Copd In Primary Care

COPD in Primary Care BY N. OPPONG

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 <80% predicted and FEV1/FVC <0.7.  Significant airflow obstruction may be present before the individual is aware of it. 

Introduction  COPD

is an important cause of morbidity and mortality (>30,000 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.

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 

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

Blue Bloaters & Pink Puffers

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 

Differentiating Asthma & COPD COPD

Asthma

Smoker or ex-smoker Nearly all

Possibly

Symptoms under age Rare 35

Often

Chronic productive cough

Common

Uncommon

Breathlessness

Persistent and progressive

Variable

Night time waking with DIB

Uncommon

Common

Significant diurnal or Uncommon daily variability

Common

Assessment of COPD Severity Multidimensional using:  Severity of airflow obstruction: FEV 501 80% = mild, FEV1 30-49% = moderate, FEV1 <30% = 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%

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

Management

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

Mgt 2 - Symptomatic Patients Intermittent breathlessness  Short-acting β2-agonists such as Terbutaline and Salbutamol. OR  Short-acting anticholinergic agent such as Ipratropium Persistent breathlessness  Long-acting β2-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.

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

Management 4 Patients with exacerbations of COPD  FEV ≤ 50% and with 2 or more 1 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.

Referral for diagnostic help Diagnostic uncertainty  Suspected severe and deteriorating COPD  Age < 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 

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 

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 FEV , FVC, MRC score, BMI 1

Pulmonary Rehabilitation A multidisciplinary programme of care for patients with chronic respiratory impairment (MRC dyspnoea score ≥3)  Individually tailored and designed to optimise each patient’s 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 

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  FEV <30% 1  Cyanosis  Polycythaemia  Cor pulmonale  SaO2 ≤92% when stable  GPs can still order oxygen usually as part of short term arrangements whilst awaiting assessment 

Exacerbations A sustained worsening of the patient’s 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 

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.

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

End of Life Issues Indicators for end of life criteria:  FEV <30% 1  Recurrent acute exacerbations of COPD (>2 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

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