Wakefield & Kirklees Guidelines for Managing Stable COPD in ...

Wakefield & Kirklees Guidelinesfor Managing Stable COPD in Primary Care (Kirklees version)GENERAL MANAGEMENT FOR ALL PATIENTS WITH COPDSMOKING CESSATION – ENCOURAGE EXERCISE – REVIEW OF INHALER TECHNIQUE –PNEUMOCOCCAL VACCINATION AND ANNUAL INFLUENZA VACCINATION – RECORD BMI AND MRC DYSPNOEA SCORE –ADJUSTED BODE SCORE (USING NUMBER OF HOURS DEDICATED TO WALKING)TREATMENT OF BREATHLESSNESS OR EXERCISE LIMITATIONEach addition to therapy should involve a 4 week trial with discontinuation of any components not demonstrating an improvementin breathlessness or exercise limitation. If patient remains symptomatic review inhaler technique, if satisfactory treatmentshould be intensified by combining therapies following the algorithm belowBreathlessness andexercise limitation*SABA or *SAMA as required =*FEV 1 > 50% FEV 1 < 50%Exacerbations orpersistentbreathlessness*LABA*LAMADiscontinue SAMAOffer LAMA inpreference toregular SAMA four timesa dayLABA + *ICSin a combinationinhalerConsider LABA +LAMA if ICS declinedor not toleratedLAMADiscontinue SAMAOffer LAMA inpreference toregular SAMA four timesa dayPersistentexacerbations orbreathlessnessLABA + ICS ina combination inhalerConsider LABA+ LAMA if ICS declinedornot toleratedLAMA + (LABA + ICS in a combination inhaler)= SABA as required may continue at all stages;discontinue SAMA when LAMA commenced.OfferConsiderTrial of TheophyllineTheophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or in patients who areunable to use inhaled therapy, as there is a need to monitor plasma levels and interactions, including effects of smoking cessation.The choice of drug(s) should take into account the person’s symptomatic response, their preference and ability to manipulate the device,the drug’s potential to reduce exacerbations, its side effects and cost.Other considerations• Mucolytics should not be routinelyused to prevent exacerbations inpeople with stable COPD but maybe of use in patients with chronicproductive cough. Discontinue ifno improvement after 4 weeks• Consider use of patient heldoral steroids and antibiotics foruse with a self management plan forprompt treatment of exacerbations(refer to guideline)• Anxiety and depression should beidentified, assessed and treatedappropriately• Osteoporosis prophylaxis shouldbe considered in patients requiringfrequent courses of oralcorticosteroids. The risks ofdeveloping osteoporosis should bediscussed with patients on high doseICS (especially in the presence ofother risk factors)• Consider referral to theExpert Patient ProgrammeCautionsBe aware of the potential risk ofdeveloping side effects (including nonfatalpneumonia) in people with COPDtreated with ICS and be prepared todiscuss this with patients***Patients with FEV 1 < 30% treatedwith inhaled steroids who arediagnosed with pneumonia shouldhave treatment reviewed by arespiratory physicianDisabilityIn view of the magnitude ofthe benefits of PulmonaryRehabilitation Programmes,the guidelines recommend that itshould be offered to all appropriatepatients with COPD managed inprimary or secondary care whoconsider themselves functionallydisabled by their disease (usually*MRC grade 3 and above) includingthose who have had a recenthospitalisation for an exacerbationOxygenationMeasure saturation by pulse oximetryif FEV 1 < 1.5 litres/40% predictedIf oxygen saturation < 92% considerreferral to Secondary CareRespiratory TeamTreatments considered unsuitablefor COPD• Routine maintenance with oralcorticosteroids is not normallyrecommended• Prophylactic antibiotics• Alpha-1 antitrypsin replacementtherapy• Antioxidant therapies• Antitussive therapy* = Abbreviations: ICS – Inhaled corticosteroid LABA – Long acting beta 2 agonist LAMA – Long acting muscarinic antagonistMRC – Medical Research Council SABA – Short acting beta 2 agonist SAMA – Short acting muscarinic antagonist

Wakefield & Kirklees Guidelines for Managing Stable COPD in Primary Care (Kirklees version)Review in Primary Care: Mild/Moderate/ Severe Airflow Obstruction Very Severe Airflow ObstructionFrequencyAT LEAST ANNUALAT LEAST TWICE PER YEARMeasurements to make• FEV 1 and *FVC measurement• Record *BMI• MRC Dyspnoea score• FEV 1 and FVC measurement• Record BMI• MRC Dyspnoea score• *SpO 2Clinical assessment* = AbbreviationsBMI – Body Mass IndexFEV1 – Forced Expiratory Volume in 1 SecondFVC – Forced Vital CapacityMRC – Medical Research CouncilSpO2 – Saturation of Peripheral Oxygen• Smoking status and desire to quit• Adequacy of symptom control- Breathlessness- Exercise tolerance- Estimated exacerbation frequency• Presence of complications• Effects of each drug treatment• Inhaler technique• Need for referral to specialist and therapy services• Need for pulmonary rehabilitation• Consider referral to Expert Patient Programme• Self management advice• Measure saturation by pulse oximetryif FEV 1 < 1.5 litres/40% predictedTo assess the impact of COPD on the patient’s wellbeingand daily life, consider the use of the COPD AssessmentTest copies to download available on line athttp://www.catestonline.org• Smoking status and desire to quit• Adequacy of symptom control- Breathlessness- Exercise tolerance- Estimated exacerbation frequency• Presence of cor pulmonale• Need for long term oxygen therapy• Patients nutritional state• Presence of depression• Effects of each drug treatment• Inhaler technique• Need for social services and occupational therapy unit• Need for referral to specialist and therapy services• Need for pulmonary rehabilitation• Presence of complications• Consider referral to Expert Patient Programme• Self management advice• Consider palliative care requirementsTo assess the impact of COPD on the patient’s wellbeingand daily life, consider the use of the COPD AssessmentTest copies to download available on line athttp://www.catestonline.org(on pulse oximetry) For video demonstrations of correct inhaler technique: http://www.medicines.org.uk/guides/pages/how-to-use-your-inhaler-videosPublished: November 2010Review: Nov 2013 (unless clinical evidence changes)Enquiries to: Sandy Smith NHS Kirklees 01414 464244References:Chronic Obstructive Pulmonary Disease, National clinical guidance formanagement of Chronic Obstructive Pulmonary Disease in adults inprimary and secondary care, updated June 2010, NICE*** MHRA Drug Safety Update October 2007 Issue 3Group responsible for development:NHS Wakefield District Respiratory Partnership GroupDeveloped in collaboration with:Mid Yorkshire NHS Hospitals Trust and NHS Kirklees