COPD (Chronic Obstructive Pulmonary Disease)

What's New

  • Access to RightBreathe website for inhaler device information
  • New GOLD ABCD poster
  • Inhaler poster
  • Guidance in triple therapy 
  • ICS (inhaled corticosteroid) Stepdown

Further Information

COPD Quick Guide - This may be useful for clinicians working in primary care in conjunction with the information below.
NICE 
GOLD
PCRS

Presentation

Differentiation of Chronic Breathlessness: Common Presentations of Asthma, COPD & Heart Failure

Symptoms:

  • Increased breathlessness on exertion
  • Cough
  • Wheeze
 

Red Flags

  • Severe SOB
  • RR over 40 bpm
  • Sudden onset Chest pain
  • Haemoptysis of unknown origin
 

 

  • Diurnal variation (worse at night)
  • Increased response with allergen exposure
  • Wide spread wheeze on osculation
  • Chest tightness
  • Increased response/symptoms after aspirin or beta blocker
  • Atopy
 
  • Regular sputum production
 
  • Oedema
  • Diurnal variation (worse at night)
  • Palpitations
  • Coarse Crepitations
  • Murmurs
  • Pink Frothy sputum
  • Hepatojugular reflux
  • Neck vein distension
AND AND AND
History of
  • Family history of atopy
  • Family history of respiratory illness
History of
  • Over 35 yrs age
  • Significant smoking history
  • Frequent winter bronchitis
History of
  • Cardiac history Angina, MI, Ischaemic Heart Disease, Hypertension, Valvular Disease/murmur
  • Diabetes
  • Alcohol excess
THEN THEN  THEN THEN

Consider emergency referral to acute services

 Consider diagnosis of Asthma

Consider diagnosis of COPD

 Consider diagnosis of Heart Failure
Assessment
  • Any history of childhood respiratory conditions or any diagnosis of adult asthma
  • Frequency of exacerbations
  • Occupational history
  • CAT score 
  • Oxygen saturations by pulse oximetry
  • Degree of airflow obstruction - post-bronchodilator FEV1 (absolute figure and percentage predicted or normal range) - send patient spirometry with referral
  • Full blood count
  • Eosinophil count (for COPD less than 0.3x109/L)
  • Chest X-ray if not done within the last year
Diagnosis

Consider a diagnosis of COPD in patients who are:

  • 35 years of age and over
  • Smokers or ex-smokers
  • Have any of the following symptoms
    • Breathlessness on exertion
    • Chronic cough
    • Regular sputum production
    • Frequent winter bronchitis or chest infections
    • Wheeze

Pose bronchodilator spirometry showing FEV1/FVC of 0.70 is essential for diagnosis of airflow obstruction.

Management of stable COPD

Widely used for its impactful message about the comparative value of interventions for COPD that rebalances the value accorded to flu vaccination, stop smoking as a treatment, pulmonary rehabilitation, inhaled medicines and telemedicine using cost per quality adjusted life year (QALY).
http://thorax.bmj.com/content/69/11.cover-expansion

  1. Promote a self-management approach at every stage. Provide the following written information and support tools.
  2. Vaccination
    All patients with COPD are to receive an annual flu vaccine and a pneumonococcal according to the Green Book Guide - immunisation against infectious diseases.  
  3. Smoking cessation
    Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.
    For professionals to effectively give brief intervention advice see: Tool
    See smoking cessation guidelines
  4. Offer pulmonary rehabilitation
  5. Promote effective inhaled therapy
Inhaled therapy in COPD

Ask the patient to demonstrate inhaler technique at every opportunity.

See RightBreathe website for inhaler technique videos and device information.
Contact the Community Respiratory Team for advice on inhaler training devices. High-uhb.communityrespiratoryteam@nhs.net 

Choose a drug based on the person's symptomatic response and preference, the drug's side effects, potential to reduce exacerbations and cost.

Highland Formulary Respiratory section

Step down of ICS

It may be appropriate in some cases to consider stepping down inhaled corticosteroid treatment, particularly in patients with previous pneumonia and those who are predominantly symptomatic but not exacerbating. This should be done cautiously, using the NHS Highland Guideline below for the withdrawal of Inhaled Corticosteroids (ICS) in patients with COPD.

When discontinuing ICS, it may be worthwhile checking blood eosinophil (provided not on oral /L corticosteroids). An eosinophil count <0.3x109 /L adds confidence that ICS may not be required.

Withdrawing ICS

Low/medium dose ICS 
  • STOP
  • Consider LAMA/LABA for dual bronchodilation
  • Monitor
High dose ICS
  • Switch to low/medium strength
  • Continue/consider LAMA/LABA for dual bronchodilation
  • Review 4-8 weeks
  • If stable or improved consider stopping low/medium strength ICS
Monitor off ICS

If increased exacerbations reconsider need for ICS and consider undiagnosed asthma

Oral therapy in COPD

Theophylline 

 See Theophylline 

  • Offer only after trials of short and long acting bronchodilators or to people who cannot use inhaled therapy.
  • Theophylline can be used in combination with beta 2 agonists and muscarinic antagonists.
  • Take care when prescribing to older people because of pharmacokinetics, co-morbidities and interactions with other medications.
  • Reduce theophylline dose if macrolide or flouroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
  • Review at least annually.

Mucolytic therapy

See Mucolytic therapy

  • Consider in people with a chronic, productive cough to reduce sputum viscosity.
  • Review in 4 weeks and continue use if symptoms improve or stop if no benefit.
  • Do not routinely use to prevent exacerbations. 

Corticosteroids

See Corticosteroids

  • These are used in the management of acute exacerbation (link to that section). Maintenance use of oral corticosteroid therapy in COPD is not normally recommended
  • Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. If considering maintenance refer to respiratory specialist.
  • Maintenance steroid doses should be kept as low as possible. In patients requiring repeated courses of corticosteroids and those requiring long-term maintenance therapy, monitor for adverse effects and consider gastro and bone protection as appropriate.

Anti-tussives are not recommended.

Prevention and Management of exacerbations
The frequency of exacerbations should be reduced by:
  • Vaccinations
  • Stopping smoking
  • Completing pulmonary rehabilitation
  • Appropriate use of inhalers
The impact of exacerbations should be minimised by:
  • Giving self-management advice on early recognition and responding promptly to the symptoms of an exacerbation
  • Starting appropriate treatment with oral steroids and/or antibiotics
  • Use of non-invasive ventilation when indicated
  • Considering a sputum culture to guide antibiotic therapy in patients who have frequent exacerbation
Management of exacerbations
  1. Increase dose or frequency of short acting beta agonist (SABA) to relieve breathlessness. Ensure patients are encouraged to use a spacer to deliver maximum dose to the lungs.
  2. Start oral corticosteroids for hospitalised patients and those in the community where breathlessness is interfering with daily activities

→ prednisolone 30mg once daily for 7-14 days
→ consider GI and bone protection (particularly if 3-4 courses annually)
→ doses of up to 40mg daily for up to three weeks do not usually need to be tapered down, however be aware if patients have had multiple recent courses, they may require a gradual dose reduction, and some patients require a long term maintenance dose of oral corticosteroid.

  1. Start antibiotics if there is purulent sputum and increased breathlessness and/or increased sputum volume. See Highland Formulary for detailed antimicrobial information.
  2. For exacerbating patients, review need for rescue medications
Referral for specialist advice

Referral for advice, specialist investigations or treatment may be appropriate at any stage of disease, not just for people who are severely disabled.

Possible reasons for referral include:

  • Diagnostic uncertainty
  • Suspected severe COPD
  • The individual requests a second opinion
  • Onset of cor pulmonale
  • Assessment for oxygen therapy, long-term nebuliser therapy or oral corticosteroid therapy
  • Bullous lung disease
  • Rapid decline in FEV1
  • Assessment for lung volume reduction surgery or lung transplantation
  • Dysfunctional breathing
  • Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency
  • Symptoms disproportionate to lung function deficit
  • Frequent infections
  • Haemoptysis

Send patient spirometry with referral

How to refer
Palliative and anticipatory care in COPD
Palliative Care

A palliative approach should be considered in the care of those individuals who

  • Have persistent severe symptoms despite optimal therapy
  • Have had  an acute episode requiring non-invasive ventilation
  • Have cor pulmonale
  • Are on LTOT (Long Term Oxygen Therapy)

SPICT tool

A palliative approach includes holistic assessment and regular review along with consideration of referral to specialist palliative care services for complex symptom control and psychospiritual support.

Palliative Care Guidelines

Anticipatory Care

Requires practitioners to adopt a thinking ahead approach that allows them to work with patients and those close to them to set and achieve goals that will ensure the right thing is being done, at the right time, by the right person(s) with the right outcome.

ACPA (Anticipatory Care Patient Alert)
Long Term Conditions ACPA Form

Oxygen
Glossary
Abbreviation Definition
SOB Shortness of breath
RR Respiratory rate
BPM Beats per minute
MI Myocardial infarction
CAT score COPD Assessment Test score
ICS Inhaled Corticosteroids 
LAMA Long-acting muscarinic antagonist 
LABA Long-acting beta2 agonist
GI Gastro-intestinal
Editorial Information

Last reviewed: 11 July 2019

Next review: 11 July 2021

Author(s): Advanced Practice Respiratory Nurse

Version: 2

Approved By: Awaiting approval by TAM Subgroup

Reviewer Name(s): Advanced Practice Respiratory Nurse