COPD in Primary Care

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COPD in Primary Care

• BY
• N. OPPONG

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Introduction

• COPD is characterised by airflow obstruction
  which is usually progressive, not fully
  reversible and does not change markedly over
  several months.
• Predominantly caused by smoking.
• Airflow obstruction is defined as FEV1 lt80
  predicted and FEV1/FVC lt0.7.
• Significant airflow obstruction may be present
  before the individual is aware of it.

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Introduction

• COPD is an important cause of morbidity and
  mortality (gt30,000 deaths / year in the UK).
• Estimated 3 million people in the UK suffering
  from the disease (900,000 diagnosed).
• June 2006 Announcement by Secretary of State for
  Health that a new NSF will be developed to
  improve standards of care and increase choice for
  patients with COPD.

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Presenting Features 1

• Over 35 years
• Smokers or ex-smokers
• Breathlessness on exertion
• Chronic cough
• Regular sputum production
• Frequent winter bronchitis
• Wheeze
• Exclude features of other diseases including
  Asthma, Bronchiectasis, CCF and Lung Cancer

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Presenting Features 2

• On examination the following may be present
• Hyper inflated chest
• Use of accessory muscles of respiration
• Wheeze or quiet breath sounds
• Peripheral oedema
• Raised JVP
• Cyanosis
• Cachexia

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Blue Bloaters Pink Puffers
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Investigations

• Spirometry is crucial to demonstrate airflow
  obstruction. Can be used for screening.
• Also as part of initial assessment at diagnosis
• Chest X-ray to exclude other pathology
• Full blood count to exclude anaemia or
  polycythaemia
• BMI
• Other invs. that may be necessary serial peak
  flow measures, CT thorax, ECG, Echo, sputum
  culture, alpha-1-antitrypsin

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Differentiating Asthma COPD
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Assessment of COPD Severity

• Multidimensional using
• Severity of airflow obstruction FEV1 50-80
  mild, FEV1 30-49 moderate, FEV1 lt30 severe
• Degree of breathlessness. Measure MRC Dyspnoea
  Score.
• Exercise limitation and disability
• Assessment of productive cough
• frequency of exacerbations
• BMI
• Signs of failing lung Cor Pulmonale, SaO2 92

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MRC Dyspnoea Score

• 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
  because of breathlessness, or has to stop for
  breath when walking at own pace.
• 4 Stops for breath after walking about 100 metres
  or after few minutes on the level.
• 5 Too breathless to leave the house or breathless
  when dressing or undressing

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Management
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Management 1

• COPD care should be delivered by a
  multidisciplinary team including resp. nurse,
  physiotherapists, dieticians, palliative care
  teams, social services, occupational therapists,
  etc
• All Patients
• Smoking cessation NRT and oral bupropion
  combined with support schemes can improve quit
  rates.
• Influenza and pnuemococcal vaccination.
• Exercise advice
• Dietary advice both over and underweight

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Mgt 2 - Symptomatic Patients

• Intermittent breathlessness
• Short-acting ß2-agonists such as Terbutaline and
  Salbutamol. OR
• Short-acting anticholinergic agent such as
  Ipratropium
• Persistent breathlessness
• Long-acting ß2-agonists given twice daily eg.
  Formoterol and Salmeterol. Main side-effects are
  tremors and palpitations.
• Long-acting anticholinergic agent eg. Tiotropium
  can be given once daily. Main side-effect is dry
  mouth.
• Oral theophyllines reserved for patients
  intolerant to inhaled therapy because of
  side-effects, drug interactions and need for
  monitoring.
• Cough
• Mucolytic agents (carbocisteine or mecysteine)
  for distressing viscid sputum.
• Physiotherapy may help.

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Management 3

• Patients with a disability
• Patients with a restriction in their daily
  activities should be referred for pulmonary
  rehabilitation.
• Patients with the failing lung
• Refer for secondary care or palliative care
  assessment

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Management 4

• Patients with exacerbations of COPD
• FEV1 50 and with 2 or more exacerbations in a
  year offer a trial of inhaled steroid and LABA
  combination. Eg. Formoterol 12mcg / budesonide
  400mcg (Symbicort) or salmeterol 50mcg /
  fluticasone 500mcg (Seretide).
• With prolonged dosing consider osteoporosis
  screening.
• Self management plans should be discussed with
  patients including the provision of standby
  antibiotics and oral steroids.

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Referral for diagnostic help

• Diagnostic uncertainty
• Suspected severe and deteriorating COPD
• Age lt 40 yrs or alpha-1-antrypsin deficiency
• Onset of cor pulmonale or presence of significant
  co-morbidities
• Red flag symptoms to exclude lung cancer
  haemoptysis, clubbing
• Patients experiencing frequent infections or
  exacerbations
• Requests for second opinion

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Referral for therapeutic help

• Assessment for pulmonary rehabilitation for
  patients with functional disability
• Assessment for lung surgery volume reduction /
  transplantation
• Assessment for long term oxygen therapy FEV1
  30, SaO2 92
• Assessment for ambulatory oxygen therapy
  patients who desaturate on exercise
• Assessment for nebulised therapy

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Follow Up

• Once or twice yearly
• Smoking status and desire to quit
• Adequacy of symptom control
• Presence of complications
• Effects of drug treatment
• Inhaler technique
• Need for referral to specialist or therapy
  services
• Need for pulmonary rehabilitation
• Measure FEV1, FVC, MRC score, BMI

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Pulmonary Rehabilitation

• A multidisciplinary programme of care for
  patients with chronic respiratory impairment (MRC
  dyspnoea score 3)
• Individually tailored and designed to optimise
  each patients physical and social performance
  and autonomy
• Involves exercise, disease education,
  nutritional, psychological and behavioural
  intervention
• Despite its proven benefits, it is available to
  only about 2 of suitable patients

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Oxygen

• Initiated by specialist service
• From Feb 1, 2006 provision of oxygen made by the
  Home Oxygen Therapy Service led from secondary
  care.
• Criteria for assessment
• FEV1 lt30
• Cyanosis
• Polycythaemia
• Cor pulmonale
• SaO2 92 when stable
• GPs can still order oxygen usually as part of
  short term arrangements whilst awaiting assessment

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Exacerbations

• A sustained worsening of the patients symptoms
  from their usual stable state
• Beyond normal day to day variations
• Acute in onset
• Requires treatment change
• Triggers
• Weather
• Viral epidemics eg. winter flu and other
  infections
• Smoky environment
• High pollen levels

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Exacerbations

• Cost of exacerbations
• Mild self managed - 15
• Moderate GP managed - 95
• Severe requiring admission - 1,658
• Frequent exacerbations associated with
• Faster lung function decline, up to 25 each year
• Worsening health status
• 50 of those who survive their first admission
  with COPD will be readmitted within 6 months. 10
  die during admission and a third will die within
  6 months.

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Exacerbations

• Self Management
• In an exacerbation, the earlier treatment is
  started the better
• Take maximal bronchodilator therapy
• Oral steroids if symptoms persist
• Antibiotics if sputum goes yellow or green
• In flu epidemics, when alerted by public health
  lab, oseltamivir should be used within 48 hrs of
  onset of flu-like illness.
• Indications for in-patient assessment
• Worsening hypoxaemia
• Unremitting severe breathlessness
• Confusion, drowsiness
• New onset of peripheral oedema or cyanosis
• Chest pain and fever

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End of Life Issues

• Indicators for end of life criteria
• FEV1 lt30
• Recurrent acute exacerbations of COPD (gt2 per
  year)
• Frequent admissions to hospital for acute COPD
• Progressive shortening of time period between
  admissions
• Severe co-morbidities eg. heart failure, diabetes
  etc
• Dependence on oxygen
• Severe unremitting dyspnoea at rest (MRC dyspnoea
  score 5)
• Inability to carry out normal activities of daily
  living, inability to self care

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End of Life Issues

• For these patients consider
• Completion of DS1500 form for DLA
• Clear management plan in consultation with
  patient and carer
• Referral to specialist services resp. nurse,
  palliative care, district nurse
• Provide alert card / patient held record for
  emergency services eg. OOH service. Include
  preferred place of death.
• Liverpool Care Pathway for the last 48 hrs of
  life

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