1. The COPD-X Plan: Australia and New Zealand guidelines for the management of COPD Presentation Authors: COPD National Program Executive Committee A/Professor Ian Yang, Professor Peter Frith, Professor Christine McDonald, Dr Kerry Hancock, Dr Julia Walters, Mrs Liz Harper Presenter: Dr Bajee Krishna Sriram

2. Affiliations

3. Overview Present Australian COPD clinical guidelines Stepwise diagnosis and management of patients with COPD Available resources for primary care Action points: Register on www.copdx.org.au to receive the updated COPD-X guidelines and the new handbook to be released soonwww.copdx.org.au Use Stepwise Management of Stable COPD Use COPD Action Plan Use COPD Assessment Tool (CAT) Use Lung Health Checklist Use Lung Foundation Australia resources for COPD

4. www.copdx.org.au New GP Handbook coming soon: COPD-X Concise Guide for Primary Care Register now on www.copdx.org.au to receive an email update as soon as it is availablewww.copdx.org.au

5. Australian COPD-X guidelines C Case ID & Confirmdiagnosis OOptimisefunction PPreventdeterioration DDevelopsupport network & self management plan XeXacerbationsmanagement COPD-X Concise Guide for Primary Care (due October 2013)

6. Chronic Obstructive Pulmonary Disease A common preventable and treatable disease Characterised by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients Spirometry

7. Case Identification

8. Case Finding – General Practice and Pharmacy Lung Health Checklist Piko6 or COPD6 Cough Sputum Chest infections Dyspnoea

9. Confirm Diagnosis

10. www.copdx.org.au

11. Diagnosis of COPD Gold Standard Test – Spirometry Cough Sputum Chest infections Dyspnoea

12. Spirometry (example of volume-time curve) Expired volume (litres) Forced vital capacity FVC 4.3 L FEV 1 3.5 L Forced expiratory volume in 1 sec

13. Examples of spirograms and flow-volume loops From: Johns and Pierce 2008: Spirometry (National Asthma Council)

14. Severity of disease (Australian guidelines) Diagnosis: Post-bronchodilator airflow obstruction that is not fully reversible

15. Investigations SpirometryPre- and post-bronchodilator Gas transferDetect emphysema physiologically Chest X-rayExclude other causes of dyspnoea 6 min walk Measure exercise capacity & desaturation SputumMicroscopy, culture, sensitivity Arterial Blood Measure gas exchange & acid- base Gases (ABGs) status CT chestExclude other causes of dyspnoea (not needed in all patients)

16. Optimise Function

18. Global Strategy for Diagnosis, Management and Prevention of COPD Modified MRC (mMRC)Questionnaire

19. www.catestonline.org Cough Sputum Chest tightness Walking up hill ADLs Leaving the house Sleep Energy levels Scores 11-20 medium impact > 20 high impact

20. Non-pharmacological interventions Consider referral to Pulmonary Rehabilitation for patients who display exertional dyspnoea and after an exacerbation -Level 1 evidence for reducing dysnoea, fatigue, anxiety and depression and improving exercise capacity, emotional function and health related quality of life outcomes -Level II evidence for reducing hospital admissions

21. Relievers - Short-acting β2-agonists (SABAs) Acute onset (1-3 min) Short duration of action (4hr) Relaxation of airway smooth muscle by stimulating β2-adrenoceptors Use as needed Salbutamol (100 mcg, 2-4 inhalations PRN) Terbutaline (500 mcg, 1-3 inhalations PRN)

22. LABAs Long-acting β2-agonists (LABAs)- bd Slow onset – salmeterol (15-20 min) MDI 25 mcg AH 50 mcg Fast onset – eformoterol (1-3 mins) Long duration of action (12 h) Relaxation of airway smooth muscle by binding and occupying β2-adrenoceptors 6, 12 mcg TH 12 mcg Aerolizer, 12 mcg bd

23. Once a day LABA Once a day - Long-acting β2-agonists (LABAs) - indacaterol DPI 150 mcg, 300 mcg 150 to 300 mcg once daily Long duration of action (24hr) Relaxation of airway smooth muscle by binding and occupying β2-adrenoceptors

24. LAMA Long-acting muscarinic antagonist (LAMA) (long-acting anticholinergic) -Tiotropium (18mcg daily) Slow onset (30min) Long duration of action (24hr) Relaxation of airway smooth muscle by binding and occupying muscarinic M3 receptors

25. Combination inhalers (ICS/LABA) salmeterol/fluticasone MDI 250/25 2 inhalations bd AH 500/50 1 inhalation bd eformoterol/budesonide TH 400/12 mcg 1 inhalation bd Preventer + Controller

27. Prevent Deterioration

28. www.copdx.org.au

29. Smoking Cessation Brief intervention Counselling – behavioural intervention Nicotine replacement therapy Pharmacological agents – Varenicline – Bupropion RACGP smoking cessation guidelines www.racgp.org.au/your-practice/guidelines/smoking- cessation

30. Immunisations Annual influenza immunisations Pneumococcal immunisation every five years or as per the Australian Immunisation Handbook

31. Long-term Oxygen Therapy for COPD Position on continuous oxygen therapy Continuous oxygen therapy is indicated to improve survival and quality of life for: PaO 2 ≤ 55 mmHg at rest, or PaO 2 56-59 mmHg with right heart failure, pulmonary hypertension or polycythaemia Flow rate to maintain oxygen saturation >90% at rest Increase by 1L/min during: - Sleep - Exertion - Air travel TSANZ guidelines: McDonald et al, MJA 2005: 182: 621-626

32. Develop a plan of care

33. www.copdx.org.au

34. Lung Foundation Resources Primary Care Respiratory Toolkit – Spirometry Calculator – Lung age estimator Stepwise Management of Stable COPD COPD online, an interactive training program for primary care nurses Website listings – Pulmonary Rehabilitation program locations – Patient support groups – Lungs in Action exercise maintenance classes Patient Resources (fact sheets, brochures, Better Living Guide, Getting Started on O 2 ) Lung Health Checklist Pulmonary Rehab Toolkit NEW (soon) – COPD-X: Concise Guide for Primary Care

35. Respiratory Education Team (Multi-disciplinary Management of COPD) COPD knowledge and symptom awareness Symptom control Inhaler technique, delivery devices Written COPD action plan Self-management education COPD first aid Palliative and Supportive Care End of Life Discussions/ Advanced Care Planning

36. www.lungfoundation.com.au Or Call 1800 654 301 to have the editable pdf emailed directly to you Indigenous version also available When to start antibiotics and prednisolone

37. Support Teams Patient Support Groups & Family, friends GP, Practice Nurse Respiratory nurse specialist Respiratory educator Allied Health: Physiotherapist, Occupational therapist, Social worker, Psychologist, Dietitian, Speech therapist Respiratory Specialist Pharmacist – Home Medicine Reviews, Quality Use of Medicines Checks, Inhaler Technique Home Carers, Oxygen suppliers Pulmonary Rehabilitation Lungs in Action classes (post rehab)

38. Manage eXacerbations

39. www.copdx.org.au

40. Primary care management of exacerbations Tests: Oximetry Spirometry (if required) Chest x-ray (if clinically indicated) Sputum MCS Treatment: Bronchodilators e.g salbutamol 100mcg, 2-4 (up to 10) inhalations via spacer Oral steroids e.g. prednisolone 30-50mg, 7-14 days Antibiotics e.g. amoxycillin 500mg tds, 5 days or doxycycline, 100 mg bd, 5 days (or consider other antibiotics)

41. When do you refer to hospital? What is NIV? Who is likely to require ICU admission? What about referral to pulmonary rehabilitation after an exacerbation?

42. New GP Handbook coming in October: COPD-X Concise Guidelines for Primary Care Visit www.copdx.org.au and register to receive COPD-X pdf. This will register you for updates.www.copdx.org.au COPD-X Concise Guide for Primary Care is available in pdf in October. It contains key recommendations and grades the strength of recommendations and quality of evidence. Stepwise diagnosis and management of patients with COPD – also available to download as pdf from www.lungfoundation.com.au (single page summary) www.lungfoundation.com.au

43. Summary Actions COPD-x guidelines Lung Foundation Australia resources – COPD Action plan – Lung health checklist – Primary Care Respiratory Toolkit – COPD Online training for practice nurses – Database of Pulmonary Rehab programs – Database of Patient Support Groups – Database of Lungs in Action classes – Patient Education materials – 1800 654 301 – www.lungfoundation.com.au www.lungfoundation.com.au