Management of Stable COPD

There are separate articles on Chronic Obstructive Pulmonary Disease, Diagnosing COPD, Acute Exacerbations of COPD and Use of Oxygen Therapy in COPD.

Following the diagnosis of chronic obstructive pulmonary disease (COPD), care should be delivered by a multidisciplinary team. The following functions should be considered when defining the activity of the multidisciplinary team:¹

· Assessing patients (e.g. spirometry, assessing need for oxygen therapy and the appropriateness of delivery systems for inhaled therapy).

· Managing patients (including pulmonary rehabilitation, palliative care, managing anxiety and depression, dietary issues, exercise, social security benefits and travel); management of pulmonary hypertension and cor pulmonale.

· Education of patients and advising patients on self-management strategies.

· Identifying and monitoring patients at high risk of exacerbations of COPD.

· Advising patients on exercise.

GMS contract quality indicators

The quality indicators for COPD are:

· The practice can produce a register of patients with COPD: 3 points

· The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing (payment stages 40-80%): 10 points

· The percentage of patients with COPD with a record of FEV₁ in the previous 15 months (payment stages 40-70%): 7 points

· The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the previous 15 months (payment stages 40-90%): 7 points

· The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March (payment stages 40-85%): 6 points

Follow up of patients with COPD in primary care¹

Frequency and nature of follow-up will depend on the situation of each individual patient. However patients with mild or moderate COPD should be reviewed at least annually and those with severe COPD should be reviewed at least twice each year. The review should include:

Mild or moderate

· Smoking cessation: smoking status and desire to quit

· Symptom control: breathlessness, exercise tolerance, estimated exacerbation frequency

· Presence of complications

· Effects of each drug treatment, inhaler technique

· Need for referral to specialist and therapy services and need for pulmonary rehabilitation

· FEV₁, FVC; Calculate BMI; MRC dyspnoea scale (see separate article on diagnosis of COPD)

Severe

· Smoking status and desire to quit

· Symptom control: breathlessness, exercise tolerance, estimated exacerbation frequency

· Presence of cor pulmonale, need for long-term oxygen

· Effects of each drug treatment, inhaler technique therapy

· Patient's nutritional state, presence of depression

· Need for Social Services and Occupational Therapy input, need for referral to specialist and therapy services, need for pulmonary rehabilitation

· FEV₁, FVC; Calculate BMI; MRC dyspnoea scale, oxygen saturations (SaO₂)

Management¹

Non-drug treatment

· Advice on how to respond promptly to symptoms of an exacerbation, including starting oral corticosteroid therapy, starting antibiotic therapy if their sputum is purulent and adjusting their bronchodilator therapy to control their symptoms.

· Advice on when and how to contact a health care professional if symptoms do not improve.

· Smoking cessation: 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. An assessment of their "readiness to change" should also be made.²

· Nutrition: BMI should be calculated. If the BMI is abnormal (high or low), or changing over time, the patient should be referred for dietetic advice. If the BMI is low, patients should also be given nutritional supplements to increase their total calorific intake, and be encouraged to take exercise to augment the effects of nutritional supplementation.

· Physiotherapy: if patients have excessive sputum, they should be taught the use of Positive Expiratory Pressure masks and active cycle of breathing techniques.

Drug therapy

· Bronchodilator therapy:

o Short-acting bronchodilators, as necessary, should be the initial empirical treatment for the relief of breathlessness and exercise limitation.

o The effectiveness of bronchodilator therapy should be assessed by a variety of factors including lung function, improvement in symptoms and exercise capacity.

o Patients who remain symptomatic should be treated with a long-acting bronchodilator or combined therapy with a short-acting beta2-agonist and a short-acting anticholinergic.

· Long-acting bronchodilators are not suitable for the relief of acute bronchospasm but may have additional benefits over combinations of short-acting drugs. However they may also have additional side effects:

o Long acting beta₂ agonists:

§ The use of long term beta₂ agonists in the absence of inhaled steroids appears to carry an increased incidence of death or near death complications in some groups.³

§ Recent research has also suggested that patients taking long acting beta₂ agents also appear to have more difficulties during an exacerbation due to down regulation of the receptors.

§ Therefore the role of long acting beta₂ agonists in the management of COPD is currently being re-evaluated.

o Tiotropium (a long-acting anticholinergic bronchodilator):⁴

§ Is effective in controlling symptoms and improve exercise capacity in patients who continue to experience problems despite the use of short-acting drugs.

§ Tiotropium reduces COPD exacerbations and hospital admissions and improves health-related quality-of-life in patients with moderate and severe disease.

§ Tiotropium possibly slows the decline in FEV₁.

§ Additional long-term studies are required to evaluate its effect on mortality and change in FEV₁, to confirm its role compared to, or in combination with, long-acting beta₂-agonists, and to assess its effectiveness in mild and very severe COPD.

· Mucolytic drug therapy: should be considered in patients with a chronic cough productive of sputum and continued if there is symptomatic improvement (e.g. reduction in frequency of cough and sputum production).

· Theophylline: should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or in patients who are unable to use inhaled therapy.

· Phosphodiesterase type 4 inhibitors: there is insufficient long-term data on which to base any evidence statements or recommendations.

· Inhaled corticosteroids:

o None of the inhaled corticosteroids currently available are licensed for use alone in the treatment of COPD.

o Oral corticosteroid reversibility tests do not predict response to inhaled corticosteroid therapy.

o Inhaled corticosteroids should be prescribed for patients with an FEV₁ 50% or less of predicted, who are having 2 or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12 month period.

o The aim of treatment is to reduce exacerbation rates and slow the decline in health status and not necessarily to improve lung function.

· Oral corticosteroids:

o Maintenance use of oral corticosteroid therapy in COPD is not normally recommended. If oral corticosteroids cannot be withdrawn following an exacerbation, the dose of oral corticosteroids should be kept as low as possible.

o Patients treated with long term oral corticosteroid therapy should be monitored for the development of osteoporosis.

· Combination therapy:

o If patients remain symptomatic on monotherapy, effective combinations include:

§ Beta 2-agonist and anticholinergic

§ Beta 2-agonist and theophylline

§ Anticholinergic and theophylline

§ Long-acting beta 2-agonist and inhaled corticosteroid

o Combination treatment should be discontinued if there is no benefit after 4 weeks.

· Delivery systems:

· In most cases bronchodilator therapy is best administered using a hand held inhaler device (including a spacer device if appropriate).

· There is no evidence to suggest superiority of nebulised therapy over the use of an MDI with a spacer device.

· Oxygen: see article on Oxygen treatment for patients with COPD.

· Non-invasive ventilation: adequately treated patients with chronic hypercapnic ventilatory failure who have required assisted ventilation (whether invasive or non-invasive) during an exacerbation or who are hypercapnic or acidotic on oxygen therapy should be referred to a specialist centre for consideration of long-term NIV.

· Treatments not recommended include anti-oxidant therapy with alpha-tocopherol and beta-carotene supplements, anti-tussive therapy and prophylactic antibiotic therapy.

Pulmonary rehabilitation

· Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD. Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction.

· Pulmonary rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention.

Vaccination and anti-viral therapy

· Pneumococcal vaccination and an annual influenza vaccination should be offered to all patients with COPD.

· Antivirals for influenza: zanamivir and oseltamivir are recommended for the treatment of at-risk adults who present with influenza-like illness and who can start therapy within 48 hours of the onset of symptoms.

· Zanamivir should be used with caution in people with COPD because of a risk of bronchospasm and patients prescribed zanamivir should have a fast-acting bronchodilator available.⁵

Lung surgery

· Patients who are breathless, and have a single large bulla on a CT scan and an FEV₁ less than 50% predicted should be referred for consideration of bullectomy.

· Patients with severe COPD who remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy should be referred for consideration of lung volume reduction surgery if they meet all of the following criteria:⁶

o FEV₁ more than 20% predicted

o PaCO₂ less than 7.3kPa

o Upper lobe predominant emphysema

o TLCO more than 20% predicted

· Patients with severe COPD who remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy should be considered for referral for assessment for lung transplantation bearing in mind comorbidities and local surgical protocols. Considerations include: age, FEV₁, PaCO₂, homogeneously distributed emphysema on CT scan, elevated pulmonary artery pressures with progressive deterioration.

Palliative care¹

· Opioids should be used when appropriate to palliate breathlessness in patients with end-stage COPD which is unresponsive to other medical therapy.

· Benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen should also be used when appropriate for breathlessness in patients with end stage COPD unresponsive to other medical therapy.

· Patients with end stage COPD and their family and carers should have access to the full range of services offered by multidisciplinary palliative care teams, including admission to hospices.