Chronic obstructive pulmonary disease (COPD)

 

Chronic obstructive pulmonary disease (COPD) is a treatable (but not curable) and largely preventable lung disease with symptoms such as cough, sputum, and increasing breathlessness.  It is characterised by airflow obstruction that is not fully reversible.  The airflow obstruction does not change markedly over several months and is usually progressive in the long term.  COPD is predominantly caused by smoking.  Other factors, particularly occupational exposures, may also contribute to the development of COPD.  Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations.  In the UK, it is estimated that more than 3 million people currently have chronic obstructive pulmonary disease (COPD), with the disease being undiagnosed in about 2 million of these people

.

Definition

The following should be used as a definition of COPD:

  • Airflow obstruction is defined as a reduced FEV1/FVC ratio (where FEV1 is forced expired volume in 1 second and FVC is forced vital capacity), such that FEV1/FVC is < 0.7
  • If FEV1 is ≥ 80% predicted normal, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough

.

Diagnosis

NOTE There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry

Symptoms - 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 one or more of the following symptoms:

  1. exertional breathlessness
  2. chronic cough
  3. regular sputum production
  4. frequent winter 'bronchitis'
  5. wheeze

.

Breathlessness - one of the primary symptoms of COPD

The Medical Research Council (MRC) dyspnoea scale should be used to grade the breathlessness according to the level of exertion required to elicit it:

Spirometry should be undertaken to help diagnose COPD:

  1. Spirometry can also be used to reconsider a patient's diagnosis if the patient shows an exceptionally good response to treatment
  2. Consider alternative diagnoses or investigations in:
    1. older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7
    2. younger people with symptoms of COPD where the FEV1/FVC ratio is ≥ 0.7

.

Further investigations, at a patient's initial diagnostic evaluation, should be carried out in addition to spirometry.  These include:

  1. Chest radiograph - to exclude other pathologies
  2. FBC - to identify anaemia or polycythaemia
  3. body mass index (BMI) calculated

.

Distinguish COPD from asthma, based on:

  1. Smoking history - almost always present in people with COPD
  2. Age - usually older than 35 years of age for COPD
  3. Chronic productive cough - common with COPD; uncommon with asthma
  4. Breathlessness - progressive with COPD; variable with asthma
  5. Variability of symptoms - common with asthma; uncommon with COPD
  6. Night time wakening with wheeze and breathlessness - common with asthma; uncommon with COPD

.

If asthma and COPD cannot be distinguished based on clinical features, consider the following:

  1. A large response (greater than 400 ml) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma
  2. If FEV1 and the FEV1/FVC return to normal with drug therapy, clinically significantly COPD is not present
  3. Significant diurnal or day-to-day variability of serial peak flow measurements suggest asthma
  4. If doubt still remains, refer the person for a specialist's opinion

.

Management of stable asthma

Smoking cessation

  1. All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity
  2. 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
  3. Unless contraindicated, offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people with COPD

.

Promote effective inhaled therapy

  1. Short-acting bronchodilators (short-acting β2 agonist  (SABA) and short-acting muscarinic antagonist (SAMA) should be the initial empirical treatment for the relief of breathlessness and exercise limitation
  2. 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:
    1. if FEV≥ 50% predicted:  either long-acting β2 agonist  (LABA) or long-acting muscarinic antagonist (LAMA)
    2. if FEV< 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA
  3. 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

.

Pulmonary rehabilitation should be:

  1. made available to all appropriate people with COPD, including those who have had a recent hospitalisation for an acute exacerbation
  2. offered to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above)

.

Physiotherapy — If patients have excessive sputum, they should be taught:

  1. the use of positive expiratory pressure masks
  2. active cycle of breathing techniques

.

Self-management — Patients at risk of having an exacerbation of COPD should be given self-management advice that encourages them to respond promptly to the symptoms of an exacerbation

.

Palliative care — Opioids should be used when appropriate to palliate breathlessness in patients with end-stage COPD, which is unresponsive to other medical therapy

.

Follow up and review

Patients with mild, moderate or severe COPD (stages 1-3) should have a review at least once a year, with a clinical assessment of the following:

  1. Smoking status and desire to quit
  2. Adequacy of symptom control (breathlessness, exercise tolerance, estimated exacerbation frequency)
  3. Presence of complications
  4. Effects of each drug treatment
  5. Inhaler technique
  6. Need for referral to specialist and therapy services
  7. Need for pulmonary rehabilitation

The review should include measurements of the following:

  1. FEV1 and FVC
  2. BMI
  3. MRC dyspnoea score

.

Patients with very severe COPD (stage 4) should be reviewed at least twice a year.  A clinical assessment should cover the same topics as the assessment for mild, moderate and severe COPD, but should also include an assessment of the following:

  1. Presence of cor pulmonale
  2. Need for long-term oxygen therapy
  3. Patient's nutritional state
  4. Presence of depression
  5. Need for social service and occupational therapy input

SaO2 should also be measured at each review

.

Management of COPD exacerbation

An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state (beyond normal day-to-day variations), and is acute on onset.  Commonly reported symptoms include worsening breathlessness, cough, increased sputum production and change in sputum colour

.

Assessment of need for hospital treatment

  • The following factors should be used to assess the need to treat patients in hospital:

Management of exacerbations in primary care

  1. Sending sputum samples for culture is not recommended in routine practice
  2. Pulse oximetry is of value if there are clear clinical features of a severe exacerbation

.

Hospital-at-home and assisted-discharge schemes should be used as an effective way of caring for patients with exacerbations of COPD who would otherwise need to be admitted or stay in hospital

.

Pharmacological management

  1. Increased breathlessness is a common feature of an exacerbation of COPD.  This is usually managed by taking increased doses of short-acting bronchodilators
  2. Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD
  3. In the absence of significant contraindications, oral corticosteroids should be considered in patients in the community who have an exacerbation with a significant increase in breathlessness, which interferes with daily activities
  4. Antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum

.

MRC Dyspnoea Scale

The Medical Research Council (MRC) dyspnoea scale should be used to grade the breathlessness according to the level of exertion required to elicit it:

.

Distinguishing COPD from Asthma

The following table listing clinical features of both COPD and asthma can be used to distinguish between the two conditions:

Microbiology

Please send sputum cultures to the Microbiology Department at East Kent Hospitals (find details here)

.

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

.

Chest radiography

For chest x-rays, you can refer the patient to the Radiology Department at East Kent Hospitals (find details here)

.

Spirometry

In combination with undertaking structured clinical assessment of the patient's signs and symptoms, GPs should carry out quality-assured spirometry.  Spirometry is performed in primary care and must be carried out by suitably trained nurses accredited to ARTP standards.  Please click on the Spirometry map register for a full list of those practices where spirometry is being undertaken to the accredited standard

Further information:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch