Management

Clinicians who are managing patients with COPD are required to be appropriately trained*, or willing to train to an appropriate standard for the level of care they will be delivering.
*COPD Diploma or equivalent or a locally approved training course to meet minimum standards

The following should form part of the consultation and should be recorded.

• Severity of COPD
  • All patients must be graded as ‘Mild’, ‘Moderate’, ‘Severe’ or ,Very Severe’ according to NICE guidelines

Patients with mild/moderate/severe COPD should be reviewed at least once a year
Patients with very severe COPD should be reviewed at least twice a year.

Provision should be made for house bound patients to be reviewed in line with the above.

• Prevention: Smoking History
  • Stopping smoking is a priority for all people with COPD, regardless of their age, and has been shown to reduce the rate of decline of FEV1 in people with COPD to that of non-smokers
    [Fletcher and Peto, 1977; Kanner, 1996; British Thoracic Society, 1997].

Record current smoking status, and where appropriate smoking cessation advice and referral for smoking cessation, also record number of pack years smoked.

• Treatment Review
  - Practices should follow the Dudley Treatment Guidelines
  Use of a nebuliser should be recorded
  Use of oxygen should be recorded, no of hours per/day and method of administration.

• Compliance
  - Poor compliance with medication is common in people with COPD, with about half under using their maintenance medication, and a similar proportion overusing their medication at times of exacerbation (particularly serious if the person is on theophylline). The importance of good compliance must be emphasised to the patient

• Inhaler Technique
  - Inhaler technique should be observed and recorded at each review (at least annually) If patient cannot use device select an appropriate device based on drug choice, suitability and cost.

• Breathlessness score
  - Recording breathlessness score will enable you to monitor the patient’s quality of life and assess any improvement/deterioration in symptoms. One of the following should be used:
  • MRC Dyspnoea Score
  • Oxygen Cost Diagram
  • Borg Scale

• Spirometry
  - Spirometry and reversibility performed at diagnosis. FEV1 to be performed every 15 months (QOF) unless it is clinically indicated sooner

• Education
  - Educating patients at an appropriate level is paramount to ensure that there is a firm understanding of ‘their’ condition. Use of available education material and referral to the Expert Patient Program and the Dudley Breathe Easy Group will widen their knowledge

• Admission to Hospital
  - If the patient has been admitted to hospital; in the previous 12 months with an exacerbation of COPD it must be recorded ensuring code 8H2R is used

• Frequency of Exacerbations
  - Record the number of exacerbations over the previous 12 months which has required antibiotics or a course of oral steroids. Ensure patient is on appropriate medication as per treatment guidelines.

• Pulse Oximetry
  • Pulse Oximetry should be performed and recorded in patients with:
  • FEV1 % predicted <50% (moderate or severe COPD) cyanosis, polycythaemia, peripheral oedema or a raised jugular venous pressure
  • Saturations on air <93% should be referred for Long Term Oxygen therapy (LTOT) (see attached oxygen guidelines)

• Immunization
  Annual influenza vaccination is strongly recommended.
  Pneumococcal vaccination once only

• BMI -Diet Advice
  - Patients should be given appropriate dietary advice. Referral should be made to a dietician if BMI < 20 as this is an indicator for an increased risk of admission

• Anxiety & Depression
  - Due to the nature of the condition a large number of patients will suffer from anxiety & depression. Depression screening (as per QOF) to be recorded

• Self Management
  - All patients to be given a locally agreed self management plan and where appropriate given a prescription for standby antibiotics and oral steroids as per Treatment Guidelines

• Pulmonary Rehabilitation
  - Patients should be referred for pulmonary rehabilitation if they have a MRC score of 3 or more or patients who consider themselves disabled by their breathlessness (see referral criteria on pulmonary rehab referral form)

It should be offered to all people with COPD who consider themselves functionally disabled. It is not suitable for people unable to walk, who have unstable angina, or who have had a recent myocardial infarction
[National Collaborating Centre for Chronic Conditions, 2004]

• Review Date
  - A diary entry will be made of for the next review date

• Referring for a Specialist Opinion
  Consider referral to a respiratory specialist in any of the following situations:
  • Diagnostic uncertainty
  • Suspected severe COPD
  • Cor pulmonale
  • A rapid decline in FEV1
  • Assessment for oxygen therapy
  • Assessment for long-term nebuliser therapy
  • Assessment for oral corticosteroid therapy

• Serum alpha1-antitrypsin
  Should be considered in the following cases:
  • COPD in a non-smoker
  • Early onset of COPD
  • Family history of alpha1-antitrypsin deficiency or of early-onset COPD.

Useful Links

https://www.dudleystopsmoking.co.uk

The Treatment of Exacerbations in COPD...

Diagnosing Severity of COPD...

Identifying Patients who are at High Risk of Admission...

Smoking...