Chronic Obstructive Pulmonary Disease

Page Created on 21st August 2019 by Chris Isles.  Due for review 21st August 2020.

Diagnosis

1. Consider in anyone with breathlessness, cough, or chronic sputum production.
2. Risk factors include smoking or occupational exposure to dust, fumes, or chemicals.
3. Diagnosis depends on the presence of fixed airflow obstruction using spirometry with FEV1/FVC ratio of <70%.
4. NB this fixed level may overdiagnose older people and underdiagnose younger people.

Ten Factors Associated with Poor Prognosis

1. FEV
2. Breathlessness using MRC scale
3. Chronic hypoxia and/or cor pulmonale
4. Low BMI
5. Severity and frequency of exacerbations
6. Hospital admissions
7. Exercise capacity eg 6 minute walk test
8. Carbon monoxide gas transfer
9. Meets criteria for long term oxygen therapy and/or home non-invasive ventilation
10. Comorbidity and/or frailty

The Five Fundamentals of COPD Care

1. Treatment and support to stop smoking
2. Pneumococcal and flu vaccinations
3. Pulmonary rehabilitation if indicated
4. Personalised self management plan
5. Optimised treatment for comorbidities

Exacerbation Action Plans

1. Offer a 5 day course of oral prednisolone 30mg and oral antibiotic to keep at home if
2. They have had an exacerbation within the last year, and remain at risk of exacerbations and
3. They understand and are confident about when and how to take these medicines, and the associated benefits and harms and
4. They know to tell their healthcare professional when they have used the medicines, and to ask for replacements.

When to Give Antibiotic

1. Many exacerbations including some severe exacerbations are not caused by bacterial infections so will not respond to antibiotic
2. Antibiotic recommended for exacerbation with history of more purulent sputum
3. Should also give if clinical or radiological signs of pneumonia
4. Oral therapy nearly always adequate
5. If no previous antibiotic, Rx Amoxicillin 500mg PO for 5 days
6. If previous antibiotic OR penicillin allergy, Doxycycline 200mg stat followed by 100mg daily for 5 days BUT NOT BOTH

Inhaled Therapies

1. Only prescribe inhalers after patients have been trained to use them and can demonstrate satisfactory technique.
2. Consider spacer or breath activated device if has difficulty using an MDI
3. If using a spacer, patient should either breathe in and out 5 times for each puff OR breathe one puff in and hold for 10 seconds.
4. Use short acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation.
5. Long acting inhalers are intended to improve day-to-day symptoms and reduce exacerbation risk. Before starting, consider whether the five fundamentals of COPD therapy have been addressed.
6. In particular consider whether the patient’s symptoms could be caused by another physical or mental health condition eg heart failure which is common and often underdiagnosed and undertreated in patients with COPD.
7. Advice on when to use long acting beta agonists (LABA), long acting muscarinic antagonists (LAMA) and inhaled corticosteroid (ICS) is shown in the flow chart
8. There are a bewildering number of inhalers out there.  The respiratory nurses will use a patient’s inspiratory flow rate to choose the one that is most suitable.
9. Dumfries Respiratory Team suggest discharging patient on SABA as sole inhaler if COPD (or presumed COPD) is a new diagnosis for review and follow up in primary care.
10. The following inhalers are commonly prescribed in D&G:-
    • LAMA/LABA – Anoro Ellipta 52/55 one inhalation daily
    • LABA/ICS – Fostair 100/6 one inhalation twice daily either as MDI or as a NEXThaler
    • LABA/LAMA/ICS – Trimbow 87/5/9 two inhalations twice daily as MDI

Features Suggesting Asthma/Steroid Responsiveness

1. Any previous, secure diagnosis of asthma or of atopy
2. A higher blood eosinophil count*
3. Variation in FEV1 over time of at least 400 mL or
4. Diurnal variation in peak expiratory flow of at least 20%.
5. If asthmatic features or features suggesting steroid responsiveness are present, consider a LABA/ICS inhaler instead of LAMA/LABA as initial long acting inhaled therapy

*’Higher’ eosinophil count has been chosen deliberately, rather than specifying a particular value. Evidence suggests a link between eosinophil count and steroid responsiveness though it is not yet clear what the precise threshold should be or on how many occasions or over what time period it should be elevated. It is likely that the threshold will lie within the upper part of the normal range.

Prophylactic Azithromycin in People with Frequent Exacerbations

1. Regular azithromycin can be beneficial in COPD but should only be considered after several criteria have been met.
2. Offer the five fundamentals of COPD care and treatment with inhaled therapies first.
3. Before starting azithromycin ensure that the person has had
   • sputum and TB culture to identify antibiotic resistant organisms, atypical mycobacteria, or pseudomonas that may need specific treatment
   • training in airway clearance techniques to optimise sputum clearance
   • CT chest to rule out bronchiectasis and other lung pathologies.
4. Subject to the above, consider prophylactic azithromycin 250 mg three times a week for people with COPD if they do not smoke (as it is ineffective in continuing smokers) who continue to have frequent or prolonged exacerbations with sputum production or exacerbations resulting in hospitalisation.
5. Before starting azithromycin, do an ECG to rule out prolonged QT interval and baseline LFTs.
6. When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs.

Stepped Care for COPD

Link

• COPD: diagnosis & management: summary of updated NICE guidance. BMJ 2019;366:l4486 doi: 10.1136/bmj.l4486 (Pub. 290719)
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