.
The NRT benefit is limited to 1 time per year and 2 courses per lifetime.
Other selected medication protocols
• Varenicline (Chantix): Patients set a date to stop smoking. Medication begins 1 week
before that date. After 1 week, the patient stops smoking and avoids all nicotine use
(including NRT). Medication titration schedule:
–– Days 1 to 3: 0.5 mg once daily
–– Days 4 to 7: 0.5 mg twice daily
–– Day 8 through end of treatment: 1 mg twice daily
Treat patients for 12 weeks. If the patient has successfully quit smoking by then,
an additional course of 12 weeks is recommended. Note that varenicline has been
associated with depression and suicide.
• Bupropion SR (Zyban): Patients set a target quit date within the first 2 weeks of
treatment with bupropion, generally during the 2nd week. Medication titration schedule:
–– Days 1 to 3: 150 mg daily (may be extended to 7 days to minimize adverse effects)
–– Day 4 through end of treatment: 150 mg twice daily
Length of treatment is generally 7 to 12 weeks. For those who quit successfully in
this time, studies have shown improved results with ongoing therapy for 26 weeks.
Note: The safety and efficacy of electronic cigarettes have not been established to
support their use.
(from Manufacturer’s Prescribing Information, plus various clinical trials)‡
Method
Success Rate
(at 3 to 12 months)
Tier*
Varenicline (Chantix)†
25% to 45%
2
Nicotine replacement therapy (NRT) plus bupropion
35%
1 (generic)
Bupropion SR (Zyban)
25% to 35%
3 (brand name)
Nicotine replacement therapy (NRT) plus counseling
25% to 35%
15% to 30%
Counseling
10% to 20%
Cold turkey
Less than 10%
• Quit for Life® Program: A
confidential, phone-based tobacco
cessation program that offers oneon-one telephone support from a
trained specialist who can help create
a personalized quit plan that fits your
lifestyle and preferences. The program
includes a quit guide and workbook,
access to an online support community,
and stress management tools and
materials. Available in English and
Spanish, this program is available at
no cost for SelectHealth members
866-784-8454, quitnow.net
• Freedom from Smoking,
ffsonline.org
Other websites:
TABLE 5. Success rates using various methods
Nicotine replacement therapy (NRT)
Programs:
utah.quitnet.com
cdc.gov/tobacco
nicotine-anonymous.org
smokefree.gov
tobaccofreeutah.org
NRT is no cost
if requirements
described above
are met.
*Tier: Tier 1 = $5 to $15 copay; Tier 2 = $30 to $45 copay; Tier 3 = $60 to $75 copay (based on typical
SelectHealth 2013 benefit design; some benefit designs may differ).
† Varenicline has been associated with depression and suicide.
‡ Sources: GON, HAY, HUR, JOR1, JOR2, KAR, OKU, ONC, TON
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
7
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Emphasize good
inhaler technique
Refer patients to Breathing Better,
a handbook for people with COPD
and other chronic lung conditions on
intermountainhealthcare.org under the
COPD topic for more information about
good inhaler technique.
F e b rua ry 2 013
Pharmacological Therapy
The role of pharmacological therapy in COPD is to prevent and control symptoms,
reduce the frequency and severity of exacerbations, and improve exercise tolerance and
overall health. None of the existing COPD medications modify long-term decline
in lung function. Medication therapy should be determined by disease classification,
symptom severity, and overall clinical status of the patient. Bronchodilators and inhaled
corticosteroids are the primary categories of medications used.GOL,ACP
Bronchodilators
Short-acting beta2-agonists (SABAs) are used as needed for monotherapy for mild COPD
(Stage 1), but can be used in combination for all stages.
Long-acting bronchodilators are used for moderate to very severe COPD (Stages 2, 3,
and 4). The choice between different long-acting bronchodilators (long-acting beta 2agonists [LABAs], anticholinergic, or combination therapy) depends on availability and
individual response (symptom relief and side effects).
Many experts recommend trying tiotropium first, followed by combination LABA/
inhaled corticosteroid (ICS) therapy.
• Discontinue ipratropium before prescribing tiotropium.VOG
• Tiotropium has been shown to be a superior scheduled long-acting bronchodilator
over salmeterol.DON
• Formoterol offers advantages similar to salmeterol, but has a quicker onset of action.KOT
Nebulizer versus inhaler
Studies show that there is no difference in
how much medication a patient receives
from a metered-dose inhaler (MDI) as
opposed to a nebulizer.GOL Most patients
should use an MDI (with a spacer if
necessary) or a powdered inhaler — and
clinicians should teach and reinforce good
inhaler technique (see above).
Use a nebulizer:
• Patients with poor MDI techniques
LABA / inhaled corticosteroids combination therapy
Regular treatment with inhaled LABA and inhaled corticosteroids is appropriate for
symptomatic patients with severe and very severe COPD (Stages 3 and 4), FEV1 <50%
of predicted, and repeated exacerbations. Inhaled corticosteroid treatment has been
shown to reduce exacerbations and improve health in these patients; it does not modify
the long-term decline of FEV1.GOL
Note: Long-term treatment with oral corticosteroids is not recommended for COPD. It has
not been shown to improve survival and has significant undesirable side effects. However, oral
corticosteroids are useful in management of exacerbations (see page 10).
A stepped approach
Combining bronchodilators may improve efficacy and decrease the risk of side effects
• Patients with severely decreased
inspiratory flow
compared to increasing the dose of a single bronchodilator.GOL Take a stepped approach
as the disease progresses to reduce exacerbation frequency. For example, start with a
SABA (e.g., abuterol), then add tiotropium, followed by a LABA/ICS combination when
the patient has frequent COPD exacerbations (>2 times yearly).
Consider a nebulizer:
New medication for prevention of exacerbations
• Patients who can’t hold their breath
for 3 seconds
• Patients whose insurance provides
better coverage for medication
delivered via nebulizer
• Patients whose emergency room visits
during exacerbations justify the cost of
a nebulizer
Phosphodiesterase-4 (PDE4) inhibitors reduce the risk of exacerbations for patients with
severe COPD associated with chronic bronchitis and prior exacerbations. Roflumilast
is the only agent currently available within this class. Through inhibition of PDE4,
roflumilast causes an increase in cyclic AMP within the lungs. This mechanism of
action does not cause broncodilation and therefore should not be used for the relief
of acute bronchospasm. Side effects of concern include intractable diarrhea, acute
pancreatitis, weight loss, psychiatric symptoms, and significantly increased prostate,
lung, and colorectal cancers.
Treatment of exacerbations (see page 10 for more on exacerbation management)
Antibiotics and oral corticosteroids are recommended for mild to severe exacerbations,
depending on symptoms. (See table 7 on page 9.) Recommended antibiotics for the
treatment of COPD include amoxicillin/clavulanate, doxycycline, and levofloxacin.
8 ©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Fe b rua ry 2 013
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
TABLE 6. Medications used in the treatment of COPDGOL,ACP
Medication class / generic (Brand) name
Dosage
Frequency
Package
size
Tier*
Cost
$†
Inhaled short-acting beta2-agonists (SABAs)
albuterol
albuterol HFA (ProAir/Proventil/Ventolin)
pirbuterol (MaxAir CFC)‡
levalbuterol HFA (Xopenex)
levalbuterol (Xopenex)
2.5 mg/3 mL (0.083%)
90 mcg
200 mcg
45 mcg
0.31, 0.63, 1.25 mg/3 mL
1 NEB every 4–6 hours
1-2 INH every 4–6 hours
1–2 INH every 4–6 hours
1–2 INH every 4–6 hours
1–2 NEB 3 times daily
70 mL, 25 NEB
200 INH
400 INH
200 INH
72 mL, 24 NEB
1
2/3/2
3
3
1
$
$$
$$$
$$
$
400 mcg
0.5 mg/2.5 mL (0.2%)
17 mcg
18 mcg
1 INH 2 times daily
1 NEB 3–4 times daily
2 INH 4 times daily
1 INH daily
60 INH/30 INH
60 mL
200 INH
30 INH
3
1
3
2
$$$$
$$
$$
$$$$
90 mcg/18 mcg
100 mcg/20 mcg
(2.5 mg/0.5 mg)/3 mL
2 INH 4 times daily
1 INH 4 times daily
1 NEB 4 times daily
200 INH
120 INH
90 mL, 30 NEB
2
3
1
$$$
$$$$
$$
12 mcg
20 mcg/2 mL
50 mcg
15 mcg/2 mL
75 mcg
1 INH 2 times daily
1 NEB 2 times daily
1 INH 2 times daily
1 NEB 2 times daily
75 mcg once daily
60 INH
120 mL, 60 NEB
60 INH
60 mL, 30 NEB
30 INH
3
3
2
3
2
$$$
$$$$$
$$$
$$$$$
$$$$
200 mcg/INH
44, 110, 220 mcg/INH
0.25, 0.5, 1.0 mg/2 mL
90, 180 mcg/INH
40, 80 mcg/INH
200–400 mcg daily
110–330 mcg 2 times daily
0.5–1 mg daily
180–360 mcg 2 times daily
120–240 mcg 2 times daily
60 INH
120 INH
60 mL, 30 NEB
120 INH
100 INH
2
2
1
2
2
$$$
$$$
$$$$
$$$$
$$$
100/50||, 250/50, 500/50||
80/4.5||, 160/4.5
100/5, 200/5
1 INH twice daily
2 INH twice daily
2 INH twice daily
60 INH
120 INH
120 INH
2
2
2
$$$$
$$$$
$$$$
500 mcg
1 tablet orally daily
30 tablets
2
$$$$
Anticholinergics
aclidinium (Tudorza)
ipratropium solution
ipratropium HFA (Atrovent)
tiotropium (Spiriva)§
SABA plus short-acting anticholinergic (combination)
albuterol/ipratropium HFA (Combivent)‡§
albuterol/ipratropium inhalation (Combivent)§
albuterol/ipratropium (Duoneb)§
Long-acting beta2-agonists (LABAs)
formoterol (Foradil)
formoterol (Perforomist)
salmeterol (Serevent Diskus)
arformoterol (Brovana)
indacaterol (Arcapta)
Inhaled corticosteroids (ICSs)
mometasone (Asmanex)||
fluticasone HFA (Flovent)||
budesonide (Pulmicort)||
budesonide (Pulmicort Flexhaler)||
beclomethoasone HFA (Qvar)||
LABA plus corticosteroid (combination)
fluticasone/salmeterol (Advair Diskus)
budesonide/formoterol (Symbicort)
mometasone/formoterol (Dulera)||
Phosphodiesterase-4 (PDE4) inhibitor
roflumilast (Daliresp)
TABLE 7. Antibiotics used in managing COPD exacerbations (information derived from manufacturer’s packaging information and review of literature(MAN,CHO1,CHO2)
Medication
Notes about coverage
doxycycline (Vibramycin)
amoxicillin (Amoxil)
amoxicillin 875 mg / clavulanate 62.5 mg (Augmentin)
H. influenzae
S. pneumoniae
M. catarrhalis
Chlamydia pneumoniae
azithromycin (Zithromax)
sulfamethoxazole 800 mg / trimethoprim 160 mg (Septra DS)
cefuroxime (Ceftin)
Note: If suspicious of pneumococcal
resistance, consider increasing dosage or
prescribing from the antibiotics below.#
Above, plus presence of resistant organisms
and enterobacteria (K. pneumoniae,
E. coli, Proteus, Enterobacter, etc.) and/or
P. aeruginosa
moxifloxacin (Avelox)
levofloxacin (Levaquin)
Above, plus:
• Risk for Pseudomonas#
ciprofloxacin (Cipro)¶
Dosage
Tier* Cost†
100 mg twice daily x 7 days
1
$
1 gram three times daily x 7 days
1
$
875 mg twice daily x 7 days
1
$
500 mg once daily x 3 days
1
$
1 tablet twice daily x 7 days
1
$
250 to 500 mg twice daily x 7 days
1
$
400 mg once daily x 5 days
3
$$
750 mg once daily x 5 days
1
$
750 mg twice daily x 7 days
1
$
*Tier: Tier 1 = $5 to $15 copay; Tier 2 = $30 to $45 copay; Tier 3 = $60 to $75 copay (based on typical SelectHealth 2013 benefit design; some benefit designs may differ).
†Cost: Estimated monthly cost based on usual dose. $=$1 to $25; $$=$26 to $75; $$$=$76 to $150; $$$$ = $150 to $300; $$$$$ = >$300
‡To be removed from market 12/31/13.
§ Do not combine ipratropium and tiotropium; there is no added effect and some data suggests that ipratroprium might interfere with tiotropium.
||Not FDA-approved for the treatment of COPD.
¶ Ciprofloxacin use in an acute exacerbation of COPD has shown favorable clinical response in several studies. However, it should be used only in specific situations where infection
with Pseudomonas is suspected. Ciprofloxacin is less active against gram-positive organisms (including S. pneumoniae) compared to levofloxacin and moxifloxacin.
#Risk for Pseudomonas: History of, current, or possible bronchiectasis; structural lung disease AND history of repeated antibiotics or long-term/chronic systemic corticosteroid use
within the last 3 months; other evidence of Pseudomonas.
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
9
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
F e b rua ry 2 013
Exacerbation prevention and Management
An exacerbation is an acute change in the clinical status of a patient, characterized by worsening dyspnea and cough and sometimes
associated with increased sputum volume and/or purulence. About ⅓ of exacerbations have no identifiable cause, but most are
associated with environmental changes or infection. Infections may be viral or bacterial. The most common bacterial infections are
H. influenzae, S. pneumoniae , and M. catarrhalis.
Preventing exacerbations through patient education. In addition to the treatments recommended in this CPM, educating patients to
do the following is critical to prevent exacerbations. (See back page for supporting resources.)
• Understand their condition and the importance of recommended treatments
• Follow self-care recommendations, including regular physical activity, breathing techniques, infection prevention, etc.
• Monitor and respond early to symptom changes before they get worse (using an individualized action plan or care plan)
See Intermountain’s Breathing Better: A handbook for people with COPD and other chronic lung conditions for more information.
Treating exacerbations. The following algorithm provides a model for assessing and treating exacerbations.GOL,ACP,BRU
1. ASSESS severity
•Review medical history, including baseline FEV1, frequency of previous exacerbations/hospitalizations, comorbidities, and age
•Measure pulse oximetry (or ABGs if available) to determine need for supplemental oxygen
•Consider performing chest x-ray to identify complications such as pneumonia and/or alternative diagnoses that may mimic symptoms of exacerbation
•Consider obtaining EKG to aid in diagnosis of right ventricular hypertrophy, arrhythmias, or ischemia
2. DETERMINE risk for poor outcome and need for hospital assessment or admission
Risk factors for poor outcomeWOO,CEL2,MIR
Other indications for hospital assessment or admission
•Severe underlying COPD (FEV1 <50% of predicted)
•Frequent previous exacerbations or hospitalizations
• Older age
• Marked increase in intensity of symptoms,
•Presence of comorbid conditions
•Antimicrobial use within the last 3 months
• Use of accessory respiratory muscles
• New onset of central cyanosis or peripheral edema
(more than 3/year)
such as sudden development of resting dyspnea
Significant risk for poor outcome, possible
need for ventilatory support,
and/or inadequate home support
yes
• Hemodynamic instability
• Signs of right heart failure
• Reduced alertness
• Newly occurring arrhythmias
• Diagnostic uncertainty
HOSPITALIZE
no
3. TREAT based on severity of exacerbation, presence of sputum volume and/or purulence,
risk for poor outcome, and/or risk for Pseudomonas
MILD
EXACERBATION
• No increased sputum volume or purulence
• No risk factors for poor outcome
Mild
exacerbation
treatment
MILD TO MODERATE
EXACERBATION
• Increased sputum volume or purulence
• Minimal risk factors for poor outcome
MODERATE TO SEVERE
EXACERBATION
• Risk factors for poor outcome AND/OR
• Risk for Pseudomonas
• Inhaled short-acting beta2-agonists (SABAs) — increase the dose and/or frequency of inhaled SABAs with or
without anticholinergics and combination LABA/ICS. All SABAs show equal efficacy.
Mild to severe
exacerbation
treatment
• Antibiotics are indicated when sputum volume an/or purulence is
increased. Antibiotics should provide coverage of the major bacterial
pathogens involved in the exacerbations, taking into account local
patterns of antibiotic sensitivity. (See table 7 on page 9 for a list of
antibiotics used in managing COPD.)
• Oral Corticosteroids are recommended if baseline FEV1 is less than
50% of predicted. May shorten recovery time, improve FEV1, and improve
hypoxemia. Recommended dose: Start with 40 to 60 mg daily. Titrate dose
downward every 3 days over 7 to 10 days.
10 ©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Fe b rua ry 2 013
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Ongoing Treatment and Follow Up
Ongoing monitoring
Follow-up spirometry should be performed in patients with a significant change in
symptoms or disease activity or to document an objective response to a change in
therapy. Otherwise, there are a lack of scientific data to support a specific
spirometry schedule.
COPD Assessment Test (CAT)
Consider using the CAT to monitor your
patient’s progress. The patient rates each
of the following on a scale 0 to 5 (0 =
none/normal to 5 = markedly abnormal):
• Cough
Peak flow monitoring is not indicated or reliable for diagnosis or ongoing monitoring
• Mucus in my chest
in COPD.
• Chest tightness
Pulmonary rehabilitation
• Breathlessness walking up a hill
According to the results of several clinical trials, pulmonary rehabilitation has many
benefits for patients at all stages of COPD, including improved quality of life, reduction
of hospital days, and improved exercise capacity.RIE
• Ability to do activities at home
Minimum length of an effective rehabilitation program is 6 weeks, with more effective
results for longer programs (12 weeks). Some benefits may decline gradually over 12
to 18 months. Most insurance providers cover up to 12 to 16 weeks of pulmonary
rehabilitation. Pulmonary rehab is a covered benefit for SelectHealth members.
• Sleeping
Palliative care
During end-stage COPD, the goal is to minimize symptoms, which can include
disabling cough, dyspnea, anxiety, and depression. ACP End-stage COPD can be
challenging to identify because the disease trajectory can be long and variable. The
BODE index and the 6-minute walk test can help identify patients with end-stage
COPD (see page 5). It is critical to provide palliative care because the symptoms can
be as debilitating and as painful as end-stage lung cancer.LEY
Do the following to provide palliative care for your patients:
• Discuss how the disease will affect the patient over time (disease progression)
• Ask patients to discuss their wishes and encourage them to create a Physician Order
for Life Sustaining Treatment (POLST)/advanced directive and to share their wishes
with family and caregivers
• Confidence leaving the home
• Energy
See the complete CAT questions and
guideline for using the CAT here:
catestonline.org.JON
Where to find pulmonary
rehabilitation programs
For help in finding pulmonary
rehabilitation programs in the
Intermountain region, refer to the
Pulmonary Rehab Fact Sheet on the
COPD topic page or at i-printstore.com.
• Encourage pulmonary rehabilitation to help lessen symptoms
• Encourage patients to follow breathing and relaxation techniques (See the Breathing
Better handbook on intermountainhealthcare.org under the COPD topic.)
• Consider treatment for anxiety and depression
• Continue to treat comorbidities to keep the patient comfortable
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
11
MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD)
Provider Tools
Oxygen Therapy Prescription
FOR USE BY PHYSICIANS AND OXYGEN PROVIDERS
Patient Name:
Order copies at
i-printstore.com.
Phone:
DOB:
Phone:
 COPD – 496
 Pneumonia – 486
 Congestive Heart Failure (CHF) – 428.0
 Cor Pulmonale – 416.9
Name:
 Obstructive Sleep Apnea Patient
– 780.53
FAX:
 Hypoxemia – 799.02
Interstitial Lung Disease – 515
Testing (PFT) Orders
Function
Pulmonary Atelectasis
V18.0
 Post-op:
 Other:
__
DOB:
Phone:
Note: O2 SAT (SpO2 or SaO2Ordering
FAX:
) must be
Phone:
<89% and/or PO2 must be <55 mm Hg at rest, during
Physician:
exercise, and/or nocturnally.
If O2 SAT = 89% OR PO2 = 55-59, must document CHF, cor pulmonale, or polycythemia.
Lab location:
Initial
O2 SAT:
60- to 90-day verification
Phone:
__ FAX:
Annual verification
__ Time:
Appointment date:
/
/
Date of test:
/
/
Instructions:Date of test:
your test % or PO2:
for at least
bronchodilators
caffeine
 Don’t
% or PO2:
mm
Hg drink
O2 SAT
: or use %
or PO2:
mm12
HghoursObefore
mm Hg
2 SAT:
 Don’t smoke for at least 2 hours before your test (preferably 24 hours)
 exercise  nocturnal
 resting  exercise  nocturnal
 resting  exercise  nocturnal
Don’t eat a heavy meal or do vigorous exercise for at least 2 hours before your test
Date of test:
 resting
APPOINTMENT INFO
This care
process model
(CPM)
Ordering Physician:
/
/

back braces L/min for each)
remove
andcircle
clothesand
loose fitting
 Wear and/or
Recommended flow rate (check continuous
nocturnal
recommended
 Other:
 Continuous: 1 2 3 4 5 6 7 8 9 10 L/min
 Nocturnal:
1
2
4 
5 ASSESSMENT
6 7 8 (diagnostic
9 10 L/min  MONITORING
3
evaluation)
 Asymptomatic, but suspected
 Routine follow-up — no specific indication
 Follow up for treatment titration/adjustment
Is pulsed portable system needed?  yes
 no (If unsure, choose yes.)
 Follow up for symptom/function exacerbation
diagnosis
 DRUG REACTIONS
 Symptomatic
 Amiodarone
 Baseline for screening after
Recommended delivery system
 General chemotherapy for cancer
acute illness (e.g., pneumonia)
 Per oxygen provider/ respiratory therapist
recommendation
 Bleomycin
for preoperative
 Baseline
 Methotrexate
for pre-chemotherapy
 Continuous:  compressed gas tank+ Baseline
O2 concentrator
 Radiation reaction
 Baseline for pre-bone marrow
 Portable:  home-filled tank + O2 concentrator
 liquid oxygen system  portable concentrator
transplant
 Nocturnal only (concentrator)
 Baseline for pre-employment
REASONS FOR TESTING
ACPQaseem A, Wilt TJ, Weinberger SE, et al.
Diagnosis and Management of Stable Chronic
Obstructive Pulmonary Disease: A Clinical
Practice Guideline Update from the American
College of Physicians, American College of
Chest Physicians, American Thoracic Society,
and European Respiratory Society.
annals.org/article.aspx?articleid=479627,
accessed February 15, 2013.
intermountainphysician.org/
ClinicalPrograms or
intermountain.net/ClinicalPrograms.
Click “C” from the “Clinical
Topics A-Z” list on the right side
of the screen, and choose COPD.
DIAGNOSIS
GOLGlobal Initiative for Chronic Obstructive Lung
Disease (GOLD) 2011. Global strategy for
the diagnosis, management, and prevention
of chronic obstructive pulmonary disease.
Available from: goldcopd.org/guidelinesglobal-strategy-for-diagnosis-management.
html. Accessed January 14, 2013.
Access this CPM and other
resources from the COPD topic
page, which is accessible from
QUALIFYING VALUES
The primary references used in the
development of this CPM are listed
below. Go to the COPD topic page
at intermountainphysician.org/
ClinicalPrograms for a complete
list of cited references.
RESOURCES
INITIAL O2 SET-UP RECOMMENDATIONS
References
F e b rua ry 2 013
Anticipated duration of need:
 90 days OR  Other:
 Baseline for insurance
 Baseline for athletics
days
month(s)
a year or longer
Cough
Dyspnea
Asthma/reactive airways disease
Chronic bronchitis
Pulmonary emphysema
Cystic fibrosis
Bronchiectasis
Heart failure
Interstitial lung disease
Sarcoidosis
Pulmonary vascular disease (e.g., thromboembolism,
pulmonary arterial hypertension)
 Central airway obstruction (e.g., goiter, tracheal/vocal
cord abnormality)











test(s) or protocol(s) below:
Selectforspecific
Initial O2 prescription is authorized
90 days. Need for continued oxygen therapy must be validated at these intervals to continue coverage:
• Within 60-90 days of initiation
therapy tests and protocols:
Mostofcommon
• Annually thereafter
 SPIROMETRY  Screening (pre-bronchodilator only)  Post-bronchodilator if indicated*
Ordering Physician Signature:
 COPD protocol: Includes spirometry with bronchodilator, 6-min walk, B.O.D.E. Index
 Full PFTs: Includes spirometry with bronchodilator if indicated*; DLCO; TLC by body plethysmography
if FVC and TLC sb is reduced; 6-min walk
 Asthma protocol: Includes spirometry with bronchodilator
Healthcare Provider: Fax or send this form directly to the oxygen provider at the time of prescription.
Other specialty tests:
Oxygen provider name:
Oxygen Provider:
1.
2.
 DISEASE/SYMPTOM/MANIFESTATION
*Indications for bronchodilator testing:
 Obstruction
 Cough
 Other symptoms of asthma/COPD
monoxide diffusing capacity (DLCO)Fax:  MUSCLE STRENGTH
 Diffusing capacity: Single-breath carbon
Phone:
 MIP/MEP  MVV (maximum voluntary ventilation)
 LUNG VOLUMES
 BRONCHOPROVOCATION
 Single breath Gas Dilution (with DLCO)
 Eucapnic voluntary hyperventilation (EVH)
 Methacholine challenge
Verify oxygen setup below and fax or send to SelectHealth for verification of oxygen benefit and payment. Exercise
 EXERCISE TESTING
Also fax a copy to ordering physician’s
of ABG
oxygen
set-up
atMannitol
top ofinhalation
form). test
line(see physician FAX number
Arterial
Maximum exercise
max forverification
 VO2office
 Walking saturation
 6-min walk
 Body box (plethysmography)
 Multiple breath N2 washout (with right to left shunt estimation)
Print copies from
i-printstore.com.
Date of setup:
Flow rate:
L/min
O2 SAT after setup:
_
Other disease-based and specialty protocols:
 Amiodarone protocol: Includes spirometry (bronchodilator if indicated*), DLCO
 Bone marrow transplant protocol: Includes spirometry (bronchodilator if indicated*), DLCO
 Diabetes (inhaled insulin) protocol: Includes spirometry, DLCO
 Heart transplant protocol: Includes spirometry with bronchodilator, DLCO, room air ABGs
 Neuromuscular disorder protocol: Includes spirometry (bronchodilator if indicated*), MIP/MEP/MVV, sitting and supine VC
 Occupational exposure protocol: MIP/MEP/MVV, R/a ABGS, spirometry with bronchodilator, DLCO, lung volumes
For more information on oxygen therapy or additional copies of this form, go to the COPD page on intermountainphysician.org.
©2007-2013 Intermountain Healthcare. All rights reserved. Clinical Education Services – 801-442-2963 IHCEDCOPD102 – 02/13.
Delivery system:
Ordering Physician Signature:
Forms, including
Pulmonary Function
Testing (PFT) Orders
and Oxygen Therapy
Prescription forms
Date:
For more information or additional copies of this form, go to intermountainphysician.org/clinicalprograms.
©2007-2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 COPD101 – 02/13
*50261*
Order 50261
Patient Education Tools
Breathing Better,
a handbook for
people with COPD
and other chronic
lung conditions
Patient education
fact sheets in
English and Spanish.
Topics include
Pulmonary Rehab
(FS173), COPD
(FS092), and
Oxygen Use at Home
(FSHC002).
(52 pages).
Order at
i-printstore.com.
Item PLM001.
Order at
i-printstore.com.
Patients can also access information about COPD directly from Intermountain’s
Health Resources. Go to intermountainhealthcare.org/health, then click Health
Topic Library from the left-hand navigation.
This CPM is based on best evidence at the
time of publication. It is not meant to be a
prescription for every patient. Clinical
judgment based on each patient’s unique
situation remains vital.
We welcome your feedback. Please contact
[email protected] with questions
or comments on clinical content.
12
COPD CPM WORKGROUP
• Roy Gandolfi, MD, Internal Medicine, Granger Clinic;
Associate Medical Director, SelectHealth - Chair
• Steven Abplanalp, RRT, Director of Respiratory
Services, Intermountain Healthcare
• Curtis Wander, PharmD, SelectHealth
• Dixie Harris, MD, Utah Valley Medical Center,
Pulmonary Division
• Denitza Blagev, MD, Intermountain Medical
Center, Pulmonary Division
• Nathan Dean, MD, Intermountain Medical
Center, Pulmonary Division
©2007-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM020 - 02/13