GP reg talk - COPD by zhangyun

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									COPD - An overview

              Managed care
                  in the

                   Jo Riley
            Lead Respiratory Nurse
                07789 986791
   Respiratory service
   Oxford 01865 402710
   Banbury 01295 229501

   Rehab referrals fax to 01865 402709
   Definition of COPD
                          COPD is a preventable and treatable
                          disease state characterised by airflow
                          limitation that is not fully reversible1

                          The airflow limitation is usually
                          progressive and is associated with an
                          abnormal inflammatory response of
                          the lungs to noxious particles or
                          gases, primarily caused by cigarette

                          Although COPD affects the lungs, it
                          also produces significant systemic

ATS/ERS Guidelines 2004
                                                          1. ATS/ERS 2004
COPD is a multi-component
   Inflammation
    has a central
    role in the
    of COPD1

                    Reduced quality of life
                     Disease progression

                                              1. GOLD Guidelines
The Impact of COPD
   Affects 1.5% of UK population – could be
    as high as 6-8% in over 75’s
   More than 30,000 deaths annually in the
   Currently the 5th greatest cause of
    mortality world-wide - over 2.5million
    deaths in 2000
   By 2020, COPD will be the 3rd leading
    cause of mortality
   Exacerbations have an impact on patient
    quality of life and can be life threatening
        The top seven causes for
        hospital admissions in UK
        (DoH, 2003/04)

                                             No. OF      COST
                                            EPISODES     IN £m
 Chronic Obstructive Pulmonary Disease
                                               106,517     253
    Angina (without major procedure)            79,228     134

  Ear, Nose and Throat infections (ENT)         72,831      52

        Convulsions and epilepsy                64,664      77

         Congestive heart failure               62,582     211

                 Asthma                         61,264      64
Flu and pneumonia (in those over 2 months
                                                56,616     158
                What is the size of the problem
                in a Primary Care Organisation
  • Population of PCO – say 500,000 people1
  • 29,000 will be known to have active asthma
  • 20% live with someone with asthma3
  • 8,500 patients known to have COPD (1.9%)2
  • 25,500 people with COPD4

1 - Population Data DH, 2006. 2 - Information Centre 2006 Quality and Outcome data http:/
3 - Asthma UK fact sheet, 2007 4 - Invisible lives 2007
COPD and women

   Incidence rising in women 3 times
    faster than in men
   More deaths than cervical cancer,
    breast cancer or skin cancer
   Women more susceptible to harmful
    effects of smoking
   89% never heard of COPD
Understanding the
   What do patients understand?
   What does “Chronic” mean to your
   Emphysema?
   Chronic bronchitis?
   Asthma???
What can you do to Help?

   Diagnosis
   Smoking cessation
   Best treatment
   Oxygen
   Pulmonary rehab
   Work together
Finding the Missing
   British Lung Foundation campaign
   What is the practice prevalence in your
    – Oxfordshire and Buckinghamshire practices 0.2 –
   What could it be in reality?
    – ?1-2% of under 50year olds
    – ?2-4% of 50-60 year olds
    – ?6-8% of over 75 year olds
   50% of all smokers over 60 Likely to have
Who might have COPD
A diagnosis of COPD should be considered in all
  patients who are:
 Over 35
 Smokers or ex-smokers >20 pack year
 Have any of these symptoms-
   – Exertional breathlessness
   – Chronic cough
   – Regular sputum production
   – Frequent winter bronchitis
   – Wheeze
 No clinical features of asthma
  Smoking Pack Years
The difference between asthma and COPD
   History                         COPD          Asthma
   Heavy smoker or ex-smoker       Yes           May be
   Was a chesty child              Maybe         Often
   Cough and sputum             For many years   Often recent
   Breathlessness started          Gradually     Sudden attacks
   Breathlessness varies           Little        A lot
   Attacks of breathlessness at rest Uncommon    Common
   Cough at night                    Uncommon     Common
   PEFR/ FEV1                      May be low    Low or normal

   Daily variations in PEFR        Little        „Morning dip‟ + day-to-
   Response to bronchodilator      Partial       Usually complete

   Blood eosinophilia              No            Sometimes
                        Risk factors for COPD
                                                   • Genes
                                                   • Exposure to particles
                                                        – Tobacco smoke
                                                        – Occupational dusts
                                                        – Indoor and outdoor air pollution
                                                   • Lung growth and development
                                                   • Oxidative stress
                                                   • Gender
                                                   • Age
 Worldwide, cigarette                              • Respiratory infections
 smoking is the most                               • Socioeconomic status
commonly encountered                               • Nutrition
  risk factor for COPD                             • Comorbidities

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management,
                                 and Prevention of Chronic Obstructive Pulmonary Disease 2006:1-100.
          Pathophysiology – decline in FEV1 in
         non-smokers and susceptible smokers

            FEV1 (% of value at age 25)




            25                               50                             75
                                           Age yrs

Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ. 1977;1:1645-1648.
Confirming diagnosis
   Spirometry
     – FEV1/FVC ratio <70%
     – FEV1<80% predicted
   Right time, right technique, right machine, right interpretation
    = right diagnosis

   Patients with very early lung damage may still have
    spirometry which is within normal limits.

   Severity
     – FEV1 50 – 80%      Mild
     – FEV1 30 – 50%      Moderate
     – FEV1 <30%                  Severe
      Reversibility Testing
   Unreliable – magnitude of FEV1 response
   Misleading – a continuous variable(Calverley et al
 Time consuming
 Attracts GMS payment

So what do we advise?
  History Suggests
                            If no             Diagnose COPD
      COPD and
                            doubt             And follow COPD
 FEV1 < 80% predicted
   FEV1/FVC < 70%

      If in doubt

                           If FEV1                 If still
    Bronchodilator        improves                In doubt
     Reversibility        < 400 mls
400 mcg Salbutamol or
 equivalent Terbutaline
                                         reversibility         If FEV1
                                      Oral Prednisolone       improves
   If FEV1 improves                    30 mg daily for        < 400 mls
       > 400 mls                           2 weeks

 Asthma likely to be                           If FEV1 improves
      present                                      > 400 mls
          Differential diagnosis:
          Heart failure

Breathless, cough, swollen ankles, basal inspiratory crackles
             Differential diagnosis:

Large volumes of sputum
     Differential diagnosis:
     Interstitial Lung Disease
Occupational history, fine basal inspiratory crackles
           Differential Diagnosis: Carcinoma
           of the lung (urgent chest xray….)

   For those with haemoptysis or any of the
    following (unexplained or present for more than
    3 weeks)
    –   Cough
    –   Chest / shoulder pain
    –   Dyspnoea
    –   Weight loss
    –   Chest signs
    –   Hoarseness
    –   Finger clubbing
    –   Signs suggesting metastases
    –   Cervical / supraclavicular lymph nodes

   Coronary Heart Disease
   Diabetes
   Joint pain 70%
   Osteoporosis 34%
   Depression 35-42%
   Carcinoma of lung (increased risk x6)

NICE, 2004; Calverley, 2007; Yawn and Kaplan, 2008
              COPD: natural history


                                            Exacerbations               Deconditioning

                                                 Hospitalisation            Systemic effects
                                         Pulmonary hypertension                 Hypoxemia

                          30              40             50        60          70        80

                                                         Age (years)
1. Fletcher C, Peto R. BMJ 1977;1 (6077):1645-1648
2. (accessed 29605)
              Goals of COPD
    NICE                            GOLD2

                                   Prevent disease progression
   Accurate diagnosis
                                   Relieve symptoms
   Stopping smoking
                                   Improve exercise tolerance
   Effective inhaled therapy
   Access to pulmonary rehab      Improve health status
                                   Prevent and treat
   Prevent and treat               complications
                                   Prevent and treat
   Multidisciplinary working       exacerbations
                                   Reduce mortality

1. NICE 2004
2. Pauwels RA et al. 2001.
        Impact of Chronic Disease

Impairment        Disability                     Handicap

               Witek TJ. Respir Care ClinNorth Am. 1999;5(4):521-536.
How do we assess COPD

               Patients sub-optimally managed:
                   – patients with COPD understate their
                     disease severity3
                   – priorities of patients and management
                     guidelines don‟t match2
                   – the tools currently used to assess patients
                     have limitations4

1 Annual   report of the Chief Medical Officer, 2004; 2 Lost in translation, BLF 2006;
3 Rennard   S et al. Eur Respir J 2002; 20: 799–805; 4 Jones P et al. PrimCare Resp J 2009; 18(3): 208-215
           There’s a need for a new
           COPD assessment tool   1

               A need exists for a tool that is:
                  –    short, simple
                  –    standardised, validated
                  –    self-administered by patients
                  –    suitable to be routinely used in clinical practice
                  –    an objective measure of disease severity and of
                       the impact of COPD on a patient‟s life
               The CAT was developed to meet this
1 Jones   P et al. Prim Care Resp J 2009; 18(3): 208-215
        Introducing… the CAT1
   Patients read the two statements
    for each item, and decide where
    on the scale they fit
   Each line gives helpful
    information to guide treatment
   Scores for each of the
    8 items are summed to give
    single, final score (minimum 0,
    maximum 40)
   This is a measure of the overall
    impact of a patient‟s condition on
    their life
   Expert guidance document for         1 Jones   P et al. Eur Respir J 2009; 34: 648-654
    interpretation of CAT available
   The CAT was designed
Help patients to express themselves meaningfully               
Enable patients and HCPs to gain a common understanding
of the impact that COPD has on a patient’s life                

Compliment measurements of lung function                       
Help ‘optimise’ the management of COPD                         
Improve effectiveness of patient monitoring and consultation   
Reveal changes in the impact of COPD on a patient’s life       
     Reduce risk factors – smoking cessation

• Smoking cessation is the single most effective – and
  cost effective – intervention in most people to reduce
  the risk of developing COPD and stop its progression
• Encouraging patients with COPD to stop smoking is
  one of the most important components of their
• All COPD patients still smoking, regardless of age,
  should be encouraged to stop and offered help to do
  so at every opportunity

  Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management,
                                   and Prevention of Chronic Obstructive Pulmonary Disease. 2006:1-100.
Effect of smoking on decline in lung
FEV1 (% of value at
age 25)
                                                  Never smoked
100                                               or not susceptible
                                                  to smoke

                        Smoked regularly
                         and susceptible              Stopped at 45
 50                       to its effects

 25                                                   Stopped at 65

      25                           50                    75
                                    Age (years)

                                                              Fletcher & Peto, 1977
Effect of smoking on decline in lung
FEV1 (% of value at
age 25)
                                                  Never smoked
100                                               or not susceptible
                                                  to smoke

                        Smoked regularly
                         and susceptible              Stopped at 45
 50                       to its effects

 25                                                   Stopped at 65

      25                           50                    75
                                    Age (years)

                                                              Fletcher & Peto, 1977
     Can:
      • Improve and prevent symptoms
      • Reduce frequency and severity of
      • Improve health status
      • Improve exercise tolerance
Commonly used formulations
of inhaled therapy
    Start with - Short-acting Bronchodilators
     – Short-acting ß2 agonists (SABA) Salbutamol or
     – Short-acting anticholinergics - Ipratropium
    Still breathless – try Long-acting
     – Long-acting anticholinergics - tiotropium
     – Long-acting ß2 agonists (LABA) Salmeterol or Formoterol
    Inhaled corticosteroids -if history of
     exacerbations in moderate to severe
What are you looking
    Less breathlessness
    Ability to be more active
    Better quality of life
    Improved health status
    Reduced mortality
    Reduction in exacerbations
    FEV1?
     – Would not expect to see
       improvements in FEV1 over time
Inhaled corticosteroids for
  ?Do not significantly reduce lung function
   decline at any stage
 Not indicated in mild COPD
In COPD as a result of long standing asthma
Studies ongoing
Clinical evidence of the presence of
   inflamaatory cells in airways at all stages of
   COPD (Hogg et al NEJM 2004)
   Symbicort 400 Turbohaler and
    Seretide 500 Accuhaler
   Moderate to severe COPD with 2 or
    more exacerbations per year
    – Reduce exacerbation rates
    – Reduce breathlessness
    – Improve health status
    – Improve lung function
Inhaled steroids not licensed for use
  in COPD except as combination
Pharmacotherapy for
   NICE and GOLD guidelines to inform
   NICE guidelines being updated –
    update in draft form for comment
   Strong evidence base – INSPIRE,
   TORCH study – Seretide versus
    Fluticasone, salmeterol and Placebo
Aim of Inhaled therapy

Deliver high concentration of drugs directly
to lungs & bronchioles while reducing
systemic side effects
Find the most suitable device
Education and re assessment of inhaler
pMDI Technique

Think Eddy Stobart lorry doing 70 miles
  per hour on a country lane trying to
           round the bends!

Needs to be slowed down to negotiate
               the bends
Dry powder devices (DPI)

Think Eddy Stobart lorry trying to round
 a country bend from stationary!!

 Needs acceleration
to get around the bends
Oral therapies

   Theophylines
    – Side effects
    – May be helpful
   Oral Beta2 agonists
    – Side effects
    – For patients who cannot take inhalers
Oral therapies -
   Indicated for chronic productive cough
   Carbocisteine (Mucodyne) – initial
    dose 750mg TDS then wean as
    response to lowest dose possible
   Mecysteine (Visclaire) 200mg QDS for
    2 days then 200mg TDs for 6 weeks
    then 200mg BD
   Stop if no response after 4 weeks
Oral therapies -
   Long term use of oral corticosteroids is not
   Some patients may need to continue to take
    oral corticosteroids following an
   These patients should be maintained on the
    lowest dose possible
   Monitor for osteoporosis and treat
What else can we do?

Lifestyle advice and
     Physical activity
   Consider early referral for pulmonary rehabilitation -
    Early PR after hospital admission for acute COPD is
    safe and leads to statistically and clinicallly
    significant improvements in exercise capacity and
    health status at 3 months Man et al (BMJ 2004)

   Physical activity reduces the risk of hospital
    admissions (Morgan, thorax 2005)
   Patients who walk for 1 hour per day versus those who
    walk 20 mins per day have >50% reduction in
    exacerbations (Efram study 1996) – supported by
    many other studies
Pulmonary rehabilitation

A multi-disciplinary programme of exercise
  and education designed specifically for
  people with chronic respiratory disease
An individually tailored programme designed
  to optimise the individuals physical and
  social performance and autonomy
For patients MRC 3 and above
        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

   3    Walks slower than contempories on the level because of
        breathlessness, or has to stop for breath when walking at own pace
   4    Stops for breath after walking about 100 metres or after a few
        minutes on the level
   5    Too breathless to leave the house, or breathless when dressing or
 Benefits of pulmonary rehabilitation in COPD

• Improves exercise capacity
• Reduces the perceived intensity of breathlessness
• Improves health status
• Reduces the number of hospitalisations and days in the hospital
• Reduces anxiety and depression associated with COPD
• Strength and endurance training of the upper limbs improves arm
• Benefits extend well beyond the immediate period of training
• Improves survival
• Respiratory muscle training is beneficial, especially when combined
  with general exercise training
• Psychosocial intervention is helpful
   Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management,
                                    and Prevention of Chronic Obstructive Pulmonary Disease. 2006:1-100.
Abnormal BMI

   Advice on healthy eating
   Refer for dietetic advice
   If BMI low
    – Frequent small meals
    – Positioning
    – Oxygen
    – Use of supplements
Anxiety and depression

   Be aware of anxiety and
    depression and screen for
    them in the most
    physically disabled
   Treat with conventional
Respiratory failure and
cor pulmonale
   Monitor Oxygen saturations
    – Refer for LTOT assessment if
      saturations below 92%
   Consider need for diuretics
   Consider referral for ambulatory
    (or short burst) oxygen
   All patients considered for
    oxygen therapy should be
    referred to a respiratory/oxygen
No evidence for oxygen for any
  patient with oxygen saturations
  above 92%

    • A sustained worsening of the
      patient’s condition, from the
      stable state and beyond
      normal day-to-day variations,
      that is acute in onset and
      necessitates a change in
      regular medication in a patient
      with underlying COPD1
    • Most common causes:2
         –Bacterial and viral infections
         –Cold weather
         –Interruption of regular

     1Rodriguez-Roisin  R. Chest. 2000;117:398S-401S.
      2Burge   S, Wedzicha JA. Eur Respir J Suppl. 2003.
Why are exacerbations important?

                  • Exacerbations have serious
                    negative impacts on
                    patients’ quality of life,
                    lung function and
                    socioeconomic costs1-3

               1SpencerS, et al. Eur Respir J. 2004;23:698-702.
                 2Donaldson G, et al. Thorax. 2002;57:847-852.
                     3Wouters E. Respir Med. 2003;97:S3-S14.
Prevention of
   Offer annual influenza vaccinations
   Offer pneumococal vaccination
   Give self management advice
   Optimise bronchodilator therapy with one or
    more long acting bronchodilator
   Add inhaled corticosteroids if FEV1<50%
    and 2 or more exacerbations per year – this
    should usually be in combination with a long
    acting bronchodilator – TORCH data!
        COPD admissions in the UK 2008
        (figures in brackets are for 2003)

    7.7% Died during hospital admission (7.5%)
    6.3% Post discharge deaths at 90 days (8%)
    13.9% Overall mortality at 90 days (15.5%)
    5 days average length of stay (6 days)
    33% Readmission rate at 90 days (31%)
    30% had more than 5 exacerbations during year
    42% had more than 3 courses of prednisolone
    60% had been previously admitted
Recognising an
   More breathless than usual (98%)
   Respiratory rate >20/min (82%)
   Usual inhaled/nebulised therapy not working
    as well as usual
   Cough develops or worsens
   Change in sputum amount (66%)
   Change in sputum colour (61%)
   Fevers/sweats/rigors
          Exacerbations -
          good assessments needed

• Important to assess and       Differential Diagnosis
  document the severity of       – Asthma
  COPD exacerbations             – Pneumonia
    • Respiratory rate           – Congestive cardiac
    • Oxygen saturation            failure
    • Symptoms                   – Pleural effusion
                                 – Pulmonary embolism
                                 – Cardiac arrythmias
Exacerbation Management
in Primary Care
   Increase frequency of bronchodilators
    (consider need for nebulised therapy)
   Give 30mg prednisolone orally for 7-14 days
    to all patients with a significant increase in
    breathlessness unless contraindicated
   Give oral antibiotics if history of purulent
   Arrange appropriate review
   Consider chest physio / adjunctive personal
Self Management Plans

Aim to help patients:
 Respond promptly to symptoms

 Start treatment appropriately
  – Oral steroids
  – Antibiotics
  – Adjusting bronchodilator therapy
  Should all patients be given back-up
   steroids and antibiotics?
    Managing Exacerbations
    Hospital or Home? - When to
    admit (R135)
   Unable to cope at          Already on LTOT?
    home                       Living alone
   Severe                     Acute confusion
    breathlessness             Rapid onset
   Deteriorating general      Significant co-
    condition                   morbidity
   Confined to bed            SaO2<90%
   Cyanosed                   Changes in chest x-
   Increased peripheral        ray
    oedema                     Arterial pH<7.35
   Impaired level of          Arterial PaO2<7kPa
             Goals of COPD management
             Take home messages
           NICE GUIDELINES *

          Accurate diagnosis – Early!*
          Stopping smoking – Early!*
          Effective inhaled therapy – Right drug, good
          Check saturations – refer for appropriate oxygen
          Access to pulmonary rehab – exercise ++*
          Prevent and treat exacerbations – self management*
          Multidisciplinary working – involve support teams*
1. NICE 2004
2. Pauwels RA et al. 2001.
       Patients with COPD -
       Do we fail them from beginning to end?

           “…If you smoke 30 cigarettes a day and have
           a myocardial infarct, you receive sympathy,
           abundant health service resources and
           research is amply funded. If you have a
           similar nicotine dependence syndrome and
           develop COPD, few speak up for you, you are
           fortunate if you receive the few interventions
           that might help, and research is poorly
           funded and not always directed at the key
Martin Partridge Thorax May 2003
The COPD Strategy

Public consultation due in next
Publication planned for mid year
High quality care for all
NHS Next Stage Review Final Report
 • Help to stay healthy                     • Raising standards
                              Quality at
 • Empowering                the heart of   • Stronger involvement of
  patients                     the NHS       clinicians in decision making at
                                             every level of the NHS
 • Most effective
  treatments for all                        • Fostering a pioneering NHS

 • Keeping patients as
  safe as possible
                            High quality
                                                          • Empowering
                            care for all                    frontline staff to
             High quality                                   lead change that
                                            Freedom to      improves quality
               care for
                                             focus on       for patients
             patients and                     quality
              the public
                                                          • Valuing the work
                                                            of NHS staff
Long term conditions
 60 per cent of all deaths attributable to LTC‟s
 In the UK it is estimated that people with a long-
  term condition account for 80 per cent of all GP
 They are twice as likely to be admitted to hospital

 Over the period 2004 to 2031, the number of people
  of working age is projected to fall by seven per cent.
  This highlights the need for effective service
  provision to ensure that patients receive good
  quality care.
2000          2001          2005

       2007          2008
       Scale of COPD
   In 2000, the WHO estimated 2.74 million deaths worldwide from COPD
   Predicted to be the third biggest cause of mortality by 2020
   In England up to 3 million people have COPD, but only 0.75 million people
    are diagnosed - mostly at severe stage
   One in eight hospital admissions are for COPD (£2500 per admission) which
    equates to 1000 admissions and 25,000 GP consultations per year in a typical PCT
    so is the second most common cause of emergency admissions to hospital
   14% of all deaths in the UK are due to lung disease
   COPD is the fifth biggest killer disease in the UK, claiming more lives than
    some cancers. In the UK, COPD is the cause of death in 6.4% of men and 3.9%
    of women
   Smoking is the most common cause of respiratory disease. 86% of COPD
    deaths are attributable to it - 15% of smokers have COPD
   Costs to NHS about £1.5bn a year including drug costs
   The overall quality of life for people with advanced COPD is, for example,
    about four times worse than for people with severe asthma
Issues the COPD Strategy
will address
   A lack of awareness of COPD by healthcare
    professionals and the public
   Little focus on prevention and risk reduction
   Large numbers of people not diagnosed or
    inaccurately classified
   No clear care pathways and models of care
    provision including for acute and chronic care
   Varying access to pulmonary rehabilitation and
    supportive care
   Access to specialist services at end of life is sparse
What the Strategy will
   Raising awareness
   Focus on prevention and risk reduction
   Early identification, confirmatory diagnosis and severity
    assessment (ongoing)
   Clear care pathways and models of care provision for acute
    (aggressive management of acute exacerbations) & chronic
    care- Wagner‟s chronic care model
   Structured support and action planning
   Recognition of the importance of both pharmacological and
    non pharmacological interventions
   Smoking cessation
   Equity of access to pulmonary rehabilitation and supportive
   Access to specialist services at end of life
          Spectrum of COPD
          Prevention and Awareness
                             •Promote sustained           The earliest point at
                              stop smoking                which airflow
   •Raising                   services                    obstruction may be
    awareness of                                          detected by
    early signs and          •Early identification

                                        ‘Lower                              ‘Upper
                                        limits of                           limits of
                                        normal’                             normal’


Unaware of Aware of       No symptoms     Symptoms but       MILD          MODERATE     SEVERE   VERY SEVERE
lung health lung health                    no diagnosis      stage           stage       stage      stage

      Well                         At-risk                               With COPD diagnosis

• Make links with other        • Roles and
disease areas, e.g. lung       responsibilities of
cancer, CHD                    employers
                               • Environmental
               Spectrum of COPD
               Screening, Detection and Diagnosis
                                                          The earliest point at
                                                          which airflow
                                                          obstruction may be
                                                          detected by
                                                           •Improve Diagnostic accuracy
                                                           •Implement case finding strategies
                                                           •Consider the case for screening
                                        ‘Lower                              ‘Upper
                                        limits of                           limits of
                                        normal’                             normal’


Unaware of Aware of       No symptoms     Symptoms but      MILD        MODERATE     SEVERE        VERY SEVERE
lung health lung health                    no diagnosis     stage         stage       stage           stage

      Well                         At-risk                             With COPD diagnosis

                                                           •Identify those with A1AT deficiency
                                                           •Establish accurate disease registers
               Spectrum of COPD
               Chronic Care
                                                        The earliest point at
                                                        which airflow
                                                        obstruction may be
                                                        detected by

                                                          Review Review 6 Review every 3 months
                                                          Annually monthly


Unaware of Aware of       No symptoms   Symptoms but       MILD          MODERATE   SEVERE    VERY SEVERE
lung health lung health                  no diagnosis      stage           stage     stage       stage

      Well                         At-risk                             With COPD diagnosis
                                                         •Comprehensive care plan for everyone with COPD
                                                         •Self-management plans
                                                         •Proactive management using disease registers
                                                         •Structured assessment using other diagnostics
                                                         every 3 years, e.g. ABG, spirometry, etc.
               Spectrum of COPD
               Acute Care
                                                          The earliest point at
                                                          which airflow
                                                                                  •Improved access to advice when
                                                          obstruction may be
                                                                                   symptoms worsen
                                                          detected by
                                                                                  •Accurate diagnosis and prompt
                                                                                   assessment of exacerbations
                                                                                  •Use of oxygen alert cards for ambulance

                                        ‘Lower                              ‘Upper
                                        limits of                           limits of
                                        normal’                             normal’


Unaware of Aware of       No symptoms     Symptoms but       MILD          MODERATE      SEVERE      VERY SEVERE
lung health lung health                    no diagnosis      stage           stage        stage         stage

      Well                         At-risk                               With COPD diagnosis
                                                            •Assessment for invasive and non-invasive
                                                            ventilation for hypercapnic patients
                                                            •Early assessment for early discharge
                                                            •Structured treatment whilst in hospital
                                                            •Follow-up post exacerbation
               Spectrum of COPD
               End of Life Care
      Defined as:                                           •Access to supportive care for patient and family
      •Very severe airflow obstruction (FEV1< 30 %          through to bereavement stage
      predicted);                                           •Managed according to guidelines, e.g. Liverpool
      •History of two or more severe exacerbations          Care Pathway
      requiring a hospital admission in the preceding
      •Housebound by disability (MRC 5);
      •Low BMI (< 20);
      •Established respiratory failure or with previous
      ventilation for respiratory failure.


Unaware of Aware of       No symptoms   Symptoms but      MILD       MODERATE     SEVERE       VERY SEVERE
lung health lung health                  no diagnosis     stage        stage       stage          stage

      Well                         At-risk                          With COPD diagnosis

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