Smoker or ex smoker nearly all possibly
Symptoms under age 35 rare often
Chronic productive cough common uncommon
Breathle...
Reason Purpose of referral
There is diagnostic uncertainty Confirm diagnosis and optimise therapy.
Suspected severe COPD C...
*Trial of short acting anticholinergic
GENERAL MANAGEMENT FOR ALL PATIENTS WITH COPDGENERAL MANAGEMENT FOR ALL PATIENTS WI...
ReviewinPrimarycare:Mild/ModerateSevere
Frequency
Clinicalassessment
ATLEASTANNUAL
•FEV1&FVCmeasurement
•RecordBMI
•MRCDys...
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  1. 1. Smoker or ex smoker nearly all possibly Symptoms under age 35 rare often Chronic productive cough common uncommon Breathlessness persistent & progressive variable Night time wakening with breathlessness &/or wheeze uncommon common Significant diurnal or day to day variability of symptoms uncommon common Consider a diagnosis of COPD In patients who are: • over 35 • smokers or ex-smokers • have any of these symptoms: - exertional breathlessness - chronic cough - regular sputum production - frequent winter ‘bronchitis’ - wheeze • and have no clinical features of asthma (see table below) Clinical features differentiating COPD and asthma COPD Asthma Wakefield, Kirklees & CalderdaleWakefield, Kirklees & Calderdale Guidelines for Diagnosing COPD in Primary CareGuidelines for Diagnosing COPD in Primary Care If considering COPD perform spirometry Airflow obstruction is defined as: • FEV1 < 80% predicted • And FEV1/FVC <0.7 Spirometric reversibility testing is not usually necessary as part of the diagnostic process or to plan initial therapy If still in doubt about diagnosis consider the following pointers If still in doubt, make a provisional diagnosis and start empirical treatment 80% Mild 50% Moderate 30% Severe80% Mild 50% Moderate 30% Severe (Read code H36) (Read code H37) (Read code(Read code H36) (Read code H37) (Read code H38)H38) FEV1 % Predicted Reassess diagnosis in view of response to treatment MRC Dyspnoea ScoreMRC Dyspnoea Score Clinically significant COPD is not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy Refer for more detailed investigations if needed Asthma may be present if: - there is a > 400 ml increase in FEV1 in response to bronchodilators - serial peak flow measurements show significant diurnal or day-to-day variability - there is a > 400 ml increase in FEV1 in response to prednisolone, at least 30mg daily, for 2 weeks 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 contemporaries on level ground because of breathlessness, or has to 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. See overleaf for review information and referral criteria 1 of 2 Appendix 1 If no doubt, diagnose COPD, perform chest x-ray, full blood count, BMI, record MRC Dyspnoea Score and start treatment
  2. 2. Reason Purpose of referral There is diagnostic uncertainty Confirm diagnosis and optimise therapy. Suspected severe COPD Confirm diagnosis and consider advanced therapies. The patient requests a second opinion Confirm diagnosis and optimise therapy. Onset of cor pulmonale Confirm diagnosis and optimise therapy. Assessment for oxygen therapy Optimise therapy and measure blood gases. Assessment for long-term nebuliser therapy Optimise therapy and exclude inappropriate prescriptions. Assessment for oral corticosteroid therapy Justify need for long-term treatment or supervise withdrawal. Bullous lung disease Patients with large bullae seen on chest x-ray may benefit from bullectomy. A rapid decline in FEV1 This is associated with early mortality and may require early intervention. Assessment for lung volume reduction surgery Some patients with severe symptoms and no comorbidity and considered fit for major surgery may benefit from LRVS. Assessment for lung transplantation Considered for patients with advanced disease and no other co morbidities. Dysfunctional breathing/Hyperventilation Confirm diagnosis, optimise pharmacotherapy and access other syndrome/Disproportionate breathlessness therapists. Aged under 40 years or a family history of Identify alpha1-antitrypsin deficiency, register for therapy when alpha1-antitrypsin deficiency available and screen family. Symptoms disproportionate to lung function Look for other explanations. deficit Frequent infections or exacerbations Consider bronchiectasis and optimise therapy. Haemoptysis Consider carcinoma of the bronchus and other diagnosis. Reasons for referral to secondary care include Published: May 2005 Enquiries to: Lisa Chandler WDPCT 01977 665877 Reviewed : November 2007 Jacqui Pollington MYHT 01977 606635 Review due: November 2009 unless clinical evidence base changes Nikki Rochnia KPCT 07984274414 Group responsible for development: WDPCT Respiratory Strategic Partnership Group Wakefield, Kirklees & CalderdaleWakefield, Kirklees & Calderdale Guidelines for Diagnosing COPD in Primary CareGuidelines for Diagnosing COPD in Primary Care 2 of 2
  3. 3. *Trial of short acting anticholinergic GENERAL MANAGEMENT FOR ALL PATIENTS WITH COPDGENERAL MANAGEMENT FOR ALL PATIENTS WITH COPD SMOKING CESSATION - ENCOURAGE EXERCISE - REVIEW OF INHALER TECHNIQUE - PNEUMOCOCCAL VACCINATION AND ANNUAL INFLUENZA VACCINATION - RECORD BMI AND MRC DYSPNOEA SCORE Treatment of symptomsTreatment of symptoms Each addition to therapy should involve a 4 week trial with discontinuation of any components not demonstrating an improvement in symptoms. If patient remains symptomatic, treatment should be intensified by combining therapies following the algorithm below. Reduction in Exacerbation FrequencyReduction in Exacerbation Frequency DisabilityDisability OxygenationOxygenation Measure saturation by pulse oximetry if FEV1 < 1.5. litres/40% predicted. If oxygen saturation < 92% consider referral to Secondary Care Respiratory Team Patients with a history of frequent exacerbations (worsening of symptoms of COPD, e.g. increasing breathlessness, increasing sputum production, change in colour of sputum, requiring treatment with antibiotics and or steroids 2 or more times per year) AND FEV11 ≤ 50% predicted should have treatment to reduce exacerbation frequency. • ADD high dose inhaled steroids and Long acting beta2 agonist •Consider long acting anticholinergic In view of the magnitude of the benefits of pulmonary rehabilitation programmes, the guidelines recommend that it should be offered to all appropriate patients with COPD managed in primary or secondary care who consider themselves functionally disabled by their disease (usually MRC grade 3 and above) *Trial of short acting beta2 agonist as required *Trial of Theophylline Other considerationsOther considerations Mucolytics may be of use in patients with chronic productive cough. Discontinue if no improvement after 4 weeks. Consider use of patient held oral steroids and antibiotics for use with self management plan for prompt treatment of exacerbations (refer to guideline) Anxiety and depression should be identified, assessed and treated appropriately Consider Bone Protection in this group of patients who may be at increased risk of osteoporosis Consider referral to the Expert Patient Programme Treatments considered unsuitableTreatments considered unsuitable for COPDfor COPD Routine maintenance with oral cortico steroids is not normally recommended Prophylactic antibiotics Alpha-1antitrypsin replacement therapy Antioxidant therapies Antitussive therapy Regular short-acting beta2 agonist References: Chronic obstructive pulmonary disease; National clinical guideline for management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 (suppl1); 1-232 •MHRA Drug Safety Update October 2007 Issue 3 Wakefield, Kirklees & CalderdaleWakefield, Kirklees & Calderdale Guidelines for Managing Stable COPD in Primary CareGuidelines for Managing Stable COPD in Primary Care Published: May 2005 Reviewed: November 2007 Review due: November 2009 unless clinical evidence base changes Enquiries to: Lisa Chandler WDPCT 01977 665877 Jacqui Pollington MYHT 01977 606635 Nikki Rochnia KPCT 07984274414 Group responsible for development: WDPCT Respiratory Strategic Partnership Group *Trial of Tiotropium or Long Acting Beta2 Agonist Stop short acting anticholinergic when starting Tiotropium *If effective but symptoms continue or worsen over time commence trial of Tiotropium plus Long Acting Beta2 Agonist * Please refer Treatment of symptoms box Patients with FEV1 < 30% treated with inhaled steroids who are diagnosed with pneumonia should have treatment reviewed by a respiratory physician Appendix 2
  4. 4. ReviewinPrimarycare:Mild/ModerateSevere Frequency Clinicalassessment ATLEASTANNUAL •FEV1&FVCmeasurement •RecordBMI •MRCDyspnoeascore •Smokingstatusanddesiretoquit •Adequacyofsymptomcontrol breathlessness exercisetolerance estimatedexacerbationfrequency •Presenceofcomplications •Effectsofeachdrugtreatment •Inhalertechnique •Needforreferraltospecialistandtherapy services •Needforpulmonaryrehabilitation •ConsiderreferraltoExpertPatientProgramme •Selfmanagementadvice Wakefield,Kirklees&CalderdaleWakefield,Kirklees&Calderdale GuidelinesforManagingStableCOPDinPrimaryCareGuidelinesforManagingStableCOPDinPrimaryCare 2of2 ATTWICEPERYEAR •FEV,&FVCmeasurement •RecordBMI •MRCDyspnoeascore •Smokingstatusanddesiretoquit •Adequacyofsymptomcontrol breathlessness exercisetolerance estimatedexacerbationfrequency •Presenceofcomplications •Effectsofeachdrugtreatment •Inhalertechnique •Needtoreferraltospecialistortherapyservices •Needforpulmonaryrehabilitation •ConsiderreferraltoExpertPatientProgramme •Presenceofcorpulmonale •Needforlongtermoxygentherapy oxygensaturationsusingpulseoximetry •Nutritionalstate •Presenceofdepression •Selfmanagementadvice •Needforsocialservicesandoccupationaltherapyinput •Considerpalliativecarerequirements

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