Primary care talk NICE 2011


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Implementing NICE Guidance and Quality Standards

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  • ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care’ (partial update). This guideline has been written for all healthcare professionals, people with COPD and their carers, patient support groups, commissioning organisations and service providers. The development of this guideline has updated sections of NICE clinical guideline 12 (published February 2004). Other recommendations from 2004 remain appropriate and form part of the new comprehensive guideline. New or updated recommendations have been made for spirometry, assessment of prognostic factors, and to the section on inhaled therapy (which now incorporates the previously separate sections on inhaled bronchodilators, inhaled corticosteroids and inhaled combination therapy). In this presentation and in the NICE guideline, recommendations are marked as following: [2004] indicates the evidence has not been updated and reviewed since the original guideline. [2007] applies to two specific recommendations that were developed as part of a technology appraisal in 2007. [2010] indicates that the evidence has been reviewed but no change has been made to the recommendation. [new 2010] indicates that the evidence has been reviewed and the recommendation has been updated or added. The guideline is available in a number of formats, including a quick reference guide. You should have copies of the quick reference guide available at your presentation so that your audience can refer to it. See the end of the presentation for ordering details. You can add your own organisation ’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
  • NOTES FOR PRESENTER There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry.
  • NOTES FOR PRESENTERS: Recommendations in full: Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [] All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results. [] Related recommendations: At the time of their initial diagnostic evaluation in addition to spirometry all patients should have: a chest radiograph to exclude other pathologies a full blood count to identify anaemia or polycythaemia body mass index (BMI) calculated. [] Additional investigations should be performed to aid management in some circumstances (see page 6 of the QRG) [] Spirometry should be performed at the time of the diagnosis and to reconsider the diagnosis. Consider alternative diagnoses in: older people without typical symptoms of COPD where the FEV 1 /FVC ratio is < 0.7 younger people with symptoms of COPD where the FEV 1 /FVC ratio is >0.7 Spirometry services should be supported by quality control processes. Use ERS 1993 reference values but be aware these may lead to under diagnosis in older people and are not applicable in black and Asian populations.
  • NOTES FOR PRESENTERS: Key points to raise: Disability in COPD can be poorly reflected in the FEV 1 . A more comprehensive assessment also includes: - degree of airflow obstruction and disability - frequency of exacerbations - prognostic factors such as breathlessness (assessed using the Medical Research Council [MRC] scale), carbon monoxide lung transfer factor [T L CO], health status, exercise capacity, BMI, partial pressure of oxygen in arterial blood [PaO 2 ] and cor pulmonale. Investigate symptoms that seem disproportionate to the spirometric impairment using a CT scan or T L CO testing. Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis (where the component information is currently available). Assess severity of airflow using the table on the slide. Recommendation in full: The severity of airflow obstruction should be assessed according to the reduction in FEV 1 as shown in table on the slide [] Abbreviations: ATS, American Thoracic Society; ERS, European Respiratory Society; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease References : Quanjer PH, Tammeling GJ, Cotes et al. (1993) Lung Volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. European Respiratory Journal (Suppl) 16:5-40. Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position Paper. European Respiratory Journal 23(6): 932-46. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
  • NOTES FOR PRESENTERS: Please refer your audience to page 10 of the QRG which focuses on delivery systems (inhalers, spacers and nebulisers). Key points to raise: In people with stable COPD and an FEV 1 ≥ 50% who remain breathless or have exacerbations despite maintenance therapy with a LABA: [] - consider LABA + ICS in a combination inhaler consider LAMA in addition to LABA where ICS is declined or not tolerated. Consider LABA+ ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with LAMA irrespective of their FEV 1 . [] The choice of drug(s) should take into account the person ’s symptomatic response and preference, and the drug’s potential to reduce exacerbations, its side effects and cost. [] Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated with inhaled corticosteroids and be prepared to discuss with patients []
  • NOTES FOR PRESENTERS: This slide shows the treatment algorithm included within the full guideline (Algorithm 2a) and is reproduced on page 9 of your QRG. On pages 12 and 13 of your QRG you will also find a useful table which summarises the recommendations for managing symptoms and conditions in stable COPD.
  • NOTES FOR PRESENTERS: Recommendations in full: An up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked), should be documented for everyone with COPD. [] Unless contraindicated, offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people with COPD. [] Additional information: See ‘Varenicline for smoking cessation’ (NICE technology appraisal guidance 123) See ‘Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities’ (NICE public health guidance 10) A NICE/BMJ Learning on-line educational module (free to all users) is available through the NICE website
  • NOTES FOR PRESENTERS: Recommendation in full: Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation. [] Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction. [] For pulmonary rehabilitation programmes to be effective, and to improve concordance, they should be held at times that suit patients, and in buildings that are easy for patients to get to and have good access for people with disabilities. Places should be available within a reasonable time of referral. [] Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions, which are tailored to the individual patient’s needs. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention . [] Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required to gain these. []
  • NOTES FOR PRESENTERS: Key points to raise Please refer your audience to page 17 of the QRG for factors to consider when deciding where to manage exacerbations. Pages 18 and 19 also show an algorithm for investigating and managing exacerbations of COPD. An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication.
  • Primary care talk NICE 2011

    1. 1. Primary Care management Chronic obstructive pulmonary disease Implementing NICE Guidance and Quality Standards NICE clinical guideline 101 Additional information can be found at On behalf of the Southampton COPD Group
    2. 2. NICE Quality outcome - spiro <ul><li>People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation. </li></ul>
    3. 3. Definition of COPD <ul><li>Airflow obstruction is defined as reduced FEV 1 /FVC ratio (< 0.7) </li></ul><ul><li>It is no longer necessary to have an FEV 1 < 80% predicted for definition of airflow obstruction </li></ul><ul><li>If FEV 1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough </li></ul>FEV 1 = forced expiratory volume in 1 second FVC = forced vital capacity
    4. 4. Diagnose COPD: 1 <ul><ul><li>The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry [new 2010] </li></ul></ul><ul><ul><li>All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results [2004] </li></ul></ul>
    5. 5. Diagnose COPD: 2 <ul><ul><li>Assess severity of airflow obstruction using reduction in FEV 1 </li></ul></ul>* Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV 1 < 50% with respiratory failure [new 2010] NICE clinical guideline 12 (2004) ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101 (2010) Post-bronchodilator FEV 1 /FVC FEV 1 % predicted Post-bronchodilator Post-bronchodilator Post-bronchodilator < 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)* < 0.7 50–79% Mild Moderate Stage 2 (moderate) Stage 2 (moderate) < 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe) < 0.7 < 30% Severe Very severe Stage 4 (very severe)** Stage 4 (very severe)**
    6. 6. Asthma or COPD <ul><li>To help resolve cases where diagnostic doubt occurs, or both COPD and asthma are present, the following findings should be used to help identify asthma: </li></ul><ul><li>1. a large (> 400 ml) response to bronchodilators </li></ul><ul><li>2. a large (> 400 ml) response to 30 mg oral prednisolone daily for 2 weeks </li></ul><ul><li>3. Serial peak flow measurements showing 20% or greater diurnal or day-to-day variability. (NICE 2010) </li></ul>
    7. 7. Basic Spirometry Patients with normal lungs empty most of their volume in the first second of expiration Patients with COPD have problems in expiration so it takes much longer to empty their lungs
    8. 8. The Flow Volume Loop Normal COPD The inspiratory parts of the flow loops look similar The expiratory parts of the flow loop are very different however with sudden loss of expiratory flow seen in COPD Inspiration Expiration
    9. 9. Other tests to confirm the diagnosis in the new patient <ul><li>CXR – excludes other conditions </li></ul><ul><li>BMI – Big predictor in mortality terms but only in moderate and severe disease </li></ul><ul><li>FBC - Polycythaemia </li></ul><ul><li>Anaemia </li></ul>
    10. 10. “ It has generally been assumed that individuals with the lowest FEV1 were also progressing the fastest as they had ‘‘ clearly ’’ lost more function than individuals with more normal lung function. However, evidence is accumulating that this assumption is in error, making it essential to distinguish between severity and activity ” JØRGEN VESTBO 2010
    11. 11. What is the decline in mls/yr ? <ul><li>TORCH UPLIFT </li></ul><ul><li>Gold II 60 49 </li></ul><ul><li>Gold III 56 41 </li></ul><ul><li>Gold IV 34 31 </li></ul>
    12. 12. NICE outcomes - therapy <ul><li>People with COPD have a current individualised comprehensive management plan </li></ul><ul><li>People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan </li></ul>
    13. 13. Promote effective inhaled therapy <ul><li>In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: </li></ul><ul><ul><li>if FEV 1 ≥ 50% predicted: either LABA or LAMA </li></ul></ul><ul><ul><li>if FEV 1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA </li></ul></ul><ul><li>Offer LAMA & LABA+ICS to people with COPD who remain </li></ul><ul><li>breathless or have exacerbations despite taking LABA+ICS, </li></ul><ul><li>Triple therapy not dependent on FEV1 </li></ul><ul><li>Inhaler technique and ability ro activate the device </li></ul>ICS = inhaled corticosteroid LABA = long-acting beta 2 agonist LAMA = long-acting muscarinic agonist [new 2010]
    14. 14. Use of inhaled therapies SABA or SAMA as required* Breathlessness and exercise limitation Exacerbations or persistent breathlessness Persistent exacerbations or breathlessness LABA LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day FEV 1 ≥ 50% FEV 1 < 50% LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler Offer Consider * SABAs (as required) may continue at all stages
    15. 15. Nice outcome - smoking <ul><li>People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. </li></ul>
    16. 16. Stop smoking <ul><ul><li>Encouraging patients with COPD to stop smoking is one of the most important components of their management </li></ul></ul><ul><ul><li>All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity </li></ul></ul><ul><ul><li>Record a smoking history, including pack years smoked </li></ul></ul><ul><ul><li>Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [2010] </li></ul></ul>[2004]
    17. 17. Intervention Stop Smoking
    18. 18. Nice Outcomes - oxygen <ul><li>People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. </li></ul><ul><li>People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service. </li></ul><ul><li>People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD </li></ul>
    19. 19. Long term oxygen therapy –who? <ul><li>FEV1 < 30% predicted </li></ul><ul><li>Cyanosis </li></ul><ul><li>Polycythaemia. </li></ul><ul><li>Peripheral oedema. </li></ul><ul><li>Raised jugular venous pressure. </li></ul><ul><li>Oxygen saturations < 92% on air. </li></ul>
    20. 20. Nebulisers <ul><li>Mainstay of therapy should be by a conventional inhaled route. </li></ul><ul><li>Majority of patients get little added benefit from nebulisers. </li></ul><ul><li>Consider nebulisers if: </li></ul><ul><li>Patient lacks dexterity to use inhalers. </li></ul><ul><li>Patient has cognitive impairment. </li></ul><ul><li>Patient has severe COPD and is still symptomatic despite high dose inhaled bronchodilator therapy . </li></ul>
    21. 21. Nice outcome - rehab <ul><li>People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme. </li></ul>
    22. 22. Provide pulmonary rehabilitation Tailor multi-component, multidisciplinary interventions to individual patient ’s needs Hold at times that suit patients, and in buildings with good access Offer to all patients who consider themselves functionally disabled by COPD [new 2010] Pulmonary rehabilitation An individually tailored multidisciplinary programme of care to optimise patients ’ physical and social performance and autonomy Make available to all appropriate people, including those recently hospitalised for an acute exacerbation
    23. 23. What does it achieve ? <ul><li>Pulmonary rehabilitation </li></ul><ul><li>Reduces the number of hospital days </li></ul><ul><li>Reduces health-care utilization </li></ul><ul><li>Increases exercise tolerance </li></ul><ul><li>Reduces need for 02 </li></ul><ul><li>Reduces exacerbation frequency </li></ul>
    24. 24. NICE outcome - exacerbations <ul><li>People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. </li></ul><ul><li>People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported- discharge scheme with appropriate community support. </li></ul><ul><li>People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non-invasive ventilation delivered by appropriately trained staff in a dedicated setting. </li></ul><ul><li>People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. </li></ul>
    25. 25. Managing exacerbations <ul><ul><li>Minimise impact of exacerbations by: </li></ul></ul><ul><ul><ul><li>- g iving self-management advice on responding promptly to symptoms of exacerbation </li></ul></ul></ul><ul><ul><ul><li>- starting appropriate treatment with oral steroids and/or antibiotics </li></ul></ul></ul><ul><ul><li>The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations </li></ul></ul>[2004]
    26. 26. Treat at home or in hospital? Characteristics Home Hospital Cyanosis No Yes Peripheral Oedema No Yes Consciousness Normal Impaired LTOT? No Yes Social Good Alone/Not coping Confusion No Yes Rapid Onset No Yes CVD or DM No Yes SaO2 >90% <90%
    27. 27. Exacerbations Aetiology <ul><li>50% of exacerbation caused by viruses (Rhinovirus and influenza viruses are the most common) </li></ul><ul><li>50% of exacerbations caused by bacteria (H. Influenzae, S. pneumoniae and M. catarrhalis) </li></ul><ul><li>Up to 20% have both </li></ul><ul><li>Consider co morbidities as a cause of an exacerbation if no obvious infective symptoms or signs e.g CFF and PE </li></ul>
    28. 28. Antibiotics <ul><li>All exacerbations should be treated with antibiotics. </li></ul><ul><li>Either doxycycline 200mg BD 2/7 then doxycycline 200mg OD 5/7 </li></ul><ul><li>If treatment fails or recent course of doxycycline then try </li></ul><ul><li>Azithromycin 500mg OD 3-5/7 </li></ul>
    29. 29. Prednisolone <ul><li>30mg OD for one week </li></ul><ul><li>If improves then stop – no tailing off </li></ul><ul><li>If not improving then use 30mg for another week </li></ul><ul><li>Do not continue beyond 2 weeks </li></ul>
    30. 30. End of life outcome <ul><li>People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs. </li></ul>