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:  indicates the evidence has not been updated and reviewed since the original guideline.  applies to two specific recommendations that were developed as part of a technology appraisal in 2007.  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 PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the key priorities for implementation. The NICE guideline contains 7 key priorities for implementation, which you can find on page 4–5 of your quick reference guide. The key priorities for implementation cover the following areas: Diagnose COPD Stop smoking Promote effective inhaled therapy Provide pulmonary rehabilitation for all who need it. Use non-invasive ventilation Manage exacerbations Ensure multidisciplinary working Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE.
NOTES FOR PRESENTER The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it. COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction. COPD is now the preferred term for the conditions in patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema.
NOTES FOR PRESENTER: The complete guideline covers adults (16 years and older) with stable COPD including: chronic bronchitis, emphysema, chronic airflow limitation/obstruction. It does not cover people with asthma, bronchopulmonary dysplasia, bronchiectasis or acute exacerbations. These issues from 2004 were not updated Diagnosing COPD Recommendations cover Symptoms Spirometry Further investigations Reversibility testing Assessment of severity and prognostic factors Assessment and classification of severity of airflow obstruction Identification of early disease Referral for specialist advice Managing stable COPD Smoking cessation Follow-up of patients with COPD Inhaled therapy (including delivery systems) Oral therapy Combined oral and inhaled therapy Oxygen Non-invasive ventilation Management of pulmonary hypertension and cor pulmonale Pulmonary rehabilitation Vaccination and anti-viral therapy Lung surgery Alpha-1 antitrypsin replacement therapy Multidisciplinary management Fitness for general surgery Management of exacerbations of COPD Definition of an exacerbation Assessment of need for hospital treatment Investigation of an exacerbation Hospital-at-home and assisted-discharge schemes Pharmacological management Oxygen therapy during exacerbations of COPD Non-invasive ventilation (NIV) and COPD exacerbations Invasive ventilation and intensive care Respiratory physiotherapy and exacerbations Monitoring recovery from an exacerbation Discharge planning
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: Key points to raise: Please refer your audience to page 6 of the QRG which shows the algorithm to support the diagnosis recommendation. Recommendations in full: A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms: exertional breathlessness chronic cough regular sputum production frequent winter ‘bronchitis’ wheeze. [184.108.40.206] Related recommendations: COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients presenting for the first time. Features from the history and examination (see page 6 of the QRG) should be used to differentiate COPD from asthma whenever possible. [220.127.116.11]
NOTES FOR PRESENTERS: Recommendations in full: Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [18.104.22.168] 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. [22.214.171.124] 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. [126.96.36.199] Additional investigations should be performed to aid management in some circumstances (see page 6 of the QRG) [188.8.131.52] 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 [184.108.40.206] 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: 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. [220.127.116.11] 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. [18.104.22.168] 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 http://www.nice.org.uk/usingguidance/education/educational_tools.jsp
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: [22.214.171.124] - 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 . [ 126.96.36.199] 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. [188.8.131.52] 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 [184.108.40.206]
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: 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. [220.127.116.11] 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. [18.104.22.168] 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. [22.214.171.124] 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 . [126.96.36.199] Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required to gain these. [188.8.131.52]
NOTES FOR PRESENTERS: Recommendations in full. NIV should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. [184.108.40.206] It is recommended that NIV should be delivered in a dedicated setting with staff who have been trained in its application, who are experienced in its use and who are aware of its limitations. [220.127.116.11] When patients are started on NIV there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed. [18.104.22.168] Additional information: Adequately treated patients with chronic hypercapnic respiratory failure who have required assisted ventilation (whether invasive or non-invasive) during an exacerbation or who are hypercapnic or acidotic on LTOT should be referred to a specialist centre for consideration of long-term NIV [22.214.171.124]
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.
NOTES FOR PRESENTERS: Please refer your audience page 14 of the QRG for more information on Referral for specialist advice and possible reasons for making a referral. Also, refer to page 15 of the QRG for follow-up and review of people with COPD in primary care. Related recommendations : The following functions should be considered when defining the activity of the multidisciplinary team: assessing patients (including performing spirometry, assessing the need for oxygen, the need for aids for daily living and the appropriateness of delivery systems for inhaled therapy). care and treatment of patients (including non-invasive ventilation, pulmonary rehabilitation, hospital-at-home/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). advising patients on self-management strategies identifying and monitoring patients at high risk of exacerbations and undertaking activities which aim to avoid emergency admissions advising patients on exercise education of patients and other health professionals. [126.96.36.199] It is recommended that respiratory nurse specialists form part of the multidisciplinary COPD team. [188.8.131.52]
NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. Additional questions: How does our service for patients needing non-invasive ventilation compare with the guideline recommendations?
NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all the recommendations. A quick reference guide – a summary of the recommendations for healthcare professionals. ‘ Understanding NICE guidance’ – information for patients and carers. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email_address] and quote reference numbers N2199 (quick reference guide) and/or N2200 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Baseline assessment tool - the document can help you identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities. NICE is developing a Quality Standard which will be published in 2011. NICE quality standards are intended to provide a clear description of what a high quality service would look like, enabling organisations to aspire and progress to improve quality and achieve excellence. They are intended to support benchmarking of current performance against evidence based measures of best practice and to identify priorities for improvement. For more information go to http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp
What this presentation covers <ul><li>Background </li></ul><ul><li>Scope </li></ul><ul><li>Key priorities for implementation </li></ul><ul><li>Discussion </li></ul><ul><li>Find out more </li></ul>
Background <ul><li>Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment </li></ul><ul><li>An estimated 3 million people have chronic pulmonary disease (COPD) in the UK, though many remain undiagnosed </li></ul><ul><li>COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term </li></ul>
Scope <ul><li>The scope for the guideline update was to examine: </li></ul><ul><li>Diagnosis and severity classification: </li></ul><ul><ul><li>spirometry and post-bronchodilator values </li></ul></ul><ul><ul><li>multidimensional severity assessment indices (for example, the BODE index) </li></ul></ul><ul><li>Management of stable COPD and prevention of disease progression </li></ul><ul><ul><li>long-acting bronchodilators: beta 2 agonists and anticholinergics (tiotropium, formoterol fumarate, salmeterol) as monotherapy and in combination, both with and without inhaled corticosteroids </li></ul></ul><ul><ul><li>mucolytic therapy (carbocisteine and mecysteine hydrochloride) </li></ul></ul>BODE = body mass index, airflow obstruction, dyspnoea and exercise tolerance
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
Diagnose COPD <ul><ul><li>Consider a diagnosis of COPD for people who are: </li></ul></ul><ul><ul><li>over 35, and </li></ul></ul><ul><ul><li>smokers or ex-smokers, and </li></ul></ul><ul><ul><li>have any of these symptoms: </li></ul></ul><ul><ul><ul><li>- exertional breathlessness </li></ul></ul></ul><ul><ul><ul><li>- chronic cough </li></ul></ul></ul><ul><ul><ul><li>- regular sputum production, </li></ul></ul></ul><ul><ul><ul><li>frequent winter ‘bronchitis’ </li></ul></ul></ul><ul><ul><ul><li>wheeze </li></ul></ul></ul>
Diagnose COPD: 2 <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  </li></ul></ul>
Diagnose COPD: 3 <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)**
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  </li></ul></ul>
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 in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV 1 </li></ul>ICS = inhaled corticosteroid LABA = long-acting beta 2 agonist LAMA = long-acting muscarinic agonist [new 2010]
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
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
Use non-invasive ventilation (NIV) <ul><ul><li>Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy </li></ul></ul><ul><ul><li>NIV should be delivered by staff trained in its application, experienced in its use and aware of its limitations </li></ul></ul><ul><ul><li>When starting NIV, make a clear plan covering what to do in the event of deterioration and agree ceilings of therapy </li></ul></ul><ul><ul><li> </li></ul></ul>
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><ul><li>- use of non-invasive ventilation when indicated </li></ul></ul></ul><ul><ul><ul><li>- use of hospital-at-home or assisted-discharge schemes </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>
Multidisciplinary working <ul><ul><li>COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists </li></ul></ul><ul><ul><li>Consider referral to specialist departments (not just respiratory physicians) </li></ul></ul> Specialist department Who might benefit? Physiotherapy People with excessive sputum Dietetic advice People with BMI that is high, low or changing over time Occupational therapy People needing help with daily living activities Social services People disabled by COPD Multidisciplinary palliative care teams People with end-stage COPD (and their families and carers)
Discussion <ul><li>How can we improve identification and diagnosis of people over 35 who have a risk factor? </li></ul><ul><li>How does our use of spirometry compare with the recommendations? </li></ul><ul><li>How will our prescribing practice need to change? </li></ul><ul><li>What pulmonary rehabilitation services are available? </li></ul><ul><li>How do we minimise the risk of exacerbations for our patients? </li></ul>
Find out more <ul><li>Visit www.nice.org.uk/CG 101 for: </li></ul><ul><ul><li>the guideline </li></ul></ul><ul><ul><li>the quick reference guide </li></ul></ul><ul><ul><li>‘ Understanding NICE guidance’ </li></ul></ul><ul><ul><li>costing report </li></ul></ul><ul><ul><li>audit support </li></ul></ul><ul><ul><li>NICE is developing a Quality Standard for COPD </li></ul></ul><ul><ul><li>which will be published in 2011 </li></ul></ul>