This guideline provides strategies for the improved diagnosis and management of adults with chronic bronchitis and emphysema (chronic obstructive pulmonary disease, COPD).
Diagnostic Code: 496 (chronic airways obstruction, not elsewhere classified)
Diagnosis
COPD is under-diagnosed. A definitive diagnosis is made with spirometry.
a) Signs and symptoms indicating the need for spirometry testing.
Use clinical judgment to select patients for spirometry testing. Consider spirometry testing for new COPD patients at high risk:*
smokers or ex-smokers 40 years of age or older
persistent cough or sputum production
frequent respiratory infections
unexplained shortness of breath
Chest X-ray is usually done to exclude co-morbidities. A chest X-ray may suggest COPD, but the definitive diagnosis of COPD requires spirometry.
*Some patients with COPD may not have used tobacco. Other risk factors include: occupational exposures, alpha-1 antitrypsin deficiency, early childhood lung infections, and exposure to air pollutants, particularly where wood is burned indoors.
b) Diagnosis by spirometry
Note: In office spirometry requires approval by the College of Physicians and Surgeons Diagnostic Accreditation Program.
A post bronchodilator FEV1 / FVC† ratio of less than 0.7 defines airflow obstruction that is not fully reversible and establishes a diagnosis of COPD.
Note: COPD and asthma commonly coexist
Compared to the baseline FEV1, asthmatic patients will have a 12% or greater improvement in FEV1 15 minutes after the use of an inhaled short-acting beta2 agonist. In adults, the FEV1 also increases by more than 200 ml.1
Long term improvements in spirometry may indicate asthma.
In some situations, a corticosteroid trial may be appropriate to differentiate COPD from asthma.
†FEV1: Forced expiratory volume in the first second, FVC: forced vital capacity
c) COPD classification by symptoms and spirometry
Table 1 adapted from the Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update.2
‡Symptoms may not correlate directly with clinical signs. As a result, patients may belong in more than 1 COPD stage (namely, clinical versus spirometric stages).
If clinical uncertainty of the diagnosis remains, specialist consultation is recommended.
Management of COPD
a) Care objectives
Physicians are encouraged to:
identify new patients with COPD by spirometry
monitor key clinical indicators of COPD using a flow sheet (refer Appendix A Patient Care Flow Sheet) or an equivalent care plan
use recall systems to ensure that patients are seen at appropriate intervals; at least twice yearly
review patient records to ensure that goals of care are met (refer Appendix A Patient Care Flow Sheet) or an equivalent care plan
consider co-morbidities
The therapeutic goals of management of COPD are to:2
prevent disease progression (smoking cessation)
alleviate breathlessness and other respiratory symptoms
improve exercise tolerance and daily activity
reduce frequency and severity of exacerbations
treat exacerbations and complications of the disease
improve health status
reduce mortality
A management strategy including pharmacotherapy and non-pharmacotherapeutic approaches can improve symptoms, activity levels and quality of life even in patients with severe COPD. The following table of severity can help guide the management of the disease.
Figure 1: Therapy should be based on a stepwise approach.
Figure 1 adapted from the Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update.2
b) Lifestyle management
Smoking Cessation
Smoking is the most important cause of and contributing factor for COPD progression.
Smoking cessation is the most important factor in slowing the progression of COPD.
Smoking cessation is effective in preventing disease progression even in long-term smokers.
Effective strategies exist to aid in smoking cessation. These include:
nicotine replacement therapy which may need to be used long term
other pharmacotherapy (note that these have significant side effects)
Even minimal intervention may be helpful and should be offered to every smoker. Counselling may be appropriate.
Consider referral of the smoker with COPD to the BC Smokers Helpline (refer Patient Guide).
Smoking cessation of the patient and household contacts should be reinforced at every contact.
For additional information, refer to the guideline Cardiovascular Disease – Primary Prevention, Appendix A - Part 1: Smoking Cessation available at www.BCGuidelines.ca
c) Education and self-management
Education of the patients and family can improve coping skills and quality of life and reduce the likelihood of hospitalization from COPD. The physician is encouraged to:
reinforce smoking cessation
encourage exercise
refer the smoker with COPD to the BC Smokers Helpline (refer Patient Guide).
help the patient identify resources and a support team (e.g. physician, pharmacist, nurse, dietitian as appropriate)
refer the patient to a pulmonary rehabilitation program where available and to community respiratory services
encourage patients to stay indoors when air quality is poor, as air quality may have a significant effect on COPD
Remaining active despite symptoms of shortness of breath must remain a priority for all patients with COPD. Clinically stable COPD patients whose activities remain symptom-limited despite optimal therapy should be referred to an exercise training program. Formal pulmonary rehabilitation programs that include patient education and exercise can reduce symptoms, decrease exacerbations, and improve exercise endurance and quality of life.
d) Pharmacologic management (refer Appendix B Prescription Medication Table of Chronic Obstructive Pulmonary Disease)
Bronchodilators are the mainstay of COPD pharmacotherapy. Pharmacological treatment of COPD has not been shown to reverse, slow, or prevent progressive decline in lung function, but can improve symptoms, reduce exacerbations and hospitalizations, and improve quality of life. Bronchodilators reduce air trapping, dyspnea, and improve quality of life even if improvement is not seen on spirometry.
Patients with mild COPD should be using a short-acting inhaled beta2 agonist as needed, and regular use of inhaled anticholinergics for symptom control.
The risks and benefits of anticholinergics should be discussed with the patient. The safety of tiotropium and ipratropium is a controversial area with studies showing a large range in clinical outcomes and adverse effects. While patients experience symptom relief, increased risks for cardiovascular death, myocardial infarction (MI), stroke, and all-cause mortality have been found in a number of long term trials. For example, comparisons of tiotropium to placebo, the NNT (number needed to treat) to prevent a COPD exacerbation is 21, and to prevent hospitalization, the NNT is 20. This should be considered with the NNH (number needed to harm) of 40 for cardiovascular death and 174 for MI.3 However, there is still controversy; a more recent randomized controlled trial over 4 years (The Uplift Trial, 5993 patients randomized) failed to find a statistically significant increase in mortality or cardiovascular events, although these were secondary endpoints.4
The risks and efficacy of inhaled corticosteroids, whether used alone or in combination therapy, also show a large range of results in randomised control trials and are also a controversial area of study. Again, the benefits to the patient in reduced exacerbations and symptom relief need to be balanced with the increased risk of pneumonia. A review of combination therapy of salmeterol and fluticasone studies showed an increased risk of pneumonia.5
Evaluate the patient’s inhaler technique regularly. Consider prescribing a spacer for metered dose inhalers.
Introduce a long-acting beta2 agonist if symptoms persist.
Add inhaled corticosteroid if asthma coexists, or if COPD with exacerbations (1 or more per year), or FEV1 < 50%.
If indications for both a long-acting beta2 agonist and an inhaled corticosteroid exist, then consider a combination product containing both.
Theophylline may be useful in select patients with persistent symptoms despite optimal inhaled therapy.
e) Ongoing care
Immunization against influenza and pneumococcal infections:
annual influenza vaccination
pneumococcal vaccination at least once and repeated in 5-10 years
Oxygen therapy
The goal of oxygen therapy is to maintain PaO2 ≥ 60 mmHg or SpO2 ≥ 90% at rest (refer to local health authority for local criteria), on exertion and during sleep. (PaO2 = partial pressure of oxygen in arterial blood, SpO2 = % oxygen saturation).
Oxygen therapy may be a useful addition to exercise therapy.
Refer to Appendix C for an example of medical indications for home oxygen.
f) Acute exacerbations (AECOPD) require more intensive management.
Acute exacerbations are characterized by sustained (48 hrs or more) worsening of shortness of breath and coughing, with or without sputum. The most common cause is a viral or bacterial infection. Develop an exacerbation plan with the patient (see example in Appendix D COPD Flare up Action Plan). Severe AECOPD complicated by acute respiratory failure is a medical emergency.
Therapies should include:
therapy with short-acting beta2 agonists and anticholinergic bronchodilators
oral corticosteroids (e.g. prednisone 25-50 mg/day) for less than two weeks in most moderate to severe COPD patients. A dose of 30 – 40 mg of prednisone equivalent per day has been used in practice.2
antibiotic use is based on risk factors (see Appendix E Antibiotic Treatment Recommendations for Acute Exacerbations of COPD (AECOPD)).
g) Manage co-morbidities
COPD patients commonly present with several co-morbidities which reduce quality of life and significantly increase the cost of care to patients and the health care system. Once detected, these co-morbidities should be treated aggressively.6
In patients with mild to moderate COPD, cardiovascular diseases are the leading causes of hospitalizations and the second leading cause of mortality after lung cancer. In severe and very severe COPD, respiratory failure and pneumonia are the leading causes of morbidity and mortality. However, even in these patients, cardiovascular diseases remain a major concern.7
h) Indications for specialist referral
The diagnosis is uncertain.
A young patient with COPD and limited smoking history or those with severe symptoms and disability which is disproportionate to their lung function decline.
There are signs and symptoms of hypoxemic or hypercarbic respiratory failure.
There are severe or recurrent exacerbations and treatment failure.
The patient has severe COPD and disability requiring more intensive interventions including surgical therapies.
More intensive co-morbidity assessment and management is required.
Difficulty in assessing home oxygen or sleep disorders.
i) End of life care
Prior to initiating end of life care:
address the precipitating factors;
explore all active therapeutic options; and
consider co-morbidity
End of life care
Manage all symptoms (including those of co-morbid conditions) and address function and quality of life issues.
Review need for home oxygen and treatment for severe dyspnea including opioids, neuroleptics and benzodiazepines.
Maintain patient autonomy. Most patients are willing to discuss advance care planning and it is best done in a non-acute setting.
It is important to ensure that advanced care planning, encompassing financial and health care decisions (e.g. Representation Agreement) has been carried out.
Decisions need to be made and documented as to whether and when to pursue hospital admission and what are the options for care and the level of intervention.
Ensure that BiPAP (bilevel positive airway pressure device) is not overlooked.
Consultation with a specialist in respirology, palliative care or geriatric medicine may be helpful.
Advance care planning allows patients to plan for end of life care. Making decisions about the intensity of end of life care is a highly individualized process and requires continuous review as COPD progresses. Refer to the Resources section for resources on end of life care.
Rationale
COPD is a respiratory disorder largely caused by smoking. It is characterized by progressive, partially reversible airway obstruction and lung hyperinflation, systemic manifestations, and increasing frequency and severity of exacerbations.2
This guideline has been developed following review of the recommendations of the Canadian Thoracic Society and other international strategies for the management of COPD.2, 7-17 It is adapted for family physicians in British Columbia using the chronic care management approach.
According to administrative health services data from the BC Ministry of Health, approximately 73,000 individuals in British Columbia have been diagnosed with COPD (approximately 4.3% of British Columbians aged 45 years and older). The true prevalence is likely much higher as Burden of Obstructive Lung Disease study (BOLD) measured moderate to severe airflow obstruction indicative of COPD in 8.2% of the population of Vancouver aged 40 and over.20 Women account for about 47% of the cases.12
COPD is the only leading cause of death whose mortality rate continues to increase.20
A chronic disease and self-management approach directed by health professionals can significantly improve health status and reduce hospital admissions for exacerbations by 40%.13
References
Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26:948-968.
O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update. Can Respir J. 2007;14 Suppl B:5B-32B.
Singh S, Loke YK, Furberg C. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease. A systematic review and meta-analysis. JAMA. 2008;300(12):1439-1450.
Tashkin DP, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. New Engl J Med. 2008;359(15):1543-1554.
Nannini LJ, Cates CJ, Lasserson TJ, et al. Combined corticosteroid and long-acting beta-agonist in one inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2007;4:CD003794. DOI: 10.1002/14651858.CD003794.pub3
Tkác J, Man SFP, and D Sin. Review: Systemic consequences of COPD. Ther Adv Respir Dis. 2007(1); 47-59.
Sin DD. Is chronic obstructive airway disease really a cardiac disease? Can Respir J. 2008;15 Suppl C:20C.
Sin DD, McAlister FA, Man SFP, et al. Contemporary management of chronic obstructive pulmonary disease. Scientific review. JAMA. 2003;290(17):2301-2312.
Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet. 2003;362(9389):1053-61.
Celli BR. A 62-year–old woman with chronic obstructive pulmonary disease. JAMA. 2003;290:2721-2729.
National Institute for Clinical Excellence. Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical guideline 12. February 2004. Available at: http://www.nice.org.uk/CG012NICEguideline. Accessed November 16, 2009.
Camp PG, Chaudhry, Platt H, et al. The sex factor: Epidemiology and management of chronic obstructive pulmonary disease in British Columbia. Can Respir J. 2008; 15(8):417-22.
Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease. Arch Intern Med. 2003;163:585-591.
Curtis JR, Weinrich MD, Carline JD, et al. Patients’ perspectives on physician skill in end-of-life care. Chest. 2002; 122:356-362.
Stockley RA, Whitehead PJ, Williams MK. Improved outcomes in patients with chronic obstructive pulmonary disease treated with salmeterol compared with placebo/usual therapy: results of a meta-analysis. Respir Res. 2006;7:147.
Calverley PMA, Anderson JA, Celli MB, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. NEJM. 2007;356:775-89.
Barr RG, Bourbeau J, Camargo CA, et al. Tiotropium for stable chronic obstructive pulmonary disease: a meta analysis. Thorax. 2006;61:854-862.
Decramer M. Tiotropium as essential maintenance therapy in COPD. Eur Respir Rev. 2006;15(99):51-57.
Wedzicha JA, Calverley PMA, Seemungal TA, et al. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Resp Crit Care Med. 2008;177:19-26.
Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prevalence of COPD (The BOLD Study): a population-based prevalence study. Lancet. 2007;370(9589):741-50.
Jemal A, Ward E, Hao Y, et al. Trends in the leading causes of death in the United States,1970-2002. JAMA. 2005;294(10): 1255-1259.
Resources
The BC Palliative Care Consultation Line 1-877-711-5757 offers advice from a palliative care physician on symptom management, 24 hours per day, 7 days per week.
Detailed strategies to assist physicians with end of life care can be found at the American College of Chest Physicians website: www.chestnet.org
Other resources for end of life care can be found at www.lung.ca and at the Ottawa Health Research Institute: http://decisionaid.ohri.ca/decaids.html (Making Choices: The Use of Intubation and Mechanical Ventilation for Severe Chronic Pulmonary Disease)
This guideline is based on scientific evidence current as of the effective date.
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.
The principles of the Guidelines and Protocols Advisory Committee are to:
encourage appropriate responses to common medical situations
recommend actions that are sufficient and efficient, neither excessive nor deficient
permit exceptions when justified by clinical circumstances.
Disclaimer
The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.
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