Furnace House Surgery Chronic Obstructive Pulmonary Disease

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Furnace House SurgeryChronic Obstructive
Pulmonary Disease

• Protocol
• Date 13th April 2005
• Review Date April 2006
• Acknowledgement Sarah Hicks

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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

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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.

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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).

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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.

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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)

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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 FEV1 predicted
• Mild 50
  80
• Moderate 30 49
• Severe lt30

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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.

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At the time of their initial diagnosticevaluation
, prior to spirometry, all patientsshould 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.

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FEV1 () and the smoking effects
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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

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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.

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• Depression Assessment
• Dyspnoea Score
• COPD Information Leaflet
• Referral back to GP for regular 6 monthly
  follow-up if spirometry confirms COPD diagnosis

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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

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• If applicable
• Bronchodilator reversibility test
• Steroid reversibility test
• Depression Assessment

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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 (gt400ml) indicates
  asthma.

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Pharmological Management of COPD
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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).

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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.

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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.
  

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cont. ExacerbationsSystemic 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.

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Cont. ExacerbationsAntibiotics

• 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.

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Cont. ExacerbationsOxygen 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.

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MRC Dyspnoea Score

• MRC Dyspnoea Score
• Grade 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 225766.

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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

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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/C
  G012_niceguidelines.pdf
• Ref British Thoracic Society. Guidelines for the
  Management of COPD. Thorax 199752 Suppl 551-28
• The Management of Chronic Obstructive Pulmonary
  Disease. MeReC 9(10) November 1998.