CHARM COPD Guidelines for the diagnosis and management of COPD in the Borough of City and Hackney
Updated September 2015
Adapted by:
Miss Hetal Dhruve, Specialist Pharmacist – Respiratory Medicine, City and Hackney CCG
Dr Matthew Hodson, Consultant Nurse Specialist – Respiratory Medicine, HUHFT
Dr Angshu Bhowmik, Consultant – Respiratory Medicine, HUHFT
Dr Raja Rajasingam, Consultant – Respiratory Medicine, HUHFT
Approved by: Homerton Hospital and City and Hackney CCG Joint Prescribing Group.
Date: 14/12/15
Review: 14/12/16
Version: 3.3
DIAGNOSING COPD
Definition of COPD
COPD is characterised by airflow obstruction.
The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.
Think of a diagnosis of COPD for patients who are: · Over 35
· Smokers or ex-smokers
· Have any of these symptoms
o exertion breathlessness
o chronic cough
o regular sputum production
o frequent winter “bronchitis” or “chest infections” o wheeze
· And have no clinical features of asthma (see table below CHARM asthma guidelines)
Perform spirometry if COPD seems likely CXR FBC at diagnosis Airflow obstruction is defined as:
· FEV180% predicted or >80% with symptoms · And FEV1/FVC< 70
Consider asthma if 15% FEV1 reversibility with bronchodilator or corticosteroids.
If still doubt about diagnosis consider the following pointers:
· Clinically significant COPD is not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy. · Asthma may be present if:
o there is a >400ml response to bronchodilators & also >15% reversibility
o serial peak flow measurements show significant diurnal or day-to-day variability o there is a >400ml response to 30mg prednisolone daily for 2 weeks
· Refer for more detailed investigations if needed
If still in doubt, consider other possible diagnosis and/or refer for further advice
If confirmed COPD: Classify COPD and then start treatment (see flowchart)
Severity - Post bronchodilator FEV1/FVC FEV1% Stage < 0.7 > 80% Mild
0.7 50 – 79% Moderate < 0.7 30-49% Severe 0.7 30% Very Severe
Reassess diagnosis in view of response to treatment
Clinical features differentiating COPD and asthmaCOPD / Asthma
Smoker or ex-smoker / Nearly all / Possibly
Symptoms under age 35 / Rare / Common
Chronic productive cough / Common / Uncommon
Breathlessness / Persistent and progressive / Variable
Night-time waking with breathlessness and/or wheeze / Uncommon / Common
Significant diurnal or day-to-day variability of symptoms / Uncommon / Common
For CXR and FBC at ANY time if blood in sputum / weight loss / change in cough
Management of stable COPD (Based on NICE 2010 clinical guideline and GOLD 2015)
SABA (Short Acting Beta Agonist) : Salbutamol* Or SAMA (Short Acting Muscarinic Antagonist): IpratropiumOptimal Inspiratory flow rate L/Min / Device
None required** / MDI/Respimat
High inspiratory effort required / Handihaler
Turbohaler
Spiromax
Genuair
Accuhaler
Ellipta
Least inspiratory effort required / Breezhaler
The right medication, the right inhaler.
*This should also be product of choice to optimise bronchodilation over a 24 hour period. Duration of action of once daily preparations varies from 18-24 hours.
** MDI with/out spacer and the Respimat device do not require inspiratory effort – but does require co-ordination to ensure sufficient inhalation of dose.
Try placebos before initiating inhalers. Check inhaler technique at every opportunity.
The right medication, the right inhaler.
Consider your patient: Select device most appropriate for your patient.
- What inhalers are they using?
- How is the inhaler technique – poor/moderate/good.
- Does the patient have a history of asthma (Asthma and COPD overlap syndrome)?
- ICS must not be stopped if there is any history of Asthma regardless of severity of COPD
What is their main symptom: persistent breathlessness (MRC>3) or frequent exacerbations (>2 or >1 leading to hospital admission).
Breathless patients, MRC 0-1, (CAT <10) - consider a LAMA or LABA 1st line.
Component / Brand / Dose / Device / Key inhaler technique* / Price/30 daysLABA / Indacaterol / Onbrez / 150-300mg 1p OD / Breezhaler / Fast and hard / £29.26
Salmeterol / Serevent / 25mcg 2p BD / Available as accuhaler/MDI / Accuhaler: Fast and hard
MDI: Slow and steady / £29.26
Formoterol / Oxis / 12mcg 1p BD / Turbohaler / Fast and hard / £24.80
LAMA / Glycopyrronium / Seebri / 44mcg 1p OD / Breezhaler / Fast and hard / £27.50
Aclidinium / Eklira / 400mcg 1p BD / Genuair / Fast and hard / £28.60
Umeclidinium / Incruse / 55mcg 1p OD / Ellipta / Fast and hard / £27.50
Tiotropium / Spiriva / 18mcg 1p OD / Handihaler / Fast and hard / £33.50 refill
£34.87 with device
Breathless patients, MRC³ 2, (CAT³10) - consider a LAMA+LABA combination
Components / Brand / Dose / Device / Key inhaler technique* / Price/30 daysLAMA+LABA / Glycopyrronium + Indacaterol / Ultibro / 85/43 1p OD / Breezhaler / Fast and hard / £32.50
Umeclidinium + Vilanterol / Anoro / 55/22 mcg 1p OD / Ellipta / Fast and hard / £32.50
Aclidinium+ Formoterol / Duaklir / 340/12mcg 1p BD / Genuair / Fast and hard / £32.50
Tiotropium + Olodaterol / Spiolto / 2.5/2.5mcg 2p OD / Respimat / Slow and steady / £32.50
Exacerbating patient (1, not leading to hospital admission), MRC 0-1, (CAT <10) - consider LABA+ICS
Components / Brand / Dose / Device / Key inhaler technique* / Price/30 daysICS + LABA / Beclomethasone + Formoterol / Fostair / 100/6 2p BD / MDI / Slow and steady / £29.32
Beclomethasone + Formoterol / Fostair / 100/6 2p BD / NextHaler / Fast and hard / £29.32
Fluticasone+
Vilanterol / Relvar / 92/22 1p OD / Ellipta / Fast and hard / £27.80
Fluticasone+
Salmeterol / Seretide / 500/50 1p BD / Accuhaler / Fast and hard / £40.92
Budesonide + Formoterol / Symbicort / 400/12 1p BD / Turbohaler / Fast and hard / £38.00
Budesonide + Formoterol / Duoresp / 320/9 1p BD / Spiromax / Fast and hard / £29.97
Exacerbating patient (>2 or >1 leading to hospital admission), MRC³ 2, (CAT³10) - consider LABA+ ICS + LAMA (same device if possible).
** Please refer to patient information leaflets/SPC’s for full instruction on inhaler technique.
Quality of Life
CAT (COPD ASSESSMENT TEST) SCORE
I never cough / 0 / 1 / 2 / 3 / 4 / 5 / I cough all the timeI have no phlegm (mucus) in my chest at all / 0 / 1 / 2 / 3 / 4 / 5 / My chest is full of phlegm (mucus)
My chest does not feel tight at all / 0 / 1 / 2 / 3 / 4 / 5 / My chest feels very tight
When I walk up a hill or one flight of stairs I am not breathless / 0 / 1 / 2 / 3 / 4 / 5 / When I walk up a hill or one flight of stairs I am very breathless
I am not limited doing any activities at home / 0 / 1 / 2 / 3 / 4 / 5 / I am very limited doing activities at home
I am confident leaving my home despite my lung condition / 0 / 1 / 2 / 3 / 4 / 5 / I am not at all confident leaving my home because of my lung condition
I sleep soundly / 0 / 1 / 2 / 3 / 4 / 5 / I don’t seem soundly because of my lung condition
I have lots of energy / 0 / 1 / 2 / 3 / 4 / 5 / I have no energy at all
MRC (MEDICAL RESEARCH COUNCIL) DYSPNOEA SCALE
Grade / Degree of breathlessness related to activities1 / Not troubled by breathlessness except on strenuous exercise
2 / Short of breath when hurrying on the level or walking up a slight hill
3 / Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace.
4 / Stops for breath after walking about 100 yards or after a few minutes on level ground
5 / Too breathless to leave the house, or breathless when undressing
OTHER PHARMACOTHERAPY
Oral theophyllines can be considered but they a have high risk side effect profile and interact with many other medication and cigarette smoke. Theophylline levels should therefore be monitored.
If a patient is unable to use the long acting anticholinergic, an ipratropium inhaler with spacer may be considered. Chronic cough productive of viscous sputum - consider 4 week trial of mucolytic agent
e.g. carbocysteine 750mg 3 times a day initially then 2 times a day; reassess benefit after 4 weeks
PULMONARY REHABILITATION (PR)
PR is gold standard symptom based treatment of exercise and education, aimed at promoting long term behaviour change and compliance with health enhancing behaviours. A referral to outpatient PR should be considered for all COPD patients with MRC grade 3-5 or MRC 2 with breathlessness on exertion as per NICE guidance. Post exacerbation PR should be considered for all patients admitted with an acute exacerbation of COPD within 4 weeks of discharge from hospital. To refer to the ACERs Pulmonary Rehabilitation Service email: or call 0208 510 5108 for a referral form.
OXYGEN ASSESSMENT
Refer to ACERS Oxygen Assessment Service, Respiratory Department, Homerton Hospital for long term and ambulatory oxygen assessment if oxygen saturations 92% on air, severe COPD, peripheral oedema.
All patients who receive LTOT should be assessed annually with Blood gas analysis – inform ACERS on 020 8510 5107 to undertake this assessment
DEPRESSION ANXIETY
There is a high prevalence (30-50%) of depression seen in COPD patients with frequent exacerbations. NICE guidelines recommend a high index of suspicion and prompt diagnosis.
Treat anxiety and depression with medication, taking time to explain to the patient why this is needed and refer to psychology services if needed
END OF LIFE CARE
Opiates should be used when appropriate to palliate breathlessness in patients with end stage COPD which is unresponsive to other medical therapy.
Patients with end stage COPD and their families should have access to the full range of services offered by the multidisciplinary palliative care teams, including admission to hospices.
Prognosis in COPD is difficult, but recognized indicators of a poor outcome are: · Hospital admissions
· Severe disease
· On long term oxygen therapy
· Depression, poor quality of life, housebound · Co-morbidity, especially heart failure
· Low BMI
Consider asking “would I be surprised if my patient were to die in the next twelve months?” Consider inclusion on supportive and palliative care register
Refer to ACERS for onward referral to the Breathing Space clinic at St Joseph’s Hospice
ACUTE INFECTIVE EXACERBATION OF COPD : ALL EXACERABTIONS REF TO ACERS TEAM Antibiotics are usually ONLY given if there is a history of increased sputum purulence:
Doxycycline 200mg stat oral then 100mg once a day oral for 4 days or clarithromycin 500mg twice a day if doxycycline contraindicated AND Oral steroids – Prednisolone 30mg daily for 7 days.
Gradual withdrawal of Prednisolone - Should be considered for the following patients
- Received more than 40mg of prednisolone daily for more than 1 week
- Been given repeat doses in the evening,
- Recently received repeated courses (particularly if taken for longer than 3 weeks),
- Taken a short course within 1 year of stopping long-term therapy
Increase frequency of salbutamol – 2 puffs every 4 hours, use spacer
Self management: Self management plans should be in place and rescue medication packs for patients who have had an exacerbation or are at risk of having one (where appropriate).
PROTOCOL FOR THE TREATMENT PREVENTION OF EXACERBATIONS IN COPD
IS IT AN EXACERBATION?
Key features typically associated with exacerbation are 2 or more of the following.
· Worsening breathlessness · Increased sputum volume · Increased cough
· Fever
· Chest tightness
Changing sputum colour Wheeze
If yes to any If no to all
FACTORS PROMPTING CONSIDERATION OF HOME MANAGEMENT VS. HOSPITAL ADMISSION
· Coping at home
· Normal level of consciousness
· Experiencing only mild breathlessness maintaining usual level of activity
· Eating & drinking normally
· Little change to usual general condition · Easy access to help if required
· Lack of significant co morbidity
If yes to most / If no to mostMANAGE PATIENT AT HOME REFER TO ACERS
DISCUSS WITH ACERS / ADMIT PATIENT TO HOSPITAL IN EMERGENCY
MANAGE ACUTE EXACERBATION
· Add or increase bronchodilator use · Review inhaler technique
· Prescribe antibiotics if sputum becomes purulent · Consider oral corticosteroids
· Pulse oximetery if severe exacerbation · Increase social support if necessary
AGREE TO FOLLOW UP REVIEW PATIENT TO ASSESS THEIR COPD
POST EXACERBATION MANAGEMENT PLAN
· Patient understands personal action plan, rescue medications prescription supplied for future use for patients who have had an exacerbation or at risk of one (where appropriate)
· Smoking cessation, exercise, pulmonary rehabilitation · Optimize inhaler therapy, check technique
· Offer vaccinations