Smoker or ex smoker nearly all possibly

1
1 of 2 Appendix 1
Wakefield, Kirklees Calderdale Guidelines for
Diagnosing COPD in Primary Care
Consider a diagnosis of COPD
If considering COPD perform spirometry

• In patients who are
• over 35
• smokers or ex-smokers
• have any of these symptoms
• - exertional breathlessness
• - chronic cough
• - regular sputum production
• - frequent winter bronchitis
• - wheeze
• and have no clinical features of asthma (see
  table below)

• Airflow obstruction is defined as
• FEV1 lt 80 predicted
• And FEV1/FVC lt0.7
• Spirometric reversibility testing is not usually
  necessary as part of the diagnostic process or to
  plan initial therapy

If no doubt, diagnose COPD, perform chest x-ray,
full blood count, BMI, record MRC Dyspnoea Score
and start treatment
If still in doubt about diagnosis consider the
following pointers

• Clinically significant COPD is not present if
  FEV1 and FEV1/FVC ratio return to normal with
  drug therapy
• Refer for more detailed investigations if
  needed
• Asthma may be present if
• - there is a gt 400 ml increase in
  FEV1 in response to bronchodilators
• - serial peak flow measurements show
  significant diurnal or day-to-day variability
• - there is a gt 400 ml increase in
  FEV1 in response to prednisolone, at least 30mg
  daily, for
• 2 weeks

Reassess diagnosis in view of response to
treatment
If still in doubt, make a provisional diagnosis
and start empirical treatment
Clinical features differentiating COPD and
asthma COPD Asthma
MRC Dyspnoea Score
Grade degree of breathlessness related to
activities 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 ground because of
breathlessness, or has to stop for
breath when walking at own pace. 4
Stops for breath after walking about 100m
or after a few minutes on level
ground. 5 Too breathless to leave the
house, or breathless when dressing or
undressing.
Smoker or ex smoker nearly all
possibly Symptoms under age 35
rare often Chronic
productive cough common
uncommon Breathlessness
persistent progressive
variable Night time wakening with breathlessness
/or wheeze uncommon
common Significant diurnal or day to day
variability of symptoms uncommon
common
2
2 of 2
Wakefield, Kirklees Calderdale Guidelines for
Diagnosing COPD in Primary Care
Reasons for referral to secondary care include
Reason Purpose of referral
There is diagnostic uncertainty Confirm
diagnosis and optimise therapy. Suspected severe
COPD Confirm diagnosis and consider advanced
therapies. The patient requests a second opinion
Confirm diagnosis and optimise therapy. Onset
of cor pulmonale Confirm diagnosis and
optimise therapy. Assessment for oxygen therapy
Optimise therapy and measure blood
gases. Assessment for long-term nebuliser
therapy Optimise therapy and exclude
inappropriate prescriptions. Assessment for oral
corticosteroid therapy Justify need for
long-term treatment or supervise
withdrawal. Bullous lung disease Patients
with large bullae seen on chest x-ray may benefit
from bullectomy. A rapid decline in
FEV1 This is associated with early mortality
and may require early intervention. Assess
ment for lung volume reduction surgery Some
patients with severe symptoms and no comorbidity
and considered fit for major surgery may
benefit from LRVS. Assessment for lung
transplantation Considered for patients with
advanced disease and no other co
morbidities. Dysfunctional breathing/Hyperventilat
ion Confirm diagnosis, optimise
pharmacotherapy and access other
syndrome/Disproportionate breathlessness
therapists. Aged under 40 years or a family
history of Identify alpha1-antitrypsin
deficiency, register for therapy when
alpha1-antitrypsin deficiency available
and screen family. Symptoms disproportionate to
lung function Look for other
explanations. deficit Frequent infections or
exacerbations Consider bronchiectasis and
optimise therapy. Haemoptysis Consider
carcinoma of the bronchus and other diagnosis.
Published May 2005 Enquiries to
Lisa Chandler WDPCT 01977 665877 Reviewed
November 2007
Jacqui Pollington MYHT 01977 606635 Review
due November 2009 unless clinical evidence
base changes Nikki
Rochnia KPCT 07984274414 Group
responsible for development WDPCT Respiratory
Strategic Partnership Group
3
Appendix 2
Wakefield, Kirklees Calderdale Guidelines for
Managing Stable COPD in Primary Care
GENERAL MANAGEMENT FOR ALL PATIENTS WITH
COPD SMOKING CESSATION - ENCOURAGE EXERCISE -
REVIEW OF INHALER TECHNIQUE - PNEUMOCOCCAL
VACCINATION AND ANNUAL INFLUENZA VACCINATION -
RECORD BMI AND MRC DYSPNOEA SCORE
Reduction in Exacerbation Frequency
Treatment of symptoms

• Patients with a history of frequent
  exacerbations (worsening of symptoms of COPD,
  e.g. increasing breathlessness, increasing sputum
  production, change in colour of sputum, requiring
  treatment with antibiotics and or steroids 2 or
  more times per year) AND FEV11 50 predicted
  should have treatment to reduce exacerbation
  frequency.
• ADD high dose inhaled steroids and
• Long acting beta2 agonist
• Consider long acting anticholinergic

Each addition to therapy should involve a 4 week
trial with discontinuation of any components not
demonstrating an improvement in symptoms. If
patient remains symptomatic, treatment should be
intensified by combining therapies following the
algorithm below.
Trial of short acting beta2 agonist as required
Patients with FEV1 lt 30 treated with inhaled
steroids who are diagnosed with pneumonia should
have treatment reviewed by a respiratory physician
Trial of short acting anticholinergic
Trial of Tiotropium or Long Acting Beta2
Agonist Stop short acting anticholinergic when
starting Tiotropium If effective but symptoms
continue or worsen over time commence trial of
Tiotropium plus Long Acting Beta2 Agonist
Disability
In view of the magnitude of the benefits of
pulmonary rehabilitation programmes, the
guidelines recommend that it should be offered to
all appropriate patients with COPD managed in
primary or secondary care who consider themselves
functionally disabled by their disease (usually
MRC grade 3 and above)
Trial of Theophylline
Please refer Treatment of symptoms box
Oxygenation
Other considerations

• Measure saturation by pulse oximetry if FEV1
  lt 1.5. litres/40 predicted. If oxygen saturation
  lt 92 consider referral to Secondary Care
  Respiratory Team

• Mucolytics may be of use in patients with
  chronic productive cough. Discontinue if no
  improvement after 4 weeks.
• Consider use of patient held oral steroids and
  antibiotics for use with self management plan for
  prompt treatment of exacerbations (refer to
  guideline)
• Anxiety and depression should be identified,
  assessed and treated appropriately
• Consider Bone Protection in this group of
  patients who may be at increased risk of
  osteoporosis
• Consider referral to the Expert Patient Programme

Treatments considered unsuitable for COPD

• Routine maintenance with oral cortico
• steroids is not normally recommended
• Prophylactic antibiotics
• Alpha-1antitrypsin replacement therapy
• Antioxidant therapies
• Antitussive therapy
• Regular short-acting beta2 agonist

Published May 2005 Reviewed November
2007 Review due November 2009 unless clinical
evidence base changes Enquiries to Lisa
Chandler WDPCT 01977 665877 Jacqui Pollington
MYHT 01977 606635 Nikki Rochnia KPCT
07984274414 Group responsible for development
WDPCT Respiratory Strategic Partnership Group

• References Chronic obstructive pulmonary
  disease National clinical guideline for
  management of chronic obstructive pulmonary
  disease in adults in primary and secondary care.
  Thorax 2004 59 (suppl1) 1-232
• MHRA Drug Safety Update October 2007 Issue 3

4
Review in Primary care Mild/Moderate Sever
e
Wakefield, Kirklees Calderdale Guidelines for
Managing Stable COPD in Primary Care

• AT LEAST ANNUAL
• FEV1 FVC measurement
• Record BMI
• MRC Dyspnoea score
• Smoking status and desire to quit
• Adequacy of symptom control
• breathlessness
• exercise tolerance
• estimated exacerbation frequency
• Presence of complications
• Effects of each drug treatment
• Inhaler technique
• Need for referral to specialist and therapy
  services
• Need for pulmonary rehabilitation
• Consider referral to Expert Patient Programme
• Self management advice

Frequency Clinical assessment
2 of 2