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BCGuidelines.ca - By BC Physicians, for BC Physicians

Chronic Obstructive Pulmonary Disease (COPD)

Effective Date: January 1, 2011

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

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: 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: 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 (COPD))

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 prescribed a short-acting inhaled beta2 agonist or ipratropium to be used as needed.
  • If symptoms persist, then consider regular use of ipratropium or a long-acting bronchodilator (tiotropium or a long-acting beta2 agonist (LABA)).
  • If the patient continues to be symptomatic despite the addition of tiotropium or LABA, the other may be added.
  • Concurrent use of tiotropium and ipratropium is not recommended.
  • Regular use of inhaled corticosteroids could be added to combination tiotropium and LABA therapy for patients with moderate to severe COPD with a history of exacerbations (one or more per year, on average, for two consecutive years) to reduce exacerbations,2 or if asthma coexists. Long term oral corticosteroid therapy is not recommended.
  • If indications for both a LABA and an inhaled corticosteroid exist, then consider a combination product containing both medications.
  • Theophylline may be useful in select patients with persistent symptoms despite optimal inhaled therapy.
  • Evaluate the patient's inhaler technique regularly. Consider prescribing a spacer for metered dose inhalers. Dry powder inhalers are not used with a spacer.

Controversies in care

  • Cohort and case-control studies have concluded that ipratropium has a small but consistent negative effect on cardiovascular safety.3,4,5 This has not been validated by a large RCT.
  • However, concerns of increased mortality and cardiovascular events with the use of tiotropium are not supported by the results of a large randomized controlled trial (RCT) and a pooled analysis.6,7
  • Large RCT's have not demonstrated the benefit of tiotropium combined with LABA compared to either agent alone.8,9
  • Retrospective analyses have shown an increased risk of pneumonia in COPD patients prescribed inhaled corticosteroids.10,11 This effect has been, in general, with higher doses of fluticasone but was not seen in a recent large individual patient systematic review of budesonide.12 The significance of the results are uncertain given the lack of standardization of the definition of pneumonia in these studies.

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

Table 2: Common Co-Morbidities with COPD

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, 14-24 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.25 Women account for about 47% of the cases.19

COPD is the only leading cause of death whose mortality rate continues to increase.25

A chronic disease and self-management approach directed by health professionals can significantly improve health status and reduce hospital admissions for exacerbations by 40%.20

References

  1. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26:948-968.
  2. 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(SupplB):5B-32B.
  3. Guite HF, Dundas R, Burney PG. Risk factors for death from asthma, chronic obstructive pulmonary disease, and cardiovascular disease after hospital admission for asthma. Thorax. 1999;54:301-307.
  4. Macie C, Wooldrage K, Manfreda J, et al. Cardiovascular morbidity and the use of inhaled bronchodilators. Int J Chron Obstruct Pulmon Dis. 2008;3(1):163-169.
  5. Ogale SS, Lee TA, Au DH, et al. Cardiovascular events associated with ipratropium bromide in COPD. Chest. 2010;137:13-19.
  6. Tashkin DP, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359(15):1543-1554.
  7. Celli B, Decramer M, Leimer I, et. al. Cardiovascular safety of tiotropium in patients with COPD. Chest. 2010;137:20-30.
  8. Vogelmeier C, Kardos P, Harari S, et al. Formoterol mono- and combination therapy with tiotropium in patients with COPD: a 6-month study. Resp Med. 2008;102:1511-1520.
  9. Aaron SD, Vandenheen KL, Fergusson D, et al. Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease. Ann Int Med. 2007;146:545-555.
  10. Calverley PMA, Anderson JA, Celli B, et al. Salmeterol and Fluticasone Propionate and Survival in Chronic Obstructive Pulmonary Disease. N Engl J Med. 2007;356:775-789.
  11. Singh S, Loke YK, Furberg CD. Outpatient Management of Severe COPD. N Engl J Med. 2010;363(5):493-5.
  12. Sin D, Tashkin D, Zhang X, et. al. Budesonide and the risk of pneumonia: a meta-analysis of individual patient data. Lancet. 2009;374(9691):712-19.
  13. Tkác J, Man SFP, and D Sin. Review: Systemic consequences of COPD. Ther Adv Respir Dis. 2007(1);47-59.
  14. Sin DD. Is chronic obstructive airway disease really a cardiac disease? Can Respir J. 2008;15 (Suppl C):20C.
  15. Sin DD, McAlister FA, Man SFP, et al. Contemporary management of chronic obstructive pulmonary disease. Scientific review. JAMA. 2003;290(17):2301-2312.
  16. Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet. 2003;362(9389):1053-61.
  17. Celli BR. A 62-year-old woman with chronic obstructive pulmonary disease. JAMA. 2003;290:2721-2729.
  18. National Institute for Health and 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/nicemedia/pdf/CG012_niceguideline.pdf Accessed November 1, 2010.
  19. 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.
  20. 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.
  21. Curtis JR, Weinrich MD, Carline JD, et al. Patients' perspectives on physician skill in end-of-life care. Chest. 2002;122:356-362.
  22. 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.
  23. Calverley PMA, Anderson JA, Celli MB, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356:775-89.
  24. Barr RG, Bourbeau J, Camargo CA, et al. Tiotropium for stable chronic obstructive pulmonary disease: a meta analysis. Thorax. 2006;61:854-862.
  25. 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.

Resources

The BC Palliative Care Consultation Line 1-877-711-5757 offers advice for late stage disease, for physicians only, 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)

List of Abbreviations

AECOPD acute exacerbations of COPD
BiPAP bilevel positive airway pressure device
COPD chronic obstructive pulmonary disease
FEV1 forced expiratory volume in the first second
FVC forced vital capacity
LABA long-acting beta2 agonist
NNH number needed to harm
NNT number needed to treat
PaO2 partial pressure of oxygen in arterial blood
RCT randomized controlled trial
SABD short-acting bronchodilator
SpO2 percent oxygen saturation

Appendices

Associated Documents

The following documents accompany this guideline:

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.

Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site: www.BCGuidelines.ca

 

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