This is an updated guideline from NICE on the diagnosis and management of COPD, published in Dec 18. It's a pretty mammoth guideline, first written in 2004.
There is a useful flow chart on management. One for the wall...
There is a separate guideline on antibiotic prescribing in COPD, which I have done another post on.
I will outline the main changes in management and things I had forgotten, rather than summarising the whole guideline. The most important changes are:
- Knowing what to do if signs of COPD show up on a CXR or CT Scan.
- Which inhalers to use in which patients.
Diagnosis - what tests should be done
Everyone should have the following tests done:
Other investigations that may be indicated:
- sputum culture.
- serial peak flows (if asthma is considered).
- ECG / BNP / Echo (if cardiac disease may be playing a part).
- CT (if bronchiectasis or fibrosis are suspected).
- serum alpha-1-antitrypsin (beware younger people, or those with a family history of lung and liver disease).
- transfer factor for carbon monoxide (TLCO - if the symptoms are disproportionate to the spirometry results). This is a measure of the efficacy of the lungs in gas exchange.
What should you do if changes of COPD are seen on CXR or CT scan?
Be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer, even if spirometry is normal and the patient has no signs or symptoms of disease and even if they have stopped smoking.
Assess the patient and perform spirometry.
If they are a current smoker and have normal spirometry and no signs or symptoms of COPD then:
- Offer smoking cessation.
- Warn that they are at higher risk of lung disease.
- Advise them to return if they develop lung symptoms.
If they are not a current smoker and have normal spirometry and no signs or symptoms of COPD then:
- Ask about a history, or family history of lung or liver disease. Consider other diagnoses, like alpha-1-antitrypsin deficiency.
- Reassure the patient that their condition is unlikely to get worse.
- Advise them to return if they develop lung symptoms.
What is the prognosis?
The following features are associated with prognosis:
- Smoking status
- Breathlessness (MRC scale)
- Chronic hypoxia / cor pulmonale
- Low BMI
- Severity and frequency of exacerbations
- Hospital admissions
- Symptoms burden (eg CAT score)
- Exercise capacity (eg 6 min walk test)
- TLCO (transfer factor for carbon monoxide)
- Whether needs home O2 or home non-invasive ventilation
Please remember that this isn't a full summary - I am giving an outline of what is new in this guidance.
What lifestyle advice should we be giving patients?
Alongside all the normal advice we give to patients with COPD, we should advise them of the following things.
Factors that may increase their risk of an exacerbation:
- smoking or passive smoking.
- viral or bacterial infections.
- indoor and outdoor air pollution.
- lack of physical exercise.
- seasonal variation in risk (ie higher in winter and spring).
What advice should we give patients to help them self-manage exacerbations?
Patients should have a written self-management plan which advises that:
- They should take their steroids if they have shortness of breath interfering with their life.
- They should take their antibiotics if their sputum is purulent and increases in volume or thickness beyond their normal day to day variation.
- They should adjust their SABA (short acting bronchodilator) use to treat their symptoms.
The British Lung Foundation has useful downloads for self-management plans.
Patients should have steroids and antibiotics at home if:
- they have had an exacerbation in the last year and remain at risk of more.
- they know when and how to use them.
- they know to inform their health care professional when they have used them and the need for more.
NICE advises that if a patient has used more than 3 courses of antibiotics and / or steroids in a year, we should look into the reasons why.
What inhalers should be used in the management of COPD?
1. SAMA (short acting muscarinic antagonist) or SABA PRN first line.
2. Step up treatment should be used if: they continue to have SOB or exacerbations despite being offered smoking cessation, having optimised non-pharmacological measures (eg vaccinations etc) and using SAMA or SABA. Use either (depending on the criteria below):
- LABA + LAMA OR
- Consider LABA + ICS
3. LABA + LAMA + ICS. This should only be used if they have asthmatic features, or features suggestive of steroid responsiveness and if they remain breathless despite using LABA + ICS.
How do you decide between LABA + LAMA or LABA + ICS?
LABA + LAMA if:
- They do not have features of asthma nor features suggestive of steroid responsiveness.
LABA + ICS if:
- They have asthmatic features or features suggestive of steroid responsiveness.
They do advise that if people are already established on combinations of inhalers which are working for them, that we do not need to change them.
What factors should you consider when prescribing inhalers?
- How much they improve symptoms.
- Person's preferences.
- Ability to use the inhaler.
- Drug's potential to reduce exacerbations.
- Minimise the numbers of inhalers and the different kinds of inhalers where possible.
What advice should we give about spacer care?
Don't clean them more than monthly as they can build up static, which can affect their performance.
Wash them in warm water with washing up liquid and leave them to drip dry.
What oral medications can be used?
The change in this section is on the advice around azithromycin. They advise that we consider asking for a specialist opinion before starting azithromycin. As I suspect that most of us won't be initiating this ourselves, I haven't gone into more detail on this, but be aware that there are a lot of criteria around when to start it and things to make sure you do before starting.
So what oral drugs can be used?
- Oral corticosteroids.
- Oral phosphodiesterase-4 inhibitors. There is separate guidance on the use of these. They should be initiated by a specialist and are to be used in people who have severe COPD and who are getting frequent exacerbations.
What else is new in the guideline?
There are a few other new details in the guideline, but most of the rest hasn't changed.
- Lung reduction therapy. This should be considered after any pulmonary rehab or at other reviews in people with severe COPD if they remain breathless.
- Telehealth. This shouldn't be offered routinely for the monitoring of the physical status of people with stable COPD.
- Starting home oxygen. We should counsel both the patient and their family about the risks of using home oxygen. This should include the risk of falls and trips over the equipment and the risk of burns and fires, especially if people continue to smoke or use e-cigarettes. Patients should not be offered home O2 if they continue to smoke.