"COPD management in non specialist care March 2011"
To access the supporting information, hold down Ctrl and left click the icon COPD- Management in Non-Specialist Care Key Background Backing Information COPD- management considerations 1 Primary Care 3 Secondary Care Information resources Consider all options for patients and carers Referral Template 4 2 Health promotion or Symptom Management of Anxiety and Palliative care preventative measures treatment complications depression 5 6 7 8 9 Encourage smoking Chronic productive Respiratory failure cessation cough & oxygen therapy 10 11 12 Exercise advice Consider referral to 13 specialist care Abnormal body 14 mass index 15 Occupational therapy COPD management 16 of breathlessness pathway Vaccination and antiviral therapy 17 Frequent exacerbations 18 Consider pulmonary rehabilitation 19 Travel and leisure advice 20 Patient education/ self management 21 Considerations for surgery 22 Go to one of the following 23 Go to Stable COPD pathway Go to stable COPD pathway exacerbations non specialist pathway Approval Date: March 2011 Page 1 of 10 Review Date: March 2013 1 Background information Scope: early detection, diagnosis, assessment and management of chronic obstructive pulmonary disease (COPD) in adults interventions include: o inhaled and oral therapies o oxygen therapy o pulmonary rehabilitation o surgical interventions o management of psychological sequelae o health promotion and preventive measures management of complications of COPD including: o respiratory failure o cor pulmonale o abnormal body mass index (BMI) covers criteria for specialist referral covers principles of palliative care in COPD Out of scope: smoking cessation palliative care Definition: COPD is characterised by airflow obstruction: o forced expiratory volume in 1 second (FEV1) less than 80% predicted and FEV1/forced vital capacity (FVC) ratio less than 0.7 airflow obstruction is due to a combination of airway and parenchymal damage COPD is an umbrella term that includes: emphysema chronic bronchitis chronic airflow limitation the definition may include some cases of chronic asthma Incidence and prevalence: an estimated 3 million people are effected by COPD in the UK: o approximately 2 million of these remain undiagnosed rate of COPD in the population is estimated to be between 2-4% incidence is difficult to determine as disease develops insidiously prevalence rates are increasing in women but have reached a plateau in men Prognosis: COPD accounts for approximately 30,000 deaths each year in the UK (more than 90% of these occur in those over age 65 years) mortality from COPD in England shows a strong urban rural gradient Risk factors: smoking occupational exposure increasing age deprived communities Click here to go back to pathway Approval Date: March 2011 Page 2 of 10 Review Date: March 2013 2 Information resources for patients and carers Patients and carers can access this pathway through NHS Choices at http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/pages/introduction.aspx The following resources have been produced by organisations certified by The Information Standard: 'COPD' (PDF) from BMJ at http://www.group.bmj.com 'Chronic Obstructive Pulmonary Disease (COPD)' (URL) from BUPA at http://www.bupa.co.uk 'Chronic obstructive pulmonary disease' (URL) from Datapharm at http://www.medguides.medicines.org.uk 'Understanding NICE guidance: Chronic obstructive pulmonary disease' (PDF) from national Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk 'Chronic Obstructive Pulmonary Disease' (URL) from Patient UK at http://www.patient.co.uk The Carers Resource at http://www.carersresource.org Information for carers and people with disabilities is available at: 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk Explanations of clinical laboratory tests used in diagnosis and treatment are available at ‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk. Click here to go back to pathway 3 COPD - management considerations consider referral to multidisciplinary team (MDT) if available for those with severe disease, which should include professionals such as respiratory nurse specialists to assess and manage chronic obstructive pulmonary disease (COPD) functions of team include: o assessing patients (including performing spirometry, assessing the need for oxygen therapy, the need for aids for daily living and the appropriateness of delivery systems for inhaled therapy) o managing patients, including: non-invasive ventilation pulmonary rehabilitation hospital-at-home or early discharge schemes providing palliative care identifying and managing anxiety and depression advising patients on relaxation techniques dietary issues exercise social security benefits and travel o advising patients on self-management, including providing a written care/self- management plan o identifying patients at risk of exacerbation o providing care to prevent emergency admissions o advising on exercise o educating patients and other health professionals sometimes may need referral to a specialist department, e.g. physiotherapy Click here to go back to pathway 5 Health promotion or preventative measures encourage smoking cessation provide exercise advice vaccination and antiviral therapy: o offer annual influenza vaccination o offer pneumococcal vaccination travel and leisure advice Approval Date: March 2011 Page 3 of 10 Review Date: March 2013 Click here to go back to pathway 6 Symptom treatment To assess effectiveness of bronchodilator therapy consider improvements in: symptoms (e.g. breathlessness, cough) activities of daily living exercise capacity rapidity of symptom relief lung function tests frequency of exacerbations hospitalisations due to chronic obstructive pulmonary disease (COPD) Choice of drug(s) to take into account: patient's response to trial of medication side-effects patient preference cost Delivery systems: inhalers: o bronchodilator therapy is usually best administered by hand-held inhaler device (including a spacer device if appropriate) o short-acting bronchodilators should be the initial empirical treatment for relief of breathlessness and exercise limitation, if necessary o inhalers should not be prescribed unless the patient has received training and demonstrated satisfactory technique: if the patient is unable to use a particular device satisfactorily or it is not suitable, an alternative should be found o regularly assess ability to use an inhaler device and re-teach correct technique if needed o dose of treatment should be titrated according to individual clinical response spacers: o should be compatible with the patient's metered-dose inhaler o use in the following way: administer drug by repeated single actuations of the metered-dose inhaler into the spacer, with each followed by inhalation ensure minimal delay between inhaler actuation and inhalation tidal breathing is as effective as single breaths o do not clean more than monthly (frequent cleaning leads to build-up of static and affects their performance) o clean with water and washing-up liquid and allow to air dry o wipe mouthpiece clean of detergent before use If patient remains symptomatic on monotherapy, consider intensifying treatment by combining therapies: beta2-agonist and theophylline anticholinergic and theophylline Treatments that are not recommended: anti-oxidant therapy (alpha tocopheryl and beta-carotene supplements) antitussive therapy prophylactic antibiotic therapy Click here to go back to pathway 7 Management of complications • Nebulisers (Referral required) Click here to go back to pathway Approval Date: March 2011 Page 4 of 10 Review Date: March 2013 8 Anxiety and depression health care professions should be aware of anxiety and depression in the following patients: o those who are hypoxic (SaO2 less than 92%) o those with severe dyspnoea o whose how have been seen at or admitted to hospital with exacerbation of chronic obstructive pulmonary disease (COPD) the presence of anxiety and depression in patients with COPD can be identified using validated assessment tools screen for anxiety and depression in those most physically disabled treat with conventional pharmacotherapy spend time explaining why depression needs to be treated alongside the physical disorder Click here to go back to pathway 9 Palliative care Palliative care: opioids can be used for the palliation of breathlessness in patients with end-stage chronic obstructive pulmonary disease (COPD) unresponsive to other medical therapy also use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen when appropriate for the palliation of breathlessness in patients with end-stage COPD unresponsive to other medical therapy involve patients with end-stage COPD, their family, and carers with multidisciplinary palliative care teams and services, including admission to hospices Click here to go back to pathway 10 Encourage smoking cessation smoking cessation is essential at all stages of the disease document an up-to-date smoking history, including pack years (number of years smoked x number of cigarettes smoked per day ÷ 20) offer help to stop smoking at every opportunity at all stages of the disease offer varenicline, bupropion or nicotine replacement therapy (unless contraindicated), combined with a support programme as an option for smokers who have expressed a desire to quit smoking smoking cessation cannot restore loss of lung function but can prevent accelerated decline unsuccessful attempt to quit smoking: o reassess readiness to quit at 6 months (may regain adequate motivation) o may be reasonable to try again sooner if external factors interfered with initial attempt Click here to go back to pathway 11 Chronic productive cough Consider trial of mucolytic therapy: continue if symptomatic improvement, e.g. reduction in: o frequency of cough o sputum production do not routinely use for the prevention of exacerbations in people with stable chronic obstructive pulmonary disease (COPD) Consider the following: referral to physiotherapy to aid sputum clearance provision of advice on hydration Click here to go back to pathway Approval Date: March 2011 Page 5 of 10 Review Date: March 2013 12 Respiratory failure and oxygen therapy Assess for appropriate oxygen therapy(referral required). patients should breathe supplemental oxygen for at least 15 hours per day assess need for oxygen therapy in patients with: o severe airflow obstruction (forced expiratory volume in 1 second [FEV1] less than 30% predicted) o cyanosis o polycythaemia o peripheral oedema o raised jugular venous pressure o oxygen saturation less than/equal to 92% breathing air consider assessment in moderate airflow obstruction (FEV1 30-49% predicted) practices should have access to pulse oximeter to ensure those needing LTOT are identified assessment of patients for LTOT should comprise measurement of arterial blood gases on two occasions at least 3 weeks apart in patients: o with a confident chronic obstructive pulmonary disease (COPD) diagnosis o who are receiving optimum medical management o whose COPD is stable use oxygen concentrators for fixed supply at home for LTOT: o warn patient about risk of fire and explosion if they continue to smoke with prescribed oxygen patient receiving LTOT should be reviewed once annually by GP, including pulse oximetry Ambulatory oxygen therapy (referral required): for those already on LTOT who want to continue therapy outside the home consider in the following patients: o patients who have exercise desaturation o patients shown to have an improvement in exercise capacity and/or dyspnoea with oxygen o patients with the motivation to use oxygen should only be prescribed after assessment has been performed by a specialist - assessment should include: o extent of desaturation o improvement in exercise capacity with supplemental oxygen o oxygen flow rate required correct desaturation, aimed at keeping the SaO2 above 90% small light weight cylinders, oxygen-conserving devices, and portable liquid oxygen systems should be available: o small cylinders - for duration of use less than 90 minutes o small cylinders with oxygen-conserving devices - for duration of use less than 4 hours but more than 90 minutes o liquid oxygen: for flow rates greater than 2L/min and duration of use of more than 30 minutes for duration of use less than 4 hours not recommended if PaO2 is greater than 7.3kPa and there is no exercise desaturation Short-burst oxygen therapy (referral required): only for episodes of severe breathlessness not relieved by other treatments should only continue to be prescribed if an improvement in breathless following therapy has been documented should be provided for cylinders when indicated consider referral for assessment for long-term domiciliary non-invasive ventilation (NIV) NB: Clinicians should be aware that inappropriate oxygen therapy in people with COPD can cause respiratory depression Click here to go back to pathway Approval Date: March 2011 Page 6 of 10 Review Date: March 2013 13 Exercise advice if patients with mild disease have few symptoms, they should be encouraged to continue with all their usual activities, including all but the most strenuous jobs exercise is both safe and desirable in patients with moderate or severe chronic obstructive pulmonary disease (COPD), exercise should be encouraged within the limitations of their airways obstruction breathlessness on exertion may be distressing but is not dangerous and many patients can continue their activities and interests in spite of their impairment patients with moderate COPD can often continue in employment as long as it does not involve heavy manual work consider pulmonary rehabilitation Local Information Refer to National Exercise Referral Schemes if MRC is 1 or 2. o Swansea=Positive steps 01792 635469 o Neath Port Talbot= PACE 01639 861144 o Bridgend= Revite-a-Life 01656 641255 If MRC is 3+ refer for pulmonary Rehab. Due to limited access to pulmonary rehab services in the ABMU Health Community this service is only available by consultant referral. Any patients assessed as meeting the criteria in primary care should be referred to a secondary care specialist, requesting assessment for pulmonary rehab. Click here to go back to pathway 15 Abnormal body mass index (BMI) Body mass index (BMI) should be calculated in all patients with chronic obstructive pulmonary disease (COPD): the normal range for BMI is 20 to less than 25 BMI = weight (kg)/[height (m)]2 give nutritional supplements if the BMI is low and encourage exercise to augment the effects of nutritional supplementation weight reduction in obese patients will reduce the energy requirements of exercise and thus improve the ability of patients to cope with their disability – appropriate dietary advice and support should be offered malnutrition is common in patients with severe COPD and may contribute to mortality – refer for dietary advice in older patients attention should also be paid to changes in weight, particularly if the change is more than 3kg although nutritional support for patients with COPD seems logical, controlled trials of its effect on morbidity, quality of life, hospital admissions, and mortality are not available Click here to go back to pathway 16 Occupational therapy Occupational therapy: patients should be regularly asked about their ability to undertake daily activities and how breathless they become when doing these clinicians should assess the patients need for occupational therapy using validated tools Consider referral for assessment by a social services department. Click here to go back to pathway 17 Vaccination and antiviral therapy offer pneumococcal and annual influenza vaccination to all patients with COPD in an influenza pandemic: Approval Date: March 2011 Page 7 of 10 Review Date: March 2013 zanamivir and oseltamivir are recommended for at-risk patients presenting within 48 hours of onset of symptoms of an influenza-like illness NB: Oseltamavir can be associated with a variety of neurological and behavioural symptoms including hallucinations, delirium and abnormal behaviour. Click here to go back to pathway 18 Frequent exacerbations Management of symptoms: offer annual influenza vaccination offer pneumococcal vaccination optimise bronchodilator therapy with long-acting bronchodilator (beta2-agonist or anticholinergic) - offer the following as maintenance therapy: o if forced expiratory volume in 1 second (FEV1) is greater than or equal to 50%, offer long-acting beta2 agonist (LABA), or long-acting muscarinic antagonist (LAMA) o if forced expiratory volume in 1 second (FEV1) is less than 50%, offer LABA with an inhaled corticosteroid (ICS) in a combination inhaler or LAMA o LABA should be offered in preference to four-times-daily short-acting muscarinic antagonist (SAMA) if patient remains breathless or has exacerbations, despite maintenance therapy with LABA, consider the following: o LABA plus ICS in a combination inhaler o LAMA in addition to LABA where ICS is declined or not tolerated offer LAMA in addition to LABA plus ICS if patient remains breathless or has exacerbations despite taking LABA plus ICE, irrespective of their FEV1 add inhaled corticosteroids if forced expiratory volume in 1 second (FEV1) is less than or equal to 50% and two or more exacerbations in a 12-month period: o used in combination with a long-acting bronchodilator o warn of risk of osteoporosis in severe COPD and potential adverse effects of steroid therapy Oral corticosteroid therapy is not normally recommended (referral required for advice regarding maintenance steroid therapy): patients with advanced COPD may require oral corticosteroid treatment patients treated with long-term oral corticosteroid should be: o monitored for the development of osteoporosis; and o given appropriate prophylaxis (patients over age 65 years should be started on prophylactic treatment, without monitoring) Provide self-management advice: encourage quick response to symptoms of exacerbation by: o starting oral corticosteroid therapy if increased breathlessness interferes with activities of daily living (unless contra-indicated)- prednisolone 30mg for 7-14 days o starting antibiotic therapy if their sputum is purulent o adjusting bronchodilator therapy to control symptoms o report exacerbations to primary care for appropriate coding to facilitate identification of frequent exacerbators give a course of antibiotic (subject to local current microbiological guidelines) and corticosteroid tablets to keep at home advise to contact a healthcare professional if symptoms do not improve monitor use of these drugs Click here to go back to pathway 19 Consider pulmonary rehabilitation Pulmonary rehabilitation: should be available to all appropriate patients with COPD, including those recently hospitalised for an acute exacerbation Approval Date: March 2011 Page 8 of 10 Review Date: March 2013 programme should be: o multidisciplinary programme of care o individually tailored to optimise the individual's physical and social performance and autonomy o be held at times that suit patients, and in buildings that are easy for the patient to get to in practice, usually offered to those who consider themselves functionally disabled by chronic obstructive pulmonary disease (COPD; usually MRC grade 3 and above) not suitable for those: o unable to walk o with unstable angina o who have had a recent myocardial infarction should include: o physical training o disease education o nutritional intervention o psychological intervention o behavioural intervention patient should be made aware of the benefits of rehabilitation and the commitment required to gain these benefits MRC dyspnoea scale. Grade Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill Walks slower than contemporaries on level ground because of breathlessness, or has to 3 stop for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Local Information Due to limited access to pulmonary rehab services in the ABMU Health Community this service is only available by consultant referral. Any patients assessed as meeting the criteria in primary care should be referred to a secondary care specialist, requesting assessment for pulmonary rehab. Click here to go back to pathway 20 Travel and leisure advice travel is possible by land and sea in virtually all cases air travel: o assess those who use long-term oxygen therapy or have forced expiratory volume in 1 second (FEV1) less than 50% predicted in line with British Thoracic Society (BTS) recommendations o warn patients with bullous disease about theoretically increased risk of pneumothorax during air travel o may be hazardous if O2 saturation is below 95%– look at guidelines on the British Thoracic Society website scuba diving is not recommended avoid high altitude Local Information If Oxygen Saturation levels are over 95%, oxygen is not required. If Oxygen Saturation levels are between 92% and 95% and the patient has additional risk factors please refer to the below guidelines: www.brit- thoracic.org.uk/ClinicalInformation/AirTravel/AirTravelGuideline/tabid/118/Default.aspx Click here to go back to pathway Approval Date: March 2011 Page 9 of 10 Review Date: March 2013 21 Patient education/self management Patient education: specific educational packages should be developed for patients with chronic obstructive pulmonary disease (COPD; do not use programmes designed for asthma): o package should take into account the different needs of patients at different stages of their disease patients with moderate to severe COPD should be made aware of the NIV technique - benefits and limitations should be explained in case it is necessary in the future Self-management: patients at risk of having an exacerbation of COPD: o should be given self-management advice which encourages a prompt response - patient should respond promptly by: starting oral corticosteroid therapy starting antibiotic therapy if their sputum is purulent adjusting their bronchodilator therapy to control symptoms o should be given a course of antibiotic and corticosteroid tablets to keep at home for use as part of a self-management strategy: appropriate use of these tablets should be monitored patient should be advised to contact a health care professional if they do not improve Click here to go back to pathway 22 Considerations for surgery Decision of whether or not to proceed with surgery should rest with the consultant anaesthetist and consultant surgeon, taking into account: functional status necessity of the surgery composite assessment tools such as American Society of Anaesthesiologists (ASA) scoring system lung function should not be the only criterion used to assess patients with COPD before surgery If time permits, medical management should be optimised before surgery and might include a course of pulmonary rehabilitation References Please click on the below icon for the list of references COPD Pathways References.doc Click here to go back to pathway Approval Date: March 2011 Page 10 of 10 Review Date: March 2013