Charmcopdguidelines for Thediagnosisand Management Ofcopd Inthe Boroughofcity Andhackney

CHARMCOPDGuidelines for thediagnosisand management ofCOPD inthe BoroughofCity andHackney

UpdatedSeptember 2015

Adapted by:

Miss Hetal Dhruve, Specialist Pharmacist – Respiratory Medicine, City and Hackney CCG

Dr Matthew Hodson, Consultant Nurse Specialist – Respiratory Medicine, HUHFT

Dr Angshu Bhowmik, Consultant – Respiratory Medicine, HUHFT

Dr Raja Rajasingam, Consultant – Respiratory Medicine, HUHFT

Approved by: Homerton Hospital and City and Hackney CCG Joint Prescribing Group.

Date: 14/12/15

Review: 14/12/16

Version: 3.3

DIAGNOSINGCOPD

DefinitionofCOPD

COPDis characterised byairflowobstruction.

Theairflowobstruction is usuallyprogressive, not fullyreversible and does not changemarkedlyover severalmonths. Thediseaseis predominantlycaused bysmoking.

Thinkof adiagnosis ofCOPDfor patientswho are: ·Over 35

·Smokersor ex-smokers

·Have anyof these symptoms

oexertion breathlessness

ochronic cough

oregularsputumproduction

ofrequent winter “bronchitis”or “chest infections” owheeze

·And have noclinicalfeatures of asthma (see table belowCHARMasthma guidelines)

PerformspirometryifCOPD seems likelyCXRFBCatdiagnosisAirflow obstruction is defined as:

·FEV180%predictedor>80%withsymptoms·AndFEV1/FVC<70

Considerasthmaif15% FEV1reversibilitywithbronchodilatororcorticosteroids.

Ifstilldoubtaboutdiagnosisconsiderthefollowingpointers:

·Clinicallysignificant COPDis notpresent ifFEV1and FEV1/FVC ratioreturn to normalwith drug therapy. ·Asthmamaybe present if:

othereis a>400ml responsetobronchodilators& also>15% reversibility

oserial peakflow measurements showsignificant diurnalorday-to-dayvariability othereis a>400ml responseto30mg prednisolone daily for 2 weeks

·Refer formoredetailed investigations ifneeded

Ifstillindoubt,considerotherpossiblediagnosisand/orreferforfurtheradvice

IfconfirmedCOPD: Classify COPD and thenstart treatment (seeflowchart)

Severity-Postbronchodilator FEV1/FVCFEV1%Stage 0.7 80% Mild

0.750 –79%Moderate < 0.7 30-49% Severe 0.7 30% Very Severe

Reassessdiagnosisinviewofresponsetotreatment

ClinicalfeaturesdifferentiatingCOPDandasthma
COPD / Asthma
Smoker or ex-smoker / Nearly all / Possibly
Symptoms under age 35 / Rare / Common
Chronicproductive cough / Common / Uncommon
Breathlessness / Persistentand progressive / Variable
Night-timewaking withbreathlessness and/or wheeze / Uncommon / Common
Significant diurnal or day-to-day variability of symptoms / Uncommon / Common

ForCXRandFBCatANYtimeifbloodinsputum/weightloss/changeincough

ManagementofstableCOPD(BasedonNICE2010clinicalguideline and GOLD 2015)

SABA(Short Acting Beta Agonist):Salbutamol*OrSAMA(Short Acting Muscarinic Antagonist): Ipratropium

Optimal Inspiratory flow rate L/Min / Device
None required** / MDI/Respimat
High inspiratory effort required / Handihaler
Turbohaler
Spiromax
Genuair
Accuhaler
Ellipta
Least inspiratory effort required / Breezhaler

The right medication, the right inhaler.

*This should also be product of choice to optimise bronchodilation over a 24 hour period. Duration of action of once daily preparations varies from 18-24 hours.

** MDI with/out spacer and the Respimat device do not require inspiratory effort – but does require co-ordination to ensure sufficient inhalation of dose.

Try placebos before initiating inhalers. Check inhaler technique at every opportunity.

The right medication, the right inhaler.

Consider your patient: Select device most appropriate for your patient.

- What inhalers are they using?

- How is the inhaler technique – poor/moderate/good.

- Does the patient have a history of asthma (Asthma and COPD overlap syndrome)?

- ICS must not be stopped if there is any history of Asthmaregardless of severity of COPD

What is their main symptom: persistent breathlessness (MRC>3) or frequent exacerbations (>2 or >1 leading to hospital admission).

Breathless patients, MRC 0-1, (CAT <10) - consider a LAMA or LABA 1st line.

Component / Brand / Dose / Device / Key inhaler technique* / Price/30 days
LABA / Indacaterol / Onbrez / 150-300mg 1pOD / Breezhaler / Fast and hard / £29.26
Salmeterol / Serevent / 25mcg 2p BD / Available as accuhaler/MDI / Accuhaler: Fast and hard
MDI: Slow and steady / £29.26
Formoterol / Oxis / 12mcg 1p BD / Turbohaler / Fast and hard / £24.80
LAMA / Glycopyrronium / Seebri / 44mcg 1p OD / Breezhaler / Fast and hard / £27.50
Aclidinium / Eklira / 400mcg 1p BD / Genuair / Fast and hard / £28.60
Umeclidinium / Incruse / 55mcg 1p OD / Ellipta / Fast and hard / £27.50
Tiotropium / Spiriva / 18mcg 1p OD / Handihaler / Fast and hard / £33.50 refill
£34.87 with device

Breathless patients, MRC 2, (CAT10) - consider a LAMA+LABA combination

Components / Brand / Dose / Device / Key inhaler technique* / Price/30 days
LAMA+LABA / Glycopyrronium + Indacaterol / Ultibro / 85/43 1p OD / Breezhaler / Fast and hard / £32.50
Umeclidinium + Vilanterol / Anoro / 55/22 mcg 1p OD / Ellipta / Fast and hard / £32.50
Aclidinium+ Formoterol / Duaklir / 340/12mcg 1p BD / Genuair / Fast and hard / £32.50
Tiotropium + Olodaterol / Spiolto / 2.5/2.5mcg 2p OD / Respimat / Slow and steady / £32.50

Exacerbating patient (1, not leading to hospital admission), MRC 0-1, (CAT <10) - consider LABA+ICS

Components / Brand / Dose / Device / Key inhaler technique* / Price/30 days
ICS + LABA / Beclomethasone + Formoterol / Fostair / 100/6 2p BD / MDI / Slow and steady / £29.32
Beclomethasone + Formoterol / Fostair / 100/6 2p BD / NextHaler / Fast and hard / £29.32
Fluticasone+
Vilanterol / Relvar / 92/22 1p OD / Ellipta / Fast and hard / £27.80
Fluticasone+
Salmeterol / Seretide / 500/50 1p BD / Accuhaler / Fast and hard / £40.92
Budesonide + Formoterol / Symbicort / 400/12 1p BD / Turbohaler / Fast and hard / £38.00
Budesonide + Formoterol / Duoresp / 320/9 1p BD / Spiromax / Fast and hard / £29.97

Exacerbating patient (>2 or >1 leading to hospital admission), MRC 2, (CAT10) - consider LABA+ ICS + LAMA (same device if possible).

** Please refer to patient information leaflets/SPC’s for full instruction on inhaler technique.

Quality of Life

CAT (COPD ASSESSMENT TEST) SCORE

I never cough / 0 / 1 / 2 / 3 / 4 / 5 / I cough all the time
I have no phlegm (mucus) in my chest at all / 0 / 1 / 2 / 3 / 4 / 5 / My chest is full of phlegm (mucus)
My chest does not feel tight at all / 0 / 1 / 2 / 3 / 4 / 5 / My chest feels very tight
When I walk up a hill or one flight of stairs I am not breathless / 0 / 1 / 2 / 3 / 4 / 5 / When I walk up a hill or one flight of stairs I am very breathless
I am not limited doing any activities at home / 0 / 1 / 2 / 3 / 4 / 5 / I am very limited doing activities at home
I am confident leaving my home despite my lung condition / 0 / 1 / 2 / 3 / 4 / 5 / I am not at all confident leaving my home because of my lung condition
I sleep soundly / 0 / 1 / 2 / 3 / 4 / 5 / I don’t seem soundly because of my lung condition
I have lots of energy / 0 / 1 / 2 / 3 / 4 / 5 / I have no energy at all

MRC (MEDICAL RESEARCH COUNCIL) DYSPNOEA SCALE

Grade / Degree of breathlessness related to activities
1 / Not troubled by breathlessness except on strenuous exercise
2 / Short of breath when hurrying on the level or walking up a slight hill
3 / Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace.
4 / Stops for breath after walking about 100 yards or after a few minutes on level ground
5 / Too breathless to leave the house, or breathless when undressing

OTHERPHARMACOTHERAPY

Oraltheophyllines canbe consideredbut they ahave highrisk side effect profile and interact with many other medication and cigarette smoke. Theophylline levels should therefore be monitored.

Ifa patientis unabletouse the long actinganticholinergic, an ipratropium inhalerwith spacer maybe considered. Chroniccough productive ofviscous sputum- consider4weektrial ofmucolyticagent

e.g. carbocysteine750mg3 timesa day initiallythen 2 timesa day; reassess benefitafter4 weeks

PULMONARY REHABILITATION(PR)

PRis gold standard symptom based treatment of exercise and education, aimed at promoting long term behaviour change and compliance with health enhancing behaviours. A referral to outpatient PR should be considered for all COPD patients with MRC grade 3-5 or MRC 2 with breathlessness on exertion as per NICE guidance. Post exacerbation PR should be considered for all patients admitted with an acute exacerbation of COPD within 4 weeks of discharge from hospital. To refer to the ACERs Pulmonary Rehabilitation Service email: or call 0208 510 5108 for a referral form.

OXYGENASSESSMENT

Refer toACERSOxygenAssessmentService, Respiratory Department,Homerton Hospitalfor long term and ambulatory oxygenassessmentif oxygensaturations92%onair, severe COPD, peripheral oedema.

All patientswho receive LTOTshouldbeassessed annually with Blood gasanalysis– informACERS on 0208510 5107 toundertakethisassessment

DEPRESSIONANXIETY

There is a highprevalence (30-50%)of depressionseen inCOPD patientswith frequentexacerbations.NICE guidelines recommend a high indexofsuspicionand prompt diagnosis.

Treat anxiety and depression with medication, taking time toexplain tothepatientwhy this isneededand refer to psychology services ifneeded

ENDOFLIFECARE

Opiates should be usedwhen appropriateto palliatebreathlessness in patientswithend stage COPD which is unresponsive toothermedical therapy.

PatientswithendstageCOPD andtheir families should have accesstothefull rangeofservices offered bythemultidisciplinary palliativecare teams,includingadmission tohospices.

Prognosis in COPD isdifficult, but recognizedindicatorsof apoor outcomeare: ·Hospital admissions

·Severe disease

·Onlong term oxygen therapy

·Depression, poor qualityoflife, housebound ·Co-morbidity,especially heartfailure

·LowBMI

Considerasking “would Ibesurprisedifmy patientwere to die inthenext twelve months?” Considerinclusion onsupportive and palliative care register

RefertoACERSforonwardreferraltotheBreathingSpaceclinicatStJoseph’sHospice

ACUTEINFECTIVEEXACERBATIONOFCOPD:ALLEXACERABTIONSREFTOACERSTEAM Antibioticsareusually ONLYgiven if there isahistory ofincreasedsputumpurulence:

Doxycycline200mg stat oral then100mg onceadayoralfor 4 daysor clarithromycin 500mg twice a day if doxycycline contraindicated AND Oralsteroids–Prednisolone 30mg dailyfor7 days.

Gradual withdrawal of Prednisolone - Should be considered for the following patients

-Received more than 40mg of prednisolone daily for more than 1 week

-Been given repeat doses in the evening,

-Recently received repeated courses (particularly if taken for longer than 3 weeks),

-Taken a short course within 1 year of stopping long-term therapy

Increasefrequency of salbutamol–2puffs every 4 hours,usespacer

Selfmanagement: Self managementplans should bein placeandrescuemedicationpacksfor patients who have had an exacerbation or are at risk of having one (whereappropriate).

PROTOCOLFORTHETREATMENTPREVENTIONOFEXACERBATIONSINCOPD

ISITANEXACERBATION?

Keyfeatures typicallyassociatedwith exacerbation are2ormore ofthe following.

·Worsening breathlessness ·Increasedsputumvolume·Increasedcough

·Fever

·Chest tightness

Changing sputumcolour Wheeze

IfyestoanyIfnotoall

FACTORSPROMPTINGCONSIDERATIONOFHOMEMANAGEMENTVS.HOSPITALADMISSION

·Coping at home

·Normallevel ofconsciousness

·Experiencing onlymildbreathlessness maintainingusual level of activity

·Eating & drinking normally

·Little change to usual general condition·Easyaccessto help if required

·Lackofsignificant co morbidity

Ifyestomost / Ifnotomost

MANAGEPATIENTATHOMEREFERTOACERS

DISCUSSWITH ACERS /ADMITPATIENT TO HOSPITALINEMERGENCY

MANAGEACUTEEXACERBATION

·Add or increase bronchodilator use ·Review inhaler technique

·Prescribe antibiotics ifsputumbecomes purulent ·Consider oral corticosteroids

·Pulseoximetery ifsevere exacerbation ·Increase social supportifnecessary

AGREETOFOLLOWUPREVIEWPATIENTTOASSESSTHEIRCOPD

POSTEXACERBATIONMANAGEMENTPLAN

·Patient understands personalactionplan,rescuemedicationsprescription supplied for future use for patients whohave hadan exacerbationor at riskofone(whereappropriate)

·Smoking cessation, exercise,pulmonaryrehabilitation·Optimize inhalertherapy, checktechnique

·Offer vaccinations