COPD (Chronic Obstructive Pulmonary Disease): Difference between revisions
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== Diagnostic Procedures == | == Diagnostic Procedures == | ||
*A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze | *A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze | ||
*The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry. All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results | *The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry. All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results | ||
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== Outcome Measures == | == Outcome Measures == | ||
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== Management / Interventions<br> == | == Management / Interventions<br> == | ||
==== Stopping Smoking ==== | ==== Stopping Smoking ==== | ||
Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity | Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity | ||
==== Exercise ==== | ==== Exercise ==== | ||
Exercise prescription is a key component of pulmonary rehabilitation programmes, which are part of the non-pharmacological approach to managing COPD. There is a high level of evidence for the benefits of pulmonary rehabilitation for people with COPD<ref>Roisin RR, Rabe KF, Anzueto A, et al. Global strategy for the diagnosis management, and prevention of chronic obstructive pulmonaryfckLRdisease. Bethesda, MD: Global Initiative for Chronic Obstructive Lung Disease, 2008; 1–91.</ref> Strength and endurance exercise are endorsed for people with COPD<ref>Skinner, Margot. Strength and endurance exercise endorsed for people with COPD. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 418-418(1)</ref><br> | Exercise prescription is a key component of pulmonary rehabilitation programmes, which are part of the non-pharmacological approach to managing COPD. There is a high level of evidence for the benefits of pulmonary rehabilitation for people with COPD<ref>Roisin RR, Rabe KF, Anzueto A, et al. Global strategy for the diagnosis management, and prevention of chronic obstructive pulmonaryfckLRdisease. Bethesda, MD: Global Initiative for Chronic Obstructive Lung Disease, 2008; 1–91.</ref> Strength and endurance exercise are endorsed for people with COPD<ref>Skinner, Margot. Strength and endurance exercise endorsed for people with COPD. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 418-418(1)</ref><br> | ||
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Muscles that are required for arm exercise are also involved in movement of the chest wall during respiration and thus the need to breathe often compromises the individual’s ability to undertake daily activities, therefore exercise prescription involving arm exercise needs to be carefully prescribed<ref>Ennis S, Alison J, McKeough Z. The effects of arm endurance and strength training on arm exercise capacity in people with chronic obstructive pulmonary disease. Phys Ther Rev 2009;14(4):226–39.</ref><br> | Muscles that are required for arm exercise are also involved in movement of the chest wall during respiration and thus the need to breathe often compromises the individual’s ability to undertake daily activities, therefore exercise prescription involving arm exercise needs to be carefully prescribed<ref>Ennis S, Alison J, McKeough Z. The effects of arm endurance and strength training on arm exercise capacity in people with chronic obstructive pulmonary disease. Phys Ther Rev 2009;14(4):226–39.</ref><br> | ||
==== Promote effective inhaled therapy ==== | ==== Promote effective inhaled therapy ==== | ||
In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy: | In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy: | ||
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Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1 | Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1 | ||
==== Provide pulmonary rehabilitation ==== | ==== Provide pulmonary rehabilitation ==== | ||
Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation | Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation | ||
==== Use non-invasive ventilation ==== | ==== Use non-invasive ventilation ==== | ||
Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnicventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations. When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed. | Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnicventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations. When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed. | ||
==== Manage exacerbations ==== | ==== Manage exacerbations ==== | ||
The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations | The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations | ||
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*use of hospital-at-home or assisted-discharge schemes | *use of hospital-at-home or assisted-discharge schemes | ||
==== Ensure multidisciplinary working ==== | ==== Ensure multidisciplinary working ==== | ||
COPD care should be delivered by a multidisciplinary team | COPD care should be delivered by a multidisciplinary team | ||
==Managing symptoms and conditions in stable COPD== | == Managing symptoms and conditions in stable COPD == | ||
====Breathlessness and exacerbations==== | ==== Breathlessness and exacerbations ==== | ||
*Manage breathlessness and exercise limitation with inhaled therapy | *Manage breathlessness and exercise limitation with inhaled therapy | ||
*For exacerbations or persistent breathlessness: | *For exacerbations or persistent breathlessness: | ||
**use long-acting bronchodilators or LABA + ICS | **use long-acting bronchodilators or LABA + ICS | ||
**consider adding theophylline if still symptomatic | **consider adding theophylline if still symptomatic | ||
*Offer pulmonary rehabilitation to all suitable people | *Offer pulmonary rehabilitation to all suitable people | ||
*Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy | *Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy | ||
*Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following: | *Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following: | ||
**FEV1 greater than 20% predicted | **FEV1 greater than 20% predicted | ||
**PaCO2 less than 7.3 kPa | **PaCO2 less than 7.3 kPa | ||
**upper lobe predominant emphysema | **upper lobe predominant emphysema | ||
**TLCO greater than 20% predicted | **TLCO greater than 20% predicted | ||
*Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy. Considerations include: | *Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy. Considerations include: | ||
**age | **age | ||
**FEV1 | **FEV1 | ||
**PaCO2 | **PaCO2 | ||
**homogeneously distributed emphysema on CT scan | **homogeneously distributed emphysema on CT scan | ||
**elevated pulmonary artery pressures with progressive deterioration | **elevated pulmonary artery pressures with progressive deterioration | ||
**comorbidities | **comorbidities | ||
**local surgical protocols | **local surgical protocols | ||
====Frequent exacerbations==== | ==== Frequent exacerbations ==== | ||
*Optimise inhaled therapy | *Optimise inhaled therapy | ||
*ffer vaccinations and prophylaxis | *ffer vaccinations and prophylaxis | ||
*Give self-management advice | *Give self-management advice | ||
*Consider osteoporosis prophylaxis for people requiring frequent oral corticosteroids | *Consider osteoporosis prophylaxis for people requiring frequent oral corticosteroids | ||
====Cor pulmonale==== | ==== Cor pulmonale ==== | ||
*Consider in people who have peripheral oedema, a raised venous pressure, a systolic parasternal heave, a loud pulmonary second heart sound | *Consider in people who have peripheral oedema, a raised venous pressure, a systolic parasternal heave, a loud pulmonary second heart sound | ||
*Exclude other causes of peripheral oedema | *Exclude other causes of peripheral oedema | ||
*Perform pulse oximetry, ECG and echocardiogram if features of cor pulmonale | *Perform pulse oximetry, ECG and echocardiogram if features of cor pulmonale | ||
*Assess need for LTOT | *Assess need for LTOT | ||
*Treat oedema with diuretic | *Treat oedema with diuretic | ||
*Angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers are not recommended | *Angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers are not recommended | ||
*Digoxin may be used where there is atrial fibrillation | *Digoxin may be used where there is atrial fibrillation | ||
====Respiratory failure==== | ==== Respiratory failure ==== | ||
*Assess for appropriate oxygen | *Assess for appropriate oxygen | ||
*Consider referral for assessment for long-term domiciliary NIV therapy | *Consider referral for assessment for long-term domiciliary NIV therapy | ||
====Abnormal BMI==== | ==== Abnormal BMI ==== | ||
*Refer for dietetic advice | *Refer for dietetic advice | ||
*Offer nutritional supplements if the BMI is low | *Offer nutritional supplements if the BMI is low | ||
*Pay attention to weight changes in older patients (especially | *Pay attention to weight changes in older patients (especially>3 kg) | ||
====Chronic productive cough==== | ==== Chronic productive cough ==== | ||
*Consider mucolytic therapy | *Consider mucolytic therapy | ||
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*Refer to NICE guidelines ‘[http://www.nice.org.uk/CG91 Depression with a chronic physical health problem]’<ref>National Institute for Health and Clinicl Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Available from http://guidance.nice.org.uk/CG91 [last accessed 2/8/10]</ref>. | *Refer to NICE guidelines ‘[http://www.nice.org.uk/CG91 Depression with a chronic physical health problem]’<ref>National Institute for Health and Clinicl Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Available from http://guidance.nice.org.uk/CG91 [last accessed 2/8/10]</ref>. | ||
====Alpha-1 antitrypsin deficiency==== | ==== Alpha-1 antitrypsin deficiency ==== | ||
*Offer referral to a specialist centre to discuss the clinical management of this condition | *Offer referral to a specialist centre to discuss the clinical management of this condition | ||
*Alpha-1 antitrypsin replacement therapy is not recommended | *Alpha-1 antitrypsin replacement therapy is not recommended | ||
====Palliative setting==== | ==== Palliative setting ==== | ||
*Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other medical therapy | *Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other medical therapy | ||
*Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness | *Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness | ||
*Provide access to multidisciplinary palliative care teams and hospices | *Provide access to multidisciplinary palliative care teams and hospices | ||
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add text here relating to key evidence with regards to any of the above headings<br> | add text here relating to key evidence with regards to any of the above headings<br> | ||
== Resources <br> == | == Resources <br> == | ||
[[Clinical_Guidelines:_Cardiopumlonary§ion=2#COPD|Clinical Guidelines for COPD]] | |||
== Case Studies == | == Case Studies == | ||
Revision as of 14:14, 2 August 2010
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Clinically Relevant Anatomy
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add text here relating to clinically relevant anatomy of the condition
Mechanism of Injury / Pathological Process
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add text here relating to the mechanism of injury and/or pathology of the condition
Clinical Presentation[edit | edit source]
add text here relating to the clinical presentation of the condition
Diagnostic Procedures[edit | edit source]
- A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze
- The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry. All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Management / Interventions
[edit | edit source]
Stopping Smoking[edit | edit source]
Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity
Exercise[edit | edit source]
Exercise prescription is a key component of pulmonary rehabilitation programmes, which are part of the non-pharmacological approach to managing COPD. There is a high level of evidence for the benefits of pulmonary rehabilitation for people with COPD[1] Strength and endurance exercise are endorsed for people with COPD[2]
Muscles that are required for arm exercise are also involved in movement of the chest wall during respiration and thus the need to breathe often compromises the individual’s ability to undertake daily activities, therefore exercise prescription involving arm exercise needs to be carefully prescribed[3]
Promote effective inhaled therapy[edit | edit source]
In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:
- if forced expiratory volume in 1 second (FEV1)≥50% predicted: either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)
- if FEV1<50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA
Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1
Provide pulmonary rehabilitation[edit | edit source]
Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation
Use non-invasive ventilation[edit | edit source]
Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnicventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations. When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed.
Manage exacerbations[edit | edit source]
The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations
The impact of exacerbations should be minimised by:
- giving self-management advice on responding promptly to the symptoms of an exacerbation
- starting appropriate treatment with oral steroids and/or antibiotics
- use of non-invasive ventilation when indicated
- use of hospital-at-home or assisted-discharge schemes
Ensure multidisciplinary working[edit | edit source]
COPD care should be delivered by a multidisciplinary team
Managing symptoms and conditions in stable COPD[edit | edit source]
Breathlessness and exacerbations[edit | edit source]
- Manage breathlessness and exercise limitation with inhaled therapy
- For exacerbations or persistent breathlessness:
- use long-acting bronchodilators or LABA + ICS
- consider adding theophylline if still symptomatic
- Offer pulmonary rehabilitation to all suitable people
- Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy
- Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following:
- FEV1 greater than 20% predicted
- PaCO2 less than 7.3 kPa
- upper lobe predominant emphysema
- TLCO greater than 20% predicted
- Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy. Considerations include:
- age
- FEV1
- PaCO2
- homogeneously distributed emphysema on CT scan
- elevated pulmonary artery pressures with progressive deterioration
- comorbidities
- local surgical protocols
Frequent exacerbations[edit | edit source]
- Optimise inhaled therapy
- ffer vaccinations and prophylaxis
- Give self-management advice
- Consider osteoporosis prophylaxis for people requiring frequent oral corticosteroids
Cor pulmonale[edit | edit source]
- Consider in people who have peripheral oedema, a raised venous pressure, a systolic parasternal heave, a loud pulmonary second heart sound
- Exclude other causes of peripheral oedema
- Perform pulse oximetry, ECG and echocardiogram if features of cor pulmonale
- Assess need for LTOT
- Treat oedema with diuretic
- Angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers are not recommended
- Digoxin may be used where there is atrial fibrillation
Respiratory failure[edit | edit source]
- Assess for appropriate oxygen
- Consider referral for assessment for long-term domiciliary NIV therapy
Abnormal BMI[edit | edit source]
- Refer for dietetic advice
- Offer nutritional supplements if the BMI is low
- Pay attention to weight changes in older patients (especially>3 kg)
Chronic productive cough[edit | edit source]
- Consider mucolytic therapy
Anxiety and depression[edit | edit source]
- Screen for anxiety and depression using validated tools in people who:
- are hypoxic
- are severely breathless or
- have recently been seen or treated at a hospital for an exacerbation
- Refer to NICE guidelines ‘Depression with a chronic physical health problem’[4].
Alpha-1 antitrypsin deficiency[edit | edit source]
- Offer referral to a specialist centre to discuss the clinical management of this condition
- Alpha-1 antitrypsin replacement therapy is not recommended
Palliative setting[edit | edit source]
- Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other medical therapy
- Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness
- Provide access to multidisciplinary palliative care teams and hospices
Differential Diagnosis
[edit | edit source]
add text here relating to the differential diagnosis of this condition
Key Evidence[edit | edit source]
add text here relating to key evidence with regards to any of the above headings
Resources
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Case Studies[edit | edit source]
add links to case studies here (case studies should be added on new pages using the case study template)
Recent Related Research (from Pubmed)[edit | edit source]
Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10
References[edit | edit source]
References will automatically be added here, see adding references tutorial.
- ↑ Roisin RR, Rabe KF, Anzueto A, et al. Global strategy for the diagnosis management, and prevention of chronic obstructive pulmonaryfckLRdisease. Bethesda, MD: Global Initiative for Chronic Obstructive Lung Disease, 2008; 1–91.
- ↑ Skinner, Margot. Strength and endurance exercise endorsed for people with COPD. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 418-418(1)
- ↑ Ennis S, Alison J, McKeough Z. The effects of arm endurance and strength training on arm exercise capacity in people with chronic obstructive pulmonary disease. Phys Ther Rev 2009;14(4):226–39.
- ↑ National Institute for Health and Clinicl Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Available from http://guidance.nice.org.uk/CG91 [last accessed 2/8/10]
