COPD Management (Read code H3)

Definition

A chronic progressive deterioration of small airway obstruction with little variation in lung function and incomplete reversibility. Spirometry essential.

Usually over the age of 35 with a history of greater than 10 pack years of smoking (daily smokes x years of smoking divided by 20).

Common (2x angina) but often undiagnosed.

Post bronchodilator FEV1 < 80% of predicted and FEV1/FVC ratio < 0.7 indicating an obstructive picturewith a history consistent with COPD.

  • Do not Read code as COPD (H3 or by severity as below) unless the diagnosis is confirmed by history and post bronchodilator spirometry. All FEV1 and FVC values should be Read coded!
  • Diagnosis should only be made with postbronchodilator spirometry and coded as such for QOF

Grading of severity

On the basis of post bronchodilator FEV1/predicted in patients with an FEV1/FVC ratio <0.7

Severity / POST bronchodilator FEV1
(% of predicted value) / Read code suggested
Mild airflow obstruction* / > 80%* / XaElV
Moderate airflow obstruction / 50–79% / XaElW
Severe airflow obstruction / 30 – 49% / XaElY
V. Severe airflow obstruction / <30% / XaN4a

* Only code as COPD if symptoms present

MRC dyspnoea scale

Grade / Degree of breathlessness related to activities
1 / Not troubled by breathlessness except on strenuous exercise
2 / Short of breath when hurrying or walking up a slight hill
3 / Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4 / Stops for breath after walking about 100m or after a few minutes on level ground
5 / Too breathless to leave the house, or breathless when dressing or undressing

Assessment at diagnosis

  • Hx > 10 pack years smoking hx and > 35 years – if not re-consider the diagnosis.
  • Objective assessment with post bronchodilator FEV1/FEV ratio < 0.7 with no significant reversibility. Record grade: mild, moderate or severe on the basis of percentage post bronchodilator FEV1 vs predicted.
  • Record BMI
  • CXR to exclude bullae, tumour, pulmonary oedema, bronchiectasis (CT may be required )
  • Consider FBC if there is a clinical suspicion of anaemia or polycythaemia.
  • Consider alpha-antrypsin deficiency if < 40 years old

When to refer

  1. Uncertain diagnosis e.g. History or Examination: age <35, < 10 pack years, wt loss, haemoptysis , unilateral signs.
  2. Atypical spirometry – restrictive rather than an obstructive picture.
  3. Failure to respond to Rx. (CHECK COMPLIANCE AND INHALER TECHNIQUE FIRST and Read code this)
  4. Consideration for oral steroids long term, home nebs or LTOT.
  5. Complications, such as Cor Pulmonale.
  6. Severe COPD.

Management

Non-pharmacological

  1. Explanation of the diagnosis.

info)

  1. Add Read code (H3) from formulary and promote to Problem. (NB Only if formal diagnosis confirmed by postbronchodilator spirometry!)
  2. Consider Read coding severity as above
  3. Smoking cessation advice.
  4. Flu & Pneumovax vaccination.
  5. Increasing exercise +/- weight loss increase lung function and decrease symptom scoring.
  6. Screen for and treat depression, which is often missed by doctors.
  7. Don’t forget carer strain in severe cases of COPD.
  8. Walking aids or wheelchair may be required if short of breath with minimal exertion.
  9. Refer to pulmonary rehabilitation if the patient agrees.

Pulmonary rehabilitation

Individually tailored and designed to optimise the individual’s physical and social performance. Offered to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk or who have had a recent MI.

Work with the patient to develop a self management plan:

  1. When to seek an antibiotic.
  2. When to seek oral steroids.
  3. When to seek medical advice.
  4. When to seek emergency medical advice.
  5. Info about COPD.

Medical Therapy

Promote effective inhaled therapy

Step 1 Add SABA ( first line ) or SAMA ( second line) as required for symptoms (not both: consider one month trial of SAMA and stop if ineffective#)

Step 2

- In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators (SAMAs or SABAs) as required, offer the following as maintenance therapy:

  • if post bronchodilator FEV1 ≥ 50% predicted: either long-acting beta2 agonist (LABA) or long-acting antimuscarinic (LAMA*)
  • if post bronchodilator FEV1 < 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA.
  • OR offer LAMA* irrespective of FEV1 percent predicted #

Step 3 -Offer LAMA* in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV1.

OR add LABA +/- ICS and consider triple therapy LABA with ICS and LAMA #

* stop SAMA if adding LAMA

# see GP update handbook 2015 p97

Consider all additions of treatment as trial: stop if no improvement in symptoms or reduction of exacerbations.

Oral therapy

Try mucolytic e.g. carbocisteine for 4 weeks if they have a chronic productive cough, only continue if it has conferred benefit (avoid if Hx of peptic ulcer).

Also consider a trial of theophylline if SAMAs and SABAs are ineffective

Maintenance oral steroids are not normally recommended.

Consider providing standby antibiotics and steroids (with instructions) and add to repeat prescriptions.

Ref for LTOT assessment if:

  • Post bronchodilator FEV/predicted < 49%
  • Cyanosis
  • Polycythemia
  • Cor pulmonale
  • Peripheral oedema
  • O2 saturation <92% in room air

Consider Palliative care if 2 or more of following consistently

  • Post bronchodilator FEV1/predicted <30%
  • SOB on any exertion
  • Significant wt loss
  • Recurrent admissions for exacerbations with no or little improvements
  • Social isolation/depression
  • Severe heart failure

Consider referral to COPD specialist nurse at any stage after diagnosis

Annual Review

Add Read code (H3) (and promote to Major Problem with no end dateif this has not already been done).

QOF points ( see below )

Factors to assess atCOPD review! (USE THE BRIG ROYD TEMPLATE and AUTOCONSULTATION FOR COPD)

  1. Is the correct Read code in the Problem Summary?
  2. Are they aware of their next annual review date?
  3. Patient understanding of their inhalers and their appropriate use.
  4. Check inhaler technique and Read code.
  5. Have they had theirFEV1 assessed during current QOF year?.
  6. Smoking status and provide cessation advice.
  7. Any exacerbations, hospital admissions or oral steroid use since last review?
  8. Review the need for inhaled steroid prophylaxis (post bronchodilator FEV1 < 50% predicted).
  9. Change self management plan or step up treatment if poor symptom control or frequent exacerbations.
  10. MRC dyspnoea scale assessment to be recorded.
  11. Consider pulmonary rehab referral (usually for patients with MRC scale score > 2)
  12. Check and record Pulse Oximetry (QOF requirement if MRC SOB scale 3 or worse ) if SpO2 < 92% on air consider referral for ?LTOT.

Use Read code “Oxygen saturation at periphery X770D” (other oximetry codes are not recognized for QOF )

  1. Consider providing standby antibiotics and steroids (with instructions) and add to repeat prescriptions.
  2. Record BMI and offer diet advice if appropriate.
  3. Consider DEXA scan or osteoporosis Rx (see protocol below)
  4. Read code annual review done (Xalet) this is a QOF requirement

Exacerbations of COPD

Antibiotics should be used to treat exacerbations associated with a history of more purulent sputum. Exacerbations without purulent sputum do not need antibiotic therapy unless there is consolidation on CXR or signs of pneumonia.

First line Amoxicillin 500mg TDS or clarithromycin 500mg BD or Doxycycline 200mg stat then 100mg OD.

+Antibiotics should be given until clinical improvement. Review after 5days-,up to 10 days treatment may be required.

If there is no clinical benefit after the first antibiotic consider using an alternative first line option and review culture and sensitivity reports (Calderdale Primary Care Antimicrobial Guidelines – September 2013)

In the absence of significant contraindications oral prednisolone 30mg per day for 7 to 14 days should be considered for patients with an exacerbation associated with a significant increase in breathlessness.

Consider CXR if no improvement with treatment (SIGNguidance)

Self-management

_ Encourage people at risk of having an exacerbation to respond quickly to the symptoms of an exacerbation by:

– starting oral corticosteroid therapy (unless contraindicated) if increased breathlessness interferes with activities of daily living

– starting antibiotic therapy if their sputum is purulent

– adjusting bronchodilator therapy to control symptoms.

_ Give people at risk of exacerbations a course of antibiotic and corticosteroid tablets to keep at home.

Indications for admission

  • Signs of a severe acute exacerbation = cyanosis, RR > 25, Pulse > 110, unable to speak in sentences or confused.
  • SaO2 <90%
  • Patient already on maximum treatment.
  • Patient on LTOT.
  • Patient unable to cope at home.
  • Failure to respond to Rx.
  • Complications e.g. Cor pulmonale.

After admission

Consider invite for review: what factors caused the exacerbation and/or admission? Are there any factors that could be improved e.g. px compliance or self management? Consider coding admission. XaJFu

Treatment strategy for preventing steroid induced osteoporosis

Consider every patient for active osteoporosis prevention who has had:

  • Oral or iv steroid treatment for greater than 3 months.
  • A cumulative lifetime dose of 1g oral prednisolone (e.g. > 4 x seven day courses in a lifetime).
  • Inhaled steroid > 1000mcg day beclomethasone.

If unable to have a DEXA then treat, 1st line = a bisphosphonate.

If steroid course likely to > 3 months then treat, 1st line = a bisphosphonate.

If able to have a DEXA and the T score above -1.5 treat with lifestyle measures +/- calcium supplementation. NB DEXA needs repeating every 3 years

If the T score is = -1.5 or lower then treat, 1st line = a bisphosphonate.

NB Consider repeat DEXA every 3 years

Another strategy for deciding who warrants a DEXA scan is to use Qfracture - (or FRAX via SystmOne) where a DEXA is indicated if risk >10%.

QOF summary points

COPD001COPD register3

COPD002post-bronchodilator spirometry5

if diagnosed after 1/4/11

(3/12 before to 12/12 after diagnosis)

COPD003Annual review, including 9

MRCdyspnoea scale

COPD004FEV1within 12 months7

COPD005SpO2 if MRC score 3 or above5

COPD007fluvax in preceding 1st August6

to 31st March

total35

Reference:

NICE 2010

The management of chronic breathlessness in patients with advanced and terminal illness

BMJ2015;349doi: 02 January 2015)

GPUpdate handbook 2015

Useful Read codes (Systm1)

COPDH3

Post bronchodilator spirometryXaXeg

Referral for spirometry XaK02

COPD annual reviewXaIet

MRC dyspnoea scale 1XaIUi

MRC dyspnoea scale 2XaIUl

MRC dyspnoea scale 3XaIUm

MRC dyspnoea scale 4XaIUn

MRC dyspnoea scale 5XaIUo

Mild COPDXaElV

Moderate COPDXaElW

Severe COPDXaElY

Very severe COPDXaN4a

Oxygen saturation at peripheryX770D

Admit COPD emergencyXaJFu

Number of COPD exacerbations in

past yearXaK8U

Summary reproduced from BNF 68 0/3 2015 p 184 3.1

Example of COPD exacerbation info for patients

BRIG ROYD SURGERY

COPD Action Plan

WHAT ACTION TO TAKE IF YOUR SYMPTOMS (cough, sputum or shortness of breath) GET WORSE

1. RELIEVER TREATMENT

Via inhaler or nebuliser

Maximum dose ______/ ______times per day

2. Check the colour of your sputum:

Cough sputum onto a white tissue

If your sputum colour has changed from clear or pale to a darker shade

e.g. yellow or green: start ANTIBIOTICS:

Please take your home supply

or obtain a prescription without delay from the surgery

3. PREDNISOLONE

If breathlessness is not improved by relievers, take 30mg once daily

(6 x 5mg tablets) for planned course (duration may vary).

4. Follow up

Let us know (same or next working day) if you have needed to use your standby treatment. We will usually want to review your chest and treatment after an episode like this

5. If you are not getting better with treatment or getting worse despite treatment, let us know (or out of hours NHS 111) as you may need an urgent assessment.

Further information for patients and carers:

Adapted from Primary Care Respiratory Society 2010

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