Download Chronic Obstructive Pulmonary Disease

Furnace House Surgery
Chronic Obstructive
Pulmonary Disease
Protocol
Date: 13th April 2005
Review Date: April 2006
Acknowledgement: Sarah Hicks
Aims and objectives of this protocol.
• to improve COPD care in this Practice
• to reduce emergency admissions to hospital due to
COPD
• to improve quality of life in COPD patients
• to improve patient education
• to encourage patients to take responsibility for their own
COPD management
Definition of COPD
• A collection of conditions that share the features of
chronic obstruction of expiratory flow, e.g. chronic
bronchitis, emphysema, chronic obstructive airways
disease, chronic airflow obstruction and some cases of
chronic asthma which have resulted in irreversible lung
destruction.
• slow progressive condition characterised by marked
airways obstruction that does not change markedly over
time.
Each patient will have varying proportions of:
• Chronic bronchitis with increased and airway wall
inflammation;
• small or peripheral airways disease increased mucus,
airway wall thickening, scarring and narrowing
• emphysema permanent destruction of the alveoli,
airspaces distal to the terminal bronchiole. On lung
expansion, elastic recoil is reduced and pressure to drive
expiration is lost. There is also a drop in intraluminal
pressure needed to maintain airway patency during
forced exhalation (demonstrated by lip pursing).
Presentation
• smoked for at least 20 pack years
• Usually present in the fifth decade with a productive
cough or an acute respiratory complaint.
• By the sixth or seventh decade, exertional dyspnoea is
usually a feature and intervals between acute
exacerbations become shorter
• earlier stages, slow, laboured expiration, plus wheezing
on forced expiration may be apparent
• Can result in hyperventilation and a gradual increase in
the anteroposterior diameter of the chest.
Causes
The underlying causes of COPD yet to be fully elucidated but include:
• cigarette smoking, with other types of tobacco smoking also being
strong risk factors
• heavy exposure to occupational dusts and chemicals (vapours,
irritants and fumes)
• indoor and outdoor air pollution.
• Alpha-1 Antitrypsin Deficiency (very small minority)
Disease classification
severity of disease rather than presumed underlying
causes. The objective measure used for this and
monitoring progression of the disease is Forced
Expiratory Volume in one second (FEV 1).
Severity of Airflow Obstruction
• Mild
• Moderate
• Severe
FEV1% predicted
50 – 80
30 – 49
<30
Making a Diagnosis
Think of a diagnosis of COPD for patients who are:
• Over 35 years
• Smokers or ex-smokers
• No relevant pathology on chest XRay
• Have any of these symptoms
– exertional breathlessness
– chronic cough
– regular sputum productions
– frequent winter bronchitis
– wheeze
Perform spirometry if COPD seems likely.
At the time of their initial diagnostic
evaluation, prior to spirometry, all patients
should have:
• a chest radiograph to exclude other pathologies
• a full blood count to identify anaemia or polycythaemia
• body mass index (BMI) calculated.
• An Alpha-1 Antitrypsin test if there is early onset of symptoms,
minimal smoking history or family history.
FEV1 (%) and the smoking effects
The COPD Clinic
• Attendance at this clinic is initially instigated via the doctor but
follow-up appointments will be generated by either the clinic nurse
or the administrating assistant at a period suitable to the patient
needs.
• The clinic will provide assessment of patient general health, in
relation to their COPD, and spirometry testing for the purpose of an
aid to either early diagnosis or management of the patients disease.
• The patient should be given the ‘Lung Function Test’ Patient
Information Leaflet (can be located in ‘Patient Information Leaflets’
in Global Server) at least 1 week prior to any spirometry tests
Initial Clinic Appointment.
The following will take place at an initial clinic appointment:
• Spirometry to confirm diagnosis
• Assessment of smoking status and desire to quit
If applicable
• Adequacy of symptom control:
– Breathlessness
– Exercise tolerance
– Estimated exacerbation frequency
• Inhaler technique
• Body Mass Index
• Pulse oximetry (SaO2)
• Flu / Pneumonia immunisation status
cont.
•
•
•
•
Depression Assessment
Dyspnoea Score
COPD Information Leaflet
Referral back to GP for regular 6 monthly follow-up if spirometry confirms
COPD diagnosis
Annual Clinic Review
The following will take place at a each follow-up clinic appointment:
• Patient education about COPD, effects of smoking and the disease
progression
• Smoking status, encouragement to stop and their desire to quit (Referral to
Smoking Cessation Service if patient agreeable)
• Adequacy of symptom control
• Presence of complications
• Effects of drug treatment
• Inhaler technique
• FEV1 and FVC
• Pulse oximetry (SaO2)
• BMI and nutritional state
• Dyspnoea Score
• Need for social services or occupational therapy input
• Need for referral to specialist and therapy services
• Need for long-term oxygen therapy
• Flu / Pneumonia immunisation status
If applicable
• Bronchodilator reversibility test
•
Steroid reversibility test
•
Depression Assessment
Ov er 35 Years of age
+ s mok ers or ex-s mokers
+have any of the following s ymptoms
- Exertional breathless ness
-Chronic cough
-R egular s putum production
-Frequent W inter bronc hitis
-W heeze
+ No c linical features of asthm a
C onsider COPD
Reques t ches t xray
R efer to COPD c linic for as sess ment
(Appointment needs to be 6 weeks pos t exacerbation / c hes t infection)
Give Lung Function Test Information Leaflet (on Global Server)
COPD (Chest) Clinic
1st appointm ent
Lung Function Test + Rever sibility to Salbutam ol
Normal Lung Func tion Res ults
Inform GP
N o follow -up appointment
at Chest Clinic
Advise to return to GP if s ymtoms
return / worsen
Ask GP to apply Read Code for
removal off COPD / Asthma register
Abnormal Lung Func tion Tes ts results
COPD
Asthma
Read Code C OPD
Inform GP
Giv e COPD Information leaflet
Lifesty le advis e inc luding smoking status
and importanc e of exercis e
Refer bac k to GP for appropriate medication
Read Code Asthma
(if not on regis ter)
Inform GP
Refer back to GP for
appropriate m edication
6 monthly review by GP
Annual COPD Clinic
Steroid revers ibility avalable (GP to indicate)
Patient knowlegde and educ ation
Sm ok ing and exerc ise s tatus
Inhaler technique
Puls e oximetry
Check s pirometry
Body mass Index
D yspnoea s core
Signs of depres sion
Im munisation status
Multidisc iplinary / spec ialis t input needed
Give Information about c ondition
GP rev iew 3 monthly until stable
then 6 monthly
Annual review at as thma c linic
Reversibility tests: differentiation of COPD from asthma
• Reversibility tests involve measuring spirometry before and after
treatment and can help distinguish between COPD and asthma.
Tests may include reversibility to bronchodilators (beta2 agonists or
anticholinergics) or inhaled / oral steroids.
• Significant reversibility is defined as a rise in FEV1 that is both
greater than 200ml and 15% of the pre-test value.
• Substantial reversibility (>400ml) indicates asthma.
Pharmological Management of COPD
Beta 2 Agonist or Anticholenergic
Salbutamol
Atrovent
2 Month Assessment or exacerbation
Asymptomatic
Maintain present treatment
Symptomatic
Add Long Acting beta2Agonist = Salmeterol (Serevent) / Formeterol( Oxis )
or
Long Acting Anticholenergic = Tiotropium (Spiriva)
2 Month Assessment or exacerbation
Asymptomatic
Maintain present treatment
Symptomatic
Add Inhaled Corticosteroid
Fluticasone (Flixotide) or Budesenide (Pulmicort)
or Consider combined treatment e.g.
Salmeterol + Fluticasone (Seretide)
Formeterol + Budesonide (Symbicort)
Discontinue if no benefit af ter 4 weeks
2 month Assessment or exacerbation
Asymptomatic
Maintain present treatment
Symptomatic
Add Theophylline slow release
Discontinue if no benefit af ter 4 weeks
NB
Mucolytics can be used at any stage to relieve chronic sputum production and reduce exacerbations
e.g. Mecysteine Hydrochloride (Visclair)
Mucolytics
Mucolytic drug therapy should be considered in patients
• with a chronic cough productive of sputum.
• Mucolytic therapy should be continued if there is
symptomatic improvement (for example, reduction in
frequency of cough and sputum production).
Exacerbation in Primary Care
Investigation
• sending sputum samples for culture is not recommended in routine
practice
• pulse oximetry is of value if there are clinical features of a severe
exacerbation.
Cont.
• usually managed by taking increased doses of shortacting
bronchodilators and these drugs may be given using different
delivery systems.
NB. Only if a patient is hypercapnic or acidotic should the nebuliser be
driven by compressed air, not oxygen (to avoid worsening
hypercapnia). The driving gas for nebulised therapy should
always be specified in the prescription.
cont. Exacerbations:
Systemic Corticosteroids
• oral corticosteroids should be considered in patients managed in the
community who have an exacerbation with a significant increase in
breathlessness which interferes with daily activities.
• Prednisolone 30 mg orally should be prescribed for 7 to 14 days. It
is recommended that a course of corticosteroid treatment should not
be longer than 14 days as there is no advantage in prolonged
therapy.
• Osteoporosis prophylaxis should be considered in patients requiring
frequent courses of oral corticosteroids.
• Patients should be made aware of the optimum duration of
treatment and the adverse effects of prolonged therapy.
Cont. Exacerbations:
Antibiotics
• Antibiotics should be used to treat exacerbations of COPD
associated with a history of more purulent sputum.
• Patients with exacerbations without more purulent sputum do not
need antibiotic therapy unless there is consolidation on a chest
radiograph or clinical signs of pneumonia.
• Initial empirical treatment should be an aminopenicillin, a macrolide,
or a tetracycline. When initiating empirical antibiotic treatment,
prescribers should always take account of any guidance issued by
their local microbiologists.
Cont. Exacerbations:
Oxygen therapy during exacerbations of COPD
• The oxygen saturation should be measured in patients with an
exacerbation of COPD
 If necessary, oxygen should be given to keep the SaO2 greater than
90% but not above 93%.
MRC Dyspnoea Score
MRC Dyspnoea Score
Grade
1.
2.
3.
4.
5.
Degree of breathlessness related to Activities
Not troubled by breathlessness except on strenuous exercise
Short of breath when hurrying on the level or walking up a slight hill
Walks slower than contemporaries on the level because of
breathlessness, or has to stop for breath when walking at own pace
Stops for breath after walking about 100m or after a fw minutes on the
level
Too breathless to leave the house, or breathless when dressing or
undressing
Reference:
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of
respiratory symptoms and the diagnosis of chronic bronchitis in a working
population. British Medical Journal 2:257–66.
Depression
Healthcare professionals should be alert to the presence of depression in
patients with moderate to severe COPD. The presence of anxiety and
depression should be considered in patients:
• who are hypoxic (SaO2 less than 92%)
• who have severe dyspnoea
• who have been seen at or admitted to a hospital with an
exacerbation of COPD.
The presence of anxiety and depression in patients with COPD can be
identified using validated assessment tools.
Patients found to be depressed or anxious should be treated with conventional
pharmacotherapy.
For antidepressant treatment to be successful, it needs to be supplemented by
spending time with the patient explaining why depression needs to be
treated alongside the physical disorder.
See depression score
Ref. Birchell et al (1989) The Depression Scoring Instrument (DSI): J Affect Disorder 16 269-281
References
•
Chronic Obstructive Pulmonary Disease: National clinical guideline for
management of Chronic Obstructive Pulmonary Disease in adults in primary and
secondary care. Thorax 2004; 59 (Suppl 1): 1-232
•
Chronic Obstructive Pulmonary Disease. A Boyter et al. Pharmaceutical Journal
(vol 261) 5.9.98
•
First UK Guidelines for Management of Chronic Obstructive Pulmonary Disease.
Pharmaceutical Journal (Vol 259) 13.12.97
•
NICE Guidelines (2004). Chronic obstructive pulmonary disease: Management of
chronic obstructive pulmonary disease in adults in primary and secondary care.
Clinical Guideline 12. National Collaborating Centre for Chronic Conditions.
London. http://www.nice.org.uk/pdf/CG012_niceguidelines.pdf
•
Ref: British Thoracic Society. Guidelines for the Management of COPD. Thorax
1997;52 Suppl 5:51-28
•
The Management of Chronic Obstructive Pulmonary Disease. MeReC 9(10)
November 1998.