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4 2 Care Process Model February 0 0 10 10 8 8 6 6 4 4 2 2 0 0 1 2 3 4 5 2013 6 Flow (L/sec) 10 M A N A G E M E N T 8O F 6 Chronic Obstructive Pulmonary Disease (COPD) Glottis closure 4 0 1 2 3 4 5 6 2013 Update 0 Volume (liters) 1 2 3 4 2 5 6 0 0 1 2 3 4 5 6 10 This care process model (CPM) was developed by multidisciplinary clinical experts from Intermountain Healthcare, based on 8 guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)GOL, the American College of Physicians, and 6 the American Thoracic Society (ATS), and others.ACP The CPM recommends screening, diagnosis, and treatment processes to improve Early Termination 4 care and outcomes for patients with chronic obstructive pulmonary disease (COPD). Related tools, such as forms, reference tables, 2 and patient education materials, support implementation of the recommended care processes. 0 0 1 2 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 5 6 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. 3 R ST I C 2 L A R M MANAGEMENT OF CHRONIC OBSTRUC TIVE PULMONARY DISEA SE (COPD) NO RE 4 TI V F e b rua ry 2 013 E 0 0 Information on spirometry testing10 for patients with COPD can be found on 8 goldcopd.org. (Search for “spirometry.”) Why spirometry? 6 3 4 5 6 L A 2 M 2 ED X A 0 0 1 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. L R M UC VE 8 Spirometry is required for diagnosing COPD, as well as for diagnosing asthma, pulmonary fibrosis, and cystic fibrosis. Spirometry should be performed for any patients 6 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 R TR TI 10 NO NO OBS Reference ranges for 2 spirometry results 2 Spirometry and Other Tests Guide to Spirometry 4 1 Criteria for diagnosis and severity assessment 0 Basic spirometry tests for evaluation and diagnosis of COPD are described in table d 3 4 5 6 0 1 2 3 4 5 6 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 10 Normal: FEV1/FVC ratio >0.70; FEV1 >80% of predicted Mild obstruction: FEV1/FVC ratio <0.70; FEV1 >80% of predicted 6 NO L A IL D R SEV AT M M DE ER 2 Moderate obstruction: FEV1/FVC ratio <0.70; FEV1 50 to 80% of predicted R 4 MO Flow (L/sec) 8 E E 0 0 1 2 3 4 Volume (liters) 5 6 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 forverification 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