COPD

Guidelines

NICE guidelines for COPD

GPIAG COPD guidelines

Early detection

Spirometry for all smokers over 40 and patients with acute bronchitis.

Spirometric tests should be carried out on all patients with suspected COPD to provide a firm diagnosis of COPD. COPD shows minimal reversibility of FEV1.
Reversibility testing is important in determining the diagnosis and the optimum treatment. ( Bronchodilator reversibility testing should be done in all patients
Corticosteroid reversibility testing should be done in patients with moderate to severe disease or those with mild disease who use a bronchodilator more than once a day to detect those who would benefit from regular inhaled corticosteroids.
Reversibility is present if FEV1 rises by 200ml and 15% after either nebulised bronchodilators, 2 weeks of prednisolone 30mg or 6 weeks of inhaled beclomethasone 500mcg bd or equivalent. For further details see reference 3.
A high degree of reversibility indicates a large component of asthma in the disease and also a much better prognosis than does a low degree of reversibility.

References

Chronic Obstructive Pulmonary Disease. A Boyter et al. Pharmaceutical Journal (vol 261) 5.9.98
First UK Guidelines for Management of Chronic Obstructive Pulmonary Disease. Pharmaceutical Journal (Vol 259) 13.12.97
The Management of Chronic Obstructive Pulmonary Disease. MeReC 9(10) November 1998.

Management

Principles

Stopping smoking is one of the most important components of COPD management and is the only proved way of slowing the progression of the disease
The drug treatments supported by the best evidence are inhaled anticholinergics and inhaled beta2 agonists
A combination of these drugs is better at improving the forced expiratory volume in one second (FEV1) than either treatment alone
Long term domiciliary oxygen therapy may improve survival in patients with moderate to severe hypoxaemia
Mucolytic drugs can reduce the duration and frequency of exacerbations in people with chronic bronchitis

The COPD escalator

Classification of treatments for patients with COPD

Beneficial

Inhaled anticholinergics - these reduce exacerbation rates, and improve symptoms and FEV₁
Inhaled anticholinergics plus beta₂ agonists - the combination improves FEV₁ more than either drug alone
Inhaled beta₂ agonists - these improve symptoms and FEV₁

Likely to be beneficial

Inhaled anticholinergics versus beta₂ agonists - inhaled anticholinergics are probably better at improving FEV₁
Long term domiciliary oxygen - is likely to improve survival in people with hypoxaemia
Mucolytics - these may reduce the rate of exacerbations

Trade off between benefits and harms

Inhaled corticosteroids - these improve exacerbation rates, but have long term harms
Theophyllines - these may improve FEV₁ but their use is limited by side effects and the need for monitoring blood concentrations

Unknown effectiveness

Alpha₁ antitrypsin infusions
Antibiotics
Deoxyribonuclease

Unlikely to be beneficial

Oral corticosteroids - there is evidence of harm but no evidence of long term benefits
Oral versus inhaled corticosteroids - there is evidence of harm but no evidence of long term benefits

Consider...

Step steroids up to 100mcg/day then step down.
Ipratropium up to 80mcg 4 times a day.
Nutrition: BMI
Vaccination: flu and pneumococcal
FEV1 or QoL as measure of improvement
Long term domiciliary O2: if FEV1 < 1.5 and O2 sat < 90-92% consider arterial blood gas measurement. Domiciliary O2 if PaO2 < 8.0kPa.

Cardiac failure and COPD

Four easily assessable clinical items (history of ischaemic disease, laterally displaced apex beat, high body mass index, and raised heart rate) provide independent diagnostic information about the presence or absence of concomitant heart failure in the individual primary care patient with COPD

The addition of natriuretic peptide measurements and electrocardiography further increases the accuracy of the diagnosis

COPD

Guidelines

Links

Early detection

Management

Cardiac failure and COPD