Presentation on theme: "Furnace House Surgery Chronic Obstructive Pulmonary Disease"— Presentation transcript:
1Furnace House Surgery Chronic Obstructive Pulmonary Disease ProtocolDate: 13th April 2005Review Date: April 2006Acknowledgement: Sarah Hicks
2Aims and objectives of this protocol. to improve COPD care in this Practiceto reduce emergency admissions to hospital due to COPDto improve quality of life in COPD patientsto improve patient educationto encourage patients to take responsibility for their own COPD management
3Definition of COPDA collection of conditions that share the features of chronic obstruction of expiratory flow, e.g. chronic bronchitis, emphysema, chronic obstructive airways disease, chronic airflow obstruction and some cases of chronic asthma which have resulted in irreversible lung destruction.slow progressive condition characterised by marked airways obstruction that does not change markedly over time.
4Each patient will have varying proportions of: Chronic bronchitis with increased and airway wall inflammation;small or peripheral airways disease increased mucus, airway wall thickening, scarring and narrowingemphysema permanent destruction of the alveoli, airspaces distal to the terminal bronchiole. On lung expansion, elastic recoil is reduced and pressure to drive expiration is lost. There is also a drop in intraluminal pressure needed to maintain airway patency during forced exhalation (demonstrated by lip pursing).
6Presentationsmoked for at least 20 pack yearsUsually present in the fifth decade with a productive cough or an acute respiratory complaint.By the sixth or seventh decade, exertional dyspnoea is usually a feature and intervals between acute exacerbations become shorterearlier stages, slow, laboured expiration, plus wheezing on forced expiration may be apparentCan result in hyperventilation and a gradual increase in the anteroposterior diameter of the chest.
7CausesThe underlying causes of COPD yet to be fully elucidated but include:cigarette smoking, with other types of tobacco smoking also being strong risk factorsheavy exposure to occupational dusts and chemicals (vapours, irritants and fumes)indoor and outdoor air pollution.Alpha-1 Antitrypsin Deficiency (very small minority)
8Disease classification severity of disease rather than presumed underlying causes. The objective measure used for this and monitoring progression of the disease is Forced Expiratory Volume in one second (FEV 1).Severity of Airflow Obstruction FEV1% predictedMild – 80Moderate – 49Severe <30
9Making a Diagnosis Think of a diagnosis of COPD for patients who are: Over 35 yearsSmokers or ex-smokersNo relevant pathology on chest XRayHave any of these symptomsexertional breathlessnesschronic coughregular sputum productionsfrequent winter bronchitiswheezePerform spirometry if COPD seems likely.
10At the time of their initial diagnostic evaluation, prior to spirometry, all patients should have: a chest radiograph to exclude other pathologiesa full blood count to identify anaemia or polycythaemiabody mass index (BMI) calculated.An Alpha-1 Antitrypsin test if there is early onset of symptoms, minimal smoking history or family history.
12The COPD ClinicAttendance at this clinic is initially instigated via the doctor but follow-up appointments will be generated by either the clinic nurse or the administrating assistant at a period suitable to the patient needs.The clinic will provide assessment of patient general health, in relation to their COPD, and spirometry testing for the purpose of an aid to either early diagnosis or management of the patients disease.The patient should be given the ‘Lung Function Test’ Patient Information Leaflet (can be located in ‘Patient Information Leaflets’ in Global Server) at least 1 week prior to any spirometry tests
13Initial Clinic Appointment. The following will take place at an initial clinic appointment:Spirometry to confirm diagnosisAssessment of smoking status and desire to quitIf applicableAdequacy of symptom control:BreathlessnessExercise toleranceEstimated exacerbation frequencyInhaler techniqueBody Mass IndexPulse oximetry (SaO2)Flu / Pneumonia immunisation status cont.
14Depression Assessment Dyspnoea ScoreCOPD Information LeafletReferral back to GP for regular 6 monthly follow-up if spirometry confirms COPD diagnosis
15Annual Clinic ReviewThe following will take place at a each follow-up clinic appointment:Patient education about COPD, effects of smoking and the disease progressionSmoking status, encouragement to stop and their desire to quit (Referral to Smoking Cessation Service if patient agreeable)Adequacy of symptom controlPresence of complicationsEffects of drug treatmentInhaler techniqueFEV1 and FVCPulse oximetry (SaO2)BMI and nutritional stateDyspnoea ScoreNeed for social services or occupational therapy inputNeed for referral to specialist and therapy servicesNeed for long-term oxygen therapyFlu / Pneumonia immunisation status
18Reversibility tests: differentiation of COPD from asthma Reversibility tests involve measuring spirometry before and after treatment and can help distinguish between COPD and asthma. Tests may include reversibility to bronchodilators (beta2 agonists or anticholinergics) or inhaled / oral steroids.Significant reversibility is defined as a rise in FEV1 that is both greater than 200ml and 15% of the pre-test value.Substantial reversibility (>400ml) indicates asthma.
20Mucolytics Mucolytic drug therapy should be considered in patients with a chronic cough productive of sputum.Mucolytic therapy should be continued if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production).
21Exacerbation in Primary Care Investigationsending sputum samples for culture is not recommended in routine practicepulse oximetry is of value if there are clinical features of a severe exacerbation.
22Cont.usually managed by taking increased doses of shortacting bronchodilators and these drugs may be given using different delivery systems.NB. Only if a patient is hypercapnic or acidotic should the nebuliser bedriven by compressed air, not oxygen (to avoid worseninghypercapnia). The driving gas for nebulised therapy shouldalways be specified in the prescription.
23cont. Exacerbations: Systemic Corticosteroids oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in breathlessness which interferes with daily activities.Prednisolone 30 mg orally should be prescribed for 7 to 14 days. It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy.Osteoporosis prophylaxis should be considered in patients requiring frequent courses of oral corticosteroids.Patients should be made aware of the optimum duration of treatment and the adverse effects of prolonged therapy.
24Cont. Exacerbations: Antibiotics Antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum.Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia.Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline. When initiating empirical antibiotic treatment, prescribers should always take account of any guidance issued by their local microbiologists.
25Cont. Exacerbations: Oxygen therapy during exacerbations of COPD The oxygen saturation should be measured in patients with an exacerbation of COPDIf necessary, oxygen should be given to keep the SaO2 greater than 90% but not above 93%.
26MRC Dyspnoea Score MRC Dyspnoea Score Grade Degree of breathlessness related to ActivitiesNot troubled by breathlessness except on strenuous exerciseShort of breath when hurrying on the level or walking up a slight hillWalks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own paceStops for breath after walking about 100m or after a fw minutes on the levelToo breathless to leave the house, or breathless when dressing or undressingReference:Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance ofrespiratory symptoms and the diagnosis of chronic bronchitis in a workingpopulation. British Medical Journal 2:257–66.
27DepressionHealthcare professionals should be alert to the presence of depression in patients with moderate to severe COPD. The presence of anxiety and depression should be considered in patients:who are hypoxic (SaO2 less than 92%)who have severe dyspnoeawho have been seen at or admitted to a hospital with anexacerbation of COPD.The presence of anxiety and depression in patients with COPD can be identified using validated assessment tools.Patients found to be depressed or anxious should be treated with conventional pharmacotherapy.For antidepressant treatment to be successful, it needs to be supplemented by spending time with the patient explaining why depression needs to be treated alongside the physical disorder.See depression scoreRef. Birchell et al (1989) The Depression Scoring Instrument (DSI): J Affect Disorder
28ReferencesChronic Obstructive Pulmonary Disease: National clinical guideline for management of Chronic Obstructive Pulmonary Disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): 1-232Chronic Obstructive Pulmonary Disease. A Boyter et al. Pharmaceutical Journal (vol 261) First UK Guidelines for Management of Chronic Obstructive Pulmonary Disease. Pharmaceutical Journal (Vol 259) NICE Guidelines (2004). Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 12. National Collaborating Centre for Chronic Conditions. London.Ref: British Thoracic Society. Guidelines for the Management of COPD. Thorax 1997;52 Suppl 5:51-28The Management of Chronic Obstructive Pulmonary Disease. MeReC 9(10) November 1998.