COPD GUIDELINES

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COPD GUIDELINES
Sarah Cowdell
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WHY GUIDELINES MATTER
Predicted to be the third leading cause of death
by 2030 Cause of over 30,000 deaths in the UK
yearly Chronically underdiagnosed ( by up to
1/3 ) The cause of massive spend in healthcare
resources (drugs, bed-days, primary care
consultations, workdays lost, comorbidities,
mortality. Impact on sufferers and their carers

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WHATS GOING ON

• 2010 NICE update ( Gold Guidance)
• COPD STRATEGY
• NICE QUALITY INDICATORS
• Oxygen suppliers reprocurement
• New HOOF /HOCF
• New Drugs

• Community COPD service
• Community referral pulmonary rehabilitation.
• ESD
• Decomissioned OP secondary care work

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Wakefield and KirkleesCOPD Guidance

• Diagnosis of COPD
• Management of Stable Disease
• Treatment of Acute Exacerbations
• Taken from the NICE (2004)2010 update

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Definition
Disease classified by airways obstruction which
is not reversible, is usually progressive and
does not vary from day today. It will usually
occur in smokers or ex smokers over the age of
50. Main symptoms include dyspnoea, cough and
sputum production.
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• Airflow obstruction is defined as a reduction in
  FEV1/FVC ratio lt0.7
• No longer necessary to have FEV1 lt80 predicted
  for definition of airflow obstruction
• If FEV1 is 80 a diagnosis of COPD should only
  be made in the presence of respiratory symptoms
  and/or reduced ratio.
• post bronchodilator

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Severity
Mild Reduced FEV1/FVC, Normal FEV1
Moderate FEV1 50-80
Severe FEV1 30-49
Very severe FEV1 lt30
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Inhaled therapy Breathless and/or exercise
limitation
SABA or SAMA as required
FEV1 50
FEV1 lt 50
Exacerbations or persistent breathlessness
LABA
LAMA 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 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 LABA ICS
Offer therapy
Persistent exacerbations or breathlessness
Consider therapy
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Thorax February 2011 6693-96
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Cost implications
Fometerol Turbohaler 23.75
Salmeterol MDI 27.80
Salmeterol Accuhaler 29.26
Symbicort Turbohaler 38.00
Seretide Accuhaler 40.92
Seretide MDI 59.58
Tiotropium Handihaler 34.87
Tiotropium Respimat 36.26
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Other therapies

• Carbocisteine
• Reduce exacerbations if chronic sputum
  production- 16.03
• Theophylline
• May improve breathless, may enhance action of
  ICS- Approx 5.00
• Montelukast
• Not recommended for COPD

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Summary

• Bronchodilators improve symptoms
• No clear benefit of 1 agent over another
• Adding on bronchodilators improves symptoms
  further
• Adding on inhaled corticosteroids has a small
  additional benefit
• Importance of the inhaler device

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Other stuff n.b presence of haemoptysis in a
newly diagnosed or otherwise stable pt require
urgent fast track referral

• Chest x-ray
• FBC/UE
• BMI
• MRC score/Ex tolerance
• Smoking status
• Infection frequency
• Vaccination

• PLAN
• Treatment level
• Disease Info
• SMOKING CESSATION
• Review frequency
• Self-management
• Pulmonary rehabilitation

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CAT COPD assessment test

• The CAT provides a reliable measure of the impact
  of COPD on a patients health status
• Score 5 (upper limit of normal in healthy
  non-smokers)
• Score lt10 (low)
• Smoking cessation
• Annual flu vaccination
• Reduce exposure to exacerbation risk factors
• Therapy as warranted by further clinical
  assessment
• Score 10-20 (medium)
• Review maintenance therapy
• Referral for pulmonary rehabilitation
• Best approaches to minimizing and managing
  exacerbations
• Review aggravating factors is the patient still
  smoking?
• Score gt20 (high)
• Additional pharmacological treatments
• Referral to pulmonary rehabilitation
• Ensuring best approaches to minimising and
  managing exacerbations

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Pulmonary Rehabilitation

• Offer to all patients who consider themselves
  functionally disabled by COPD
• Make available to all appropriate people,
  including those recently hospitalised from an
  acute exacerbation 2010
• Hold at times that suit patients and in buildings
  with good access

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Pulmonary rehabilitation

• Paddock Jubilee Centre
• Twice weekly for 8 weeks
• Structured exercise programme
• Education component
• MRC score of 3
• Transport cannot be provided

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12 months before PR 12 months after PR Change
Admissions 9 7 -22
Length of stay (days) 8.5 5.1 -40
Bed days 76.5 35.7 -53
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Managing exacerbations

• The frequency of exacerbations should be reduced
  by appropriate use of inhaled corticosteroids and
  bronchodilators
• Give self management advice on responding
  promptly to symptoms of exacerbation.
• Start appropriate treatment with oral steroids
  and antibiotics
• Use of hospital-at-home or assisted-discharge
  schemes
• Use of NIV as indicated

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EXACERBATIONS

• A SUSTAINED WORSENING ( 24 hours) OF SYMPTOMS
  REQUIRING A CHANGE IN TREATMENT
• CHANGE IN SPUTUM COLOUR
• INCREASE IN COUGH
• CHANGE IN VOLUME OF SPUTUM ( LESS OR MORE)
• INCREASED BREATHLESSNESS OR TAKING LONGER THAN
  USUAL TO RECOVER FROM USUAL ACTIVITY
• Amoxicillin 500mg TDS 7 days
• Prednisolone 30mg OD 7 days

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Reducing mortality
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Exacerbationsand mortality
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GLOW3 Seebri significantly improved exercise
tolerance on Days 1 and 21 against placebo
? (95 CI) 88.9 (44.7,133.2) seconds, plt0.001
? (95 CI) 43.1 (10.9,75.4) seconds, plt0.001

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Day 21
Day 1
SBH12-C038 Date of Prep October 2012
Beeh KM et al. International Journal of COPD,
20127 5013-513
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Whats New?

• INDERCATEROL ONBREZ
• GLYCOPYRRONIUM BROMIDE SEEBREE
• ACLIDINIUM

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Indercaterol - once daily long acting beta2
agonist Dry powder device
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GLYCOPYRRONIUM BROMIDE Once daily long acting
anti muscarinic MUSCARINIC
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Aclidinium

• Twice daily long acting antimuscarinic
• Novel inhaler device

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Roflumilast

• Anti-inflammatory, reduces exacerbations
• Not approved by NICE
• 37.71

Placebo Roflumilast
Moderate/severe exacerbations 1.37 1.14 (ARR -17)
Use of systemic steroids and/or antibiotics 1.35 1.13 (ARR -16)
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The future?

• Anti-inflammatories?
• Exacerbation reduction
• Disease progression?
• More combinations of current molecules
• Once daily triple therapy in 1 inhaler?

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http//ckw.wdpct.nhs.uk/documents/long-term-con
ditions/