Chronic Obstructive Pulmonary Disease (COPD) - East Cheshire ...

COPD Treatment PathwayBreathlessness & exercise limitation• Trial treatments sequentially until symptoms are adequately controlled• Ensure appropriate inhaler technique for device selected; press and breathe MDI and spacer is recommendedfor most patients• Discontinue any medication that does not improve symptoms of breathlessness or increase exercise capacity• Offer pulmonary rehabilitation to all patients with functional impairmentShort-acting bronchodilators• Salbutamol as required is usual first-choice• Administer salbutamol regularly if symptoms persist(2 puffs 4 times daily)• Terbutaline is a more costly alternative for patientswho prefer the Turbohaler device• Ipratropium is more costly than salbutamolLong-acting bronchodilators (beta agonistand / or anticholinergic)Licensed dosages are:• Formoterol - 12 micrograms twice daily• Salmeterol - 50 micrograms twice daily• Tiotropium - 18 micrograms once daily (Handihalerdevice)- 5 micrograms once daily (Respimatdevice).Stop ipratropium if tiotropium is used.• NB Review each bronchodilator after 8 weeks and ifthere has been no improvement in symptoms STOP.• If there is improvement with the first agent but stillfunctional limitation consider using both tiotropiumand a long-acting beta agonist.If still breathless despite optimal inhaledbronchodilators• Trial of inhaled steroids - note that individualinhaled steroids are not licensed for use in COPDand that combination inhalers are only licensed foruse to prevent exacerbations. Discontinue if nosymptomatic benefit.• Trial of theophylline - prescribe by brand name• Referral to Respiratory Nurse Specialist team forassessment for long-term oxygen and / or nebulisedtreatmentConsider need to manage exacerbations / coughFrequent exacerbations(≥2 per year)Optimise symptomatic management.Ensure patient has exacerbationmanagement plan including access tooral prednisolone +/- antibiotics.Consider prophylactic inhaled steroidsand long-acting bronchodilators toreduce risk of exacerbations if FEV 1