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COPD

Guidelines NICE guidelines for COPD Management of stable chronic obstructive pulmonary disease in primary and secondary care: summary of updated NICE guidance (2010) Inhaled corticosteroids for chronic obstructive pulmonary disease (2012) Links Early detection and diagnosis Interpreting spirometry More on spirometry MRC dyspnoea scale Management Preventing exacerbations in chronic obstructive pulmonary disease (2011) Nebuliser therapy Oxygen therapy Referring patients with COPD for specialist advice or further investigation Cardiac failure and COPD

Early detection and diagnosis

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.
• 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.

• Consider a diagnosis of COPD in patients aged over 35 years who have a risk factor (generally smoking) and present with exertional breathlessness, chronic cough, regular sputum production, frequent winter "bronchitis" or wheeze.
• Measure post-bronchodilator spirometry to confirm the diagnosis of COPD.
• Consider alternative diagnoses or investigations in:
  • Older people without typical symptoms of COPD where the ratio of forced expiratory volume in one second (FEV₁) to forced vital capacity (FVC) is <0.7
  • Younger people with symptoms of COPD where the FEV₁/FVC ratio is 0.7.
• Assess the severity of airflow obstruction according to the reduction in FEV₁
• Disability related to COPD can be poorly reflected in the FEV₁. A more comprehensive assessment of severity includes the degree of airflow obstruction and disability, the frequency of exacerbations, and the following known prognostic factors: breathlessness (Medical Research Council dyspnoea scale)

 

Classification of severity of airflow obstruction (when post-bronchodilator ratio of forced expiratory volume in one second (FEV₁) to forced vital capacity (FVC) is <0.7)

FEV1 (% predicted) NICE 2004 ATS/ERS 2004 GOLD 2008 NICE 2010 80 Not classified Mild Stage 1: Mild Stage 1: Mild* 50-79 Mild Moderate Stage 2: Moderate Stage 2: Moderate 30-49 Moderate Severe Stage 3: Severe Stage 3: Severe <30 Severe Very severe Stage 4: Very severe Stage 4: Very severe

*Symptoms should be present to diagnose COPD in people with mild airflow obstruction.

Or when FEV₁ <50% is accompanied by respiratory failure.

 

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
• Offer pulmonary rehabilitation to all patients who consider themselves functionally disabled by COPD (usually Medical Research Council grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina, or had a recent myocardial infarction.

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

 

• Brad Cheek: last updated Oct 2012
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