Download chronic obstructive pulmonary disease clinical

CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CLINICAL PRACTICE GUIDELINES
Reviewed and approved 5/2014
Risk
Intervention
Definition
Components
of COPD
Management
Recommendations
COPD, a common preventable and treatable disease, is characterized by
persistent airflow limitation that is usually both progressive and associated with an
enhanced chronic inflammatory response of the lungs to noxious particles or
gases. Exacerbations and comorbidities contribute to the overall severity in
individual patients. COPD is a major cause of disability, and it’s the third leading
cause of death in the United States.




Assess and monitor disease
Reduce risk factors
Manage Stable COPD
Manage Exacerbations
Goals
Determine the severity of the disease, including the severity of airflow limitation,
the impact on the patient’s health status, and the risk of future events (such as
exacerbations, hospital admissions or death, in order to guide therapy.
 Prevent disease progression
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
 Prevent and treat complications
 Prevent and treat exacerbations
 Reduce mortality
 Prevent or minimize side effects from treatment
Medication
Reconciliation
Accurately and completely reconcile all medications patient is taking across the
continuum.
Diagnosis
1
A diagnosis of COPD should be considered in any patient who has cough, sputum
production, or dyspnea that is progressive and worse with exercise, and/or a
history of exposure to risk factors objective for disease.
● Obtain detailed medical history
 Conduct Spirometry testing. Spirometry is required to make a clinical
diagnosis of COPD; the presence of a post-bronchodilator FEV1/FVC
<0.70 confirms the presence of persistent airflow limitation and thus of
COPD. All health care workers who care for COPD patients should have
access to spirometry.
 Assessment of symptoms with the COPD Assessment test (CAT)
 Assessment of co-morbidities
SummaCare Clinical Care Guidelines
Risk
Intervention
Determining
Etiology and
Objective
Measures
Recommendations
Medical History: A detailed medical history of a new patient known or thought to
have COPD should assess:
 Exposure to risk factors, such as smoking and occupational or
environmental exposures.
 Past medical history, including asthma, allergy, sinusitis or nasal polyps,
respiratory infections in childhood, and other respiratory diseases.
 Family history of COPD or other chronic respiratory disease (such as
asthma or CF).
 Pattern of symptom development. Typically develops in adult life and most
patients are conscious of increased breathlessness, prolonged “winter
colds” and some social restrictions.
 History of exacerbations or previous hospitalizations for respiratory disorder.
 Presence of comorbidities, such as heart disease, osteoporosis,
musculoskeletal disorders and malignancies that may also contribute to
restriction of activity.
 Impact of disease on patient’s life, including limitation of activity; missed
work and economic impact; effect on family routines; and feelings of
depression or anxiety, well-being and sexual activity.
 Social and family support available to the patient.
 Possibilities for reducing risk factors, especially smoking cessation.
Physical: Though an important part of patient care, a physical examination is
rarely diagnostic in COPD. Physical signs of airflow limitation are rarely present
until significant impairment of lung function has occurred.
 Evidence of airflow obstruction (wheezes, prolonged expiratory time).
 Signs of emphysema (over distension of lungs in stable state, low
diaphragmatic position, hyper-resonance to percussion).
 Characteristics that suggest severe disease (pursed-lip breathing, use of
accessory respiratory muscles, in drawing of lower interspaces).
 Unusual positions to relieve dyspnea at rest, dependent edema, digital
clubbing.
Testing and
Additional
Investigations
2
The following tests should be undertaken for the assessment of a patient with
moderate (Stage II), Severe (Stage III), and very severe (Stage IV):
 Spirometry should be done IN ALL CASES once COPD is considered
(including mild (Stage I) COPD).
 Chest x-ray to diagnose emphysema and rule out other disease. Repeat xray to rule out malignancy, based on clinical judgment.
 Arterial blood gases in patients with more severe disease with FEV1 <40%
predicted or with clinical signs suggestive of respiratory failure or right heart
failure.
 Bronchodilator reversibility testing: once at the time of diagnosis to help
rule out a diagnosis of asthma, to establish a patient’s best attainable lung
function, to gauge a patient’s prognosis, and to guide treatment decisions.
 Alpha-1 antitrypsin deficiency screening: In patients who develop COPD at
SummaCare Clinical Care Guidelines
Risk
Intervention
Recommendations
a young age (<45 years) or who have a strong family history of the disease
to identify coexisting alpha-1 antitrypsin deficiency.

Risk Factor
Reduction
Member
Education
Smoking Prevention
o Strongly encourage patient and family to stop smoking.
o Provide counseling, nicotine replacement, and formal cessation
programs as appropriate.
 Eliminate Occupation Exposures
 Reduce indoor and outdoor pollution
 Influenza and pneumococcal vaccination should be offered in older patients
and those with more severe disease of cardiac comorbidity. Influenza
vaccine can reduce serious illness and death in COPD by about 50%.
 All patients who get short of breath when walking at their own pace on level
ground should be offered rehabilitation to improve symptoms, quality of life,
and physical and emotional participation in everyday activities.








Pharmacologic
Treatment





3
Diagnosis
Prognosis
Symptoms of exacerbation
Exercise training/physical activity/pulmonary rehabilitation
Smoking cessation
Medication management including use of oxygen therapy, aerosols, PFM,
spacers
Influenza vaccine, annually.
Bronchodilators are central to symptom management given on an asneeded basis or on a regular basis to prevent or reduce symptoms: inhaled
therapy is preferred; type and dose depends on availability and individual
response.
Beta-agonist to relax airway smooth muscle, Regular- and as needed use
improves FEV and symptoms.
Anticholinergics last longer than the short-acting beta-agonists to reduce
exacerbations and related hospitalizations, improves symptoms and health
status.
Alpha-1 Antitrypsin Augmentation Therapy may benefit young patients with
severe hereditary alpha-1 antitrypsin deficiency and established
emphysema.
Add long-term oxygen if chronic respiratory failure, RA p02 ≤ 55, or RA p02 ≤
88%.
Antibiotics +/- oral glucocorticoid for AECB.
SummaCare Clinical Care Guidelines
Old
0: At Risk
New
0: At Risk
Characteristics Chronic symptoms
Exposure to risk
factors
Normal spirometry
I: Mild
I: Mild
FEV1/FVC<70%
FEV1≥80%
With or without
symptoms
II: Moderate
IIA
II: Moderate
FEV1/FVC<70%
50%≤FEV1<80%
With or without
symptoms
IIB
III: Severe
FEV1/FVC<70%
30%≤FEV1<50%
With or without
symptoms
III: Severe
IV: Very Severe
FEV1/FVC<70%FEV1<3
0% or FEV1<50%
predicted plus chronic
respiratory failure
Avoidance of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting
bronchodilators
Add inhaled glucocorticosteroids if repeated
exacerbations
Add long-term oxygen if
chronic respiratory
failure
Consider surgical
treatments
Risk
Intervention
Pulmonary
Rehab
Candidates
Oxygen
Management
4
Recommendations
Patients at all stages of disease benefit from exercise training programs with
improvements in exercise tolerance and symptoms of dyspnea and fatigue.
Benefits can be sustained even after a single pulmonary rehabilitation program.
Although the minimum length of an effective program is 6 weeks, the longer the
program continues the more effective are the results. However, no mechanism
has been developed to maintain the effects over time.
The long term administration of oxygen (>15 hours per day) to patients with
chronic respiratory failure has been shown to increase survival. Long term
oxygen therapy is introduced in very severe COPD patients who have PaO2 at 55
mm Hg or SaO2 at 88% or patients with pulmonary hypertension, peripheral
edema suggesting congestive heart failure, or polycythemia with PaO2 between
55 and 60 mmHg or a PaO2 of 89% with a goal to increase the PaO2 to 90%.
SummaCare Clinical Care Guidelines
Reduce Symptoms
 Relieve symptoms
 Improve exercise tolerance
 Improve Health Status
Reduce Risk
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
Pharmacologic Management
Management
of Stable
COPD
Bronchodilator Recommendations:
 For both beta2 agonists and anticholinergics, long-acting formulations are
preferred. (A)
 The combined use of short- or long-acting beta2 agonists and
anticholinergics may be considered if symptoms are not improved with
single agents (B)
 Based on efficacy and side effects inhaled bronchodilators are preferred
over oral bronchodilators. (A)
 Based on relatively low efficacy and more side effects, treatment with
theophylline is not recommended unless long-term treatment
bronchodilators are unavailable or unaffordable. (B)
Corticosteroids
 Long-term treatment with inhaled corticosteroids is recommended for
patients with severe and very severe COPD and frequent exacerbations
that are not adequately controlled by long-acting bronchodilators (A)
 Long-term monotherapy with inhaled corticosteroids is not recommended
in COPD because it is less effective than the combination of inhaled
corticosteroids with long-acting beta2 antagonists. (A)
 The phosphodiesteracse-4 inhibitor, roflumilast, may also be used to
reduce exacerbations for patients with chronic bronchitis, sever and very
sever COPD, and frequent exacerbations that are not adequately
controlled by long-acting bronchodilators. (B)
Monitoring and Follow Up
 Decline in lung function is best tracked by spirometry performed at least
once a year. Questionnaires such as COPD Assessment Test (CAT) can
be performed every 2-3 months. Trends and changes are more valuable
than single measurements.
 Inquire about changes in symptoms since last visit including cough and
sputum, breathlessness, fatigue, activity limitation and sleep disturbances.
 Monitor exacerbation history and comorbidities.
5
SummaCare Clinical Care Guidelines
An exacerbation of COPD is defined as an acute event characterized by a
worsening of the patient’s respiratory symptoms that is beyond normal dayto-day variations and leads to a change in medication.
Treatment Options
 Oxygen: Supplemental oxygen should be titrated to improve the patient’s
hypoxemia with a target saturation of 88-92%.
 Bronchodilators: Increase dose and/or frequency of existing short-acting
bronchodilator therapy, preferably with 2-agonists. If not already used,
anticholinergics until symptoms improve.
 Systemic Coricosteroids: Corticosteroids shorten recovery time, improve
lung function (FEV1) and arterial hypoxemia (PaO2) and reduce the risk of
early relapse, treatment failure, and length of hospital stay. A dose of 40
mg prednisolone per day x 5days is recommended.
Management
of
Exacerbations



Antibiotics: Antibiotics should be given to patients:
With all three of cardinal symptoms of increased dyspnea, increased
sputum volume and increased sputum purulence
With increased sputum purulence and one other cardinal symptom
Who require mechanical ventilation
Hospitalizations Indications for Exacerbations
 Marked increase in intensity of symptoms
 Severe underlying of COPD
 Onset of new physical findings
 Failure to respond to medical management
 Frequent exacerbations
 New arrhythmias
 Older age
 Insufficient Home Support
Surgical
Treatment
6
Lung volume reduction surgery has been demonstrated to result in improved
survival in sever emphysema patients with upper lobe emphysema and low postrehabilitation exercise capacity.
SummaCare Clinical Care Guidelines
Vaccines: Infections can lead to COPD exacerbations. The influenza vaccine is
recommended annually in all COPD patients. Pneumonoccocal vaccine is
recommended for COPD patients 65 years and older, and has been shown to
reduce community-acquired pneumonia in those under age 65 with FEV1 <40%.
Alpha-1 Antitrypsin Augmentation Therapy: Not recommended for patients
with COPD that is unrelated to alpha-1 antitrypsin deficiency.
Other
Antibiotics: Not recommended except for treatment of infectious exacerbations
Pharmacologic and other bacterial infections.
Treatments
Mucolytic Agents: Patients with viscous sputum may benefit from mucolytics, but
overall benefits are very small.
Antitussives: Use is not recommended.
Vasodilators: Nitric oxide is contraindicated in stable COPD. The use of
endothelium-modulating agents for the treatment of pulmonary hypertension
associated with COPD is not recommended.
SelfManagement
Education



Assess educational needs and provide self-management education.
Provide access to an interdisciplinary team (RN, Pulmonary Rehab
therapist, PCP)
Develop individualized educational plans
Source:
Global Initiative for Chronic Obstructive Lung Disease World Health Organization National Institute of
Health, Revised 2014.
Guidelines reviewed/updated:
4/23/02 Clinical Quality Committee
5/25/04 Clinical Quality Committee
4/6/06 Clinical Quality Committee
6/5/08 Clinical Quality and Resource Management Committee
6/3/2010 Clinical Quality and Resource Management Committee
6/7/2012 Clinical Quality and Resource Management Committee
5/8/2014 Medical Policy Committee Meeting
7
SummaCare Clinical Care Guidelines