Transcript Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease
What will we cover?
• Diagnosis
• Management of stable COPD
• Management of exacerbations of COPD
What’s new?
NICE CG 101 June 2010
(partial update to CG 12)
What does the guidance cover?
NICE Clinical Guideline 101, June 2010
• Diagnosis
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Symptoms
Spirometry
Assessment of severity
Referral for specialist advice
• Management of stable COPD
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Smoking cessation
Inhaled therapy
Oral therapy
Oxygen therapy
Pulmonary hypertension and cor
pulmonale
Pulmonary rehabilitation
Vaccination and anti-viral therapy
Lung surgery
Multidisciplinary management
Fitness for general surgery
• Management of exacerbations
– Definition of an exacerbation
– Assessment and need for hospital
treatment
– Investigation of an exacerbation
– Hospital-at-home and assisted
discharge schemes
– Pharmacological management
– Non-invasive ventilation
– Invasive ventilation
– Respiratory physiotherapy
– Monitoring recovery
– Discharge planning
Diagnosis
Working definition of COPD
NICE Clinical Guideline 101, June 2010
• COPD is characterised by airflow obstruction that is not fully reversible
– Airflow obstruction defined as FEV1/FVC ratio <0.7
– If FEV1 is ≥ 80% predicted, diagnosis requires respiratory symptoms eg
breathlessness or cough
• “There is no single diagnostic test for COPD. Making a diagnosis relies on
clinical judgement based on a combination of history, physical
examination and confirmation of the presence of airflow obstruction using
spirometry”
– All health professionals involved in the care of people with COPD
should have access to spirometry and be competent in the
interpretation of results
Diagnosing COPD
NICE Clinical Guideline 101, June 2010
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Consider a diagnosis of COPD in patients over the age of 35 who have a risk factor
(generally smoking) and who present with one or more of the following symptoms:
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Exertional breathlessness
Chronic cough
Regular sputum production
Frequent winter ‘bronchitis’
Wheeze
Also ask about:
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Weight loss
Effort intolerance
Waking at night
Ankle swelling
Fatigue
Occupational hazards
Chest pain
Haemoptysis
Use the MRC dyspnoea scale for grading the
degree of a patient’s breathlessness
NICE Clinical Guideline 101, June 2010
Grade
Degree of breathlessness related to activities
1
Not troubled by breathlessness except on strenuous exercise
2
Short of breath when hurrying or walking up a slight hill
3
Walks slower than contemporaries on level ground because of
breathlessness, or has to stop for breath when walking at own
pace
4
Stops for breath after walking about 100 metres or after a few
minutes on level ground
5
Too breathless to leave the house, or breathless when dressing
or undressing
Spirometry in COPD
NICE Clinical Guideline 101, June 2010
• Spirometry should be performed
– At the time of diagnosis
– To reconsider the diagnosis, if patients show an exceptionally good
response to treatment
• Measure post-bronchodilator spirometry to confirm diagnosis of COPD
• Consider alternative diagnoses or investigations in:
– Older people without typical symptoms of COPD where the FEV1/FVC
ratio is < 0.7
– Younger people with symptoms of COPD where the FEV1/FVC ratio is ≥
0.7
• In most patients routine reversibility testing is not necessary as part of the
diagnostic process or to plan initial therapy. It may be unhelpful or
misleading
Further investigations at diagnosis
NICE Clinical Guideline 101, June 2010
• At the time of initial diagnostic evaluation in addition to spirometry all
patients should have:
– A CXR to exclude other pathologies
– A FBC to identify anaemia or polycythaemia
– A BMI calculated
• Additional investigations should be performed to aid management in
some circumstances:
– PEFR (to exclude asthma if doubt remains)
– ECG (to assess cardiac status if features of cor pulmonale)
Clinical features differentiating COPD and asthma
NICE Clinical Guideline 101, June 2010
Feature
COPD
Asthma
Nearly all
Possibly
Rare
Often
Common
Uncommon
Persistent and
progressive
Variable
Night time waking with
breathlessness and/or
wheeze
Uncommon
Common
Significant diurnal or
day-to-day variability of
symptoms
Uncommon
Common
Smoker or ex-smoker
Symptoms under age 35
Chronic productive
cough
Breathlessness
Diagnosis still in doubt?
NICE Clinical Guideline 101, June 2010
• Repeated observations of patients over time should be used to help
differentiate COPD and asthma
• The following findings should be used to help identify asthma:
– A large (> 400ml) response to bronchodilators
– A large (> 400ml) response to 30mg oral prednisolone daily for 2
weeks
– Serial peak flow measurements showing 20% or greater diurnal or dayto-day variability
• Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio
return to normal with drug therapy
Assessment of severity and prognostic features
NICE Clinical Guideline 101, June 2010
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Disability in COPD can be poorly reflected in the FEV1
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Assess severity by the degree of airflow obstruction and disability, the frequency of
exacerbations and the following prognostic factors:
– FEV1
– Transfer factor for CO (TLCO)
– Breathlessness (MRC scale)
– Health status
– Exercise capacity (eg 6 minute walk test)
– BMI
– Partial pressure of oxygen in arterial blood (PaO2)
– Cor pulmonale
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Calculate the BODE index to assess prognosis where its component information is currently
available
What is BODE?
Celli B, et al. NEJM 2004; 350: 1005-12
Points on the BODE scale
Component
Variable
BMI
0
1
2
3
BMI (kg/m²)
>21
≤21
Airway
Obstruction
FEV1 %
predicted
>65
50-64
36-49
≤35
Dyspnoea
MRC scale
1-2
3
4
5
Exercise
capacity
Distance (m)
walked in 6
min
≥350
250-349
150-249
≤149
Assessment and classification of airflow obstruction
NICE Clinical Guideline 101, June 2010
NICE CG 12
2004
Postbronchodilator
FEV1/FVC
FEV1 %
predicted
< 0.7
≥ 80%
<0.7
50-79%
<0.7
<0.7
GOLD 2008
NICE CG 101
2010
Post-bronchodilator
Stage 1 (mild)
Stage 1 (mild)*
Mild
Stage 2
(moderate)
Stage 2
(moderate)
30-49%
Moderate
Stage 3
(severe)
Stage 3
(severe)
< 30%**
Severe
Stage 4
(very severe)
Stage 4
(very severe)
•*Symptoms should be present to diagnose COPD in people with mild airflow
obstruction
•**Or FEV1 <50% with respiratory failure
Follow up of patients in primary care
NICE Clinical Guideline 101, June 2010
Mild / moderate / severe
(Stages 1 to 3)
Very severe
(Stage 4)
Frequency
At least annual
At least twice per year
Clinical assessment
Smoking status and desire to
quit
Adequacy of symptom control
Presence of complications
Effects of drug treatment
Inhaler technique
Need for referral to specialist
and therapy services
Need for pulmonary
rehabilitation
As stages 1 to 3 plus:
Presence of cor pulmonale
Need for long-term oxygen
therapy (LTOT)
Nutritional state
Presence of depression
Need for social services and
occupational therapy input
Measurements to make
FEV1 and FVC
Calculate BMI
MRC dyspnoea scale
As stages 1 to 3 plus SaO2
Referral for specialist advice
NICE Clinical Guideline 101, June 2010
Reasons for referral include:
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Diagnostic uncertainty
Suspected severe COPD
Patient requests a second opinion
Onset of cor pulmonale
Assessment for oxygen therapy
Assessment for long-term
nebuliser therapy
Assessment for oral
corticosteroid therapy
Bullous lung disease
Rapid decline in FEV1
Assessment for pulmonary
rehabilitation
• Assessment for lung volume
reduction surgery
• Assessment for lung
transplantation
• Dysfunctional breathing
• Onset of symptoms <40 years or a
family history of alpha-1
antitrypsin deficiency
• Uncertain diagnosis
• Symptoms disproportionate to
lung function deficit
• Frequent infections
• haemoptysis
Multidisciplinary management
NICE Clinical Guideline 101, June 2010
•
“...breaking down historic demarcation of roles...Competencies are more
important than professional boundaries”
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Guidance on activity of MDT and specifically:
– Respiratory nurse specialists
– Physiotherapy
– Identifying and managing anxiety and depression
– Nutritional factors
– Palliative care
– Assessment for occupational therapy
– Social services
– Advice on travel
– Education
– self-management
Summary
Diagnosis
• New NICE guidance June 2010
• Key priorities in diagnosing COPD:
– Consider in people >35 years who have a risk factor (generally
smoking) with symptoms
– Post-bronchodilator spirometry to confirm diagnosis; reversibility
testing usually not necessary
• New NICE classification of severity of airflow obstruction
• New recommendations on assessment of severity
Management of stable COPD
Management of stable COPD
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Smoking cessation
Inhaled therapy
Oral therapy
Oxygen therapy
Pulmonary hypertension and cor pulmonale
Pulmonary rehabilitation
Vaccination and anti-viral therapy
Lung surgery
Multidisciplinary management
Fitness for general surgery
What’s new?
NICE Clinical Guideline 101, June 2010
• Previous NICE guidance had separate recommendations on bronchidilators
and inhaled corticosteroids for:
– Symptom control
– Reduction in risk of exacerbations
• The current guidance combines and revises these recommendation for
– SABA
short acting beta2 agonist(s)
– LABA
long acting beta2 agonist(s)
– SAMA
short acting muscarinic antagonist(s)
– LAMA
long acting muscarinic antagonist(s)
– ICS
Inhaled corticosteroid(s)
Smoking cessation
NICE Clinical Guideline 101, June 2010
• Document an up to date smoking history, including pack years smoked, for
everyone with COPD
Pack years = no cigarettes smoked per day x no years smoked
20
• Encourage all COPD patients still smoking to stop, and offer help to do so,
at every opportunity
• Unless contraindicated, offer NRT, varenicline or bupropion as appropriate,
combined with an appropriate support programme
Stop smoking
NICE Clinical Guideline 101, June 2010
National Knowledge Week for COPD 2008. Available from www.library.nhs.uk
• Approximately 80% of COPD is caused by smoking
• Getting patients with COPD to stop smoking is one of the single most
important interventions
• Stopping smoking slows the rate of decline in FEV1 with consequent
benefits in terms of progression of symptoms and survival
• Campaigns aimed at smokers need to emphasise link between smoking
and COPD
Inhaled therapy – assessing response
NICE Clinical Guideline 101, June 2010
• The effectiveness of bronchodilator therapy should not be assessed by
lung function alone but should include a variety of other measures such as
improvement in:
– Symptoms
– Activities of daily living
– Exercise capacity
– Rapidity of symptoms relief
• The choice of drug should take into account:
– Person’s symptomatic response and preference
– Drug’s potential to reduce exacerbations
– Side-effects
– Costs
Inhaled therapy – what device?
NICE Clinical Guideline 101, June 2010
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In most, bronchodilators are best administered using a hand-held inhaler (with spacer is
appropriate)
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Prescribe inhalers only after patients have been trained in their use and demonstrated
satisfactory technique
– Assess ability regularly and re-teach if necessary
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Consider patients for nebulisers if they are on maximal inhaler therapy but still have
distressing or disabling breathlessness
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Continue with nebulisers if there is one or more of:
– Reduction in symptoms
– Increased ability to undertake activities of daily living
– Increased exercise capacity
– Improvement in lung function
Inhaled therapy – level 1
Breathlessness and exercise limitation
NICE Clinical Guideline 101, June 2010
• SABA (salbutamol)
• or
• SAMA (ipratropium) as required
• Short-acting bronchodilators, as necessary, should be the empirical
treatment for the relief of breathlessness and exercise limitation
• Should we offer a SABA or SAMA first?
• Is it worth swapping if the first one doesn’t work?
Should I offer a SABA or a SAMA first?
Efficacy
Safety
No clear evidence for a difference of
efficacy
Possible but uncertain CV safety signal
with ipratropium
Cost
Patient factors
Differentials depend on dose and device
used
Particular inhaler devices may be more or
less suitable for individuals
Is it worth swapping if the first option chosen
doesn’t work?
• NICE doesn’t address this
• Seems a reasonable approach
• Choice for individuals probably depends most on:
– Which device they can use
– Which drug they tolerate best
– How effective it is for their symptoms
Inhaled therapy – level 2a
Mild to moderate disease
NICE Clinical Guideline 101, June 2010
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Offer a LABA (salmeterol) or LAMA (tiotropium) to people who:
– Remain breathless or have exacerbations despite SABA or SAMA as required
and
– Have FEV1 ≥ 50% predicted
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Use a LAMA in preference to regular 4x daily SAMA if regular therapy with an
antimuscarinic is chosen
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Those started on a LABA can continue with their SABA or SAMA
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Those started on a LAMA should stop their SAMA (if they were using one)
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Should we use a LABA or LAMA?
Is it worth swapping between LABA and LAMA is the first one tried doesn’t work?
Should we offer a LABA or LAMA first?
Efficacy
Safety
No clear evidence of a difference
Previous concerns about CV safety of both
classes now not thought to be valid
Cost
Patient factors
Differences in acquisition costs
Different inhaler devices may be more or
less suitable for individuals
Is it worth swapping if the first option chosen doesn’t work?
• NICE does not address this
• Seems a reasonable approach
Inhaled therapy – level 2b
Severe to very severe disease
NICE Clinical Guideline 101, June 2010
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Offer a LABA + ICS combination inhaler (symbicort), or LAMA to people with stable
COPD who:
– Remain breathless or have exacerbations despite SABA or SAMA as required and
– Have FEV1 <50% predicted
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Use a LAMA in preference to regular 4x daily SAMA if regular therapy with an
antimuscarinic is chosen
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Those started on a LABA + ICS can continue with their SABA or SAMA
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Those started on a LAMA should stop their SAMA (if they were using one)
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Should we offer a LABA + ICS or a LAMA?
Is it worth swapping if the first option chosen does not work?
What are the risks of ICS?
What about LABA + LAMA
Inhaled corticosteroids – what does NICE say?
NICE Clinical Guideline 101, June 2010
• Oral corticosteroid reversibility tests do not predict response to ICS
– Do not use them to identify which patients should be prescribed ICS
• Be aware of the potential risk of developing side effects (including nonfatal pneumonia) in people with COPD treated with ICS and be prepared to
discuss with patients
Should we offer a LABA + ICS or a LAMA first?
Efficacy
Safety
Data from INSPIRE. Primary outcome: no
significant difference in exacerbations
requiring oral corticosteroids or
antibiotics or hospitalisations
Secondary outcomes include reduction in
all-cause mortality and 2 point benefit in
SGRQ from LABA + ICS vs LAMA
ICS increase risk of pneumonia compared
with LABA alone
Possible systemic risks of ICS eg adrenal
suppression, BMD, ocular effects etc Give
steroid card?
Uncertainty regarding worsening of COPD
if ICS discontinued
Reassurance over tiotropium CV safety
Cost
Patient factors
Comparative cost-effectiveness uncertain. Different inhaler devices may be more or
LABA + ICS has higher acquisition costs
less suitable for individuals
Inhaled therapy – level 3
NICE Clinical Guideline 101, June 2010
• For people with stable COPD and FEV1 ≥ 50% predicted who are using a
LABA and who remain breathless or have exacerbations
– Consider a LABA + ICS combination inhaler (less strong evidence)
– Consider LAMA + LABA if ICS declined or not tolerated (less strong
evidence)
• Irrespective of FEV1 if person is breathless or has exacerbations
– Offer LAMA + LABA + ICS for those on LABA + ICS (strong evidence)
– Consider LAMA + LABA + ICS for those on LAMA (less strong evidence
Other therapies and
interventions
Oral corticosteroids
NICE Clinical Guideline 101, June 2010
• Maintenance use of oral corticosteroid therapy in COPD is not normally
recommended
• If oral steroids cannot be withdrawn following an exacerbation in patients
with advanced COPD, keep the maintenance dose as low as possible
• Monitor patients with long-term oral corticosteroid therapy for the
development of osteoporosis and give appropriate prophylaxis
• Start patients over the age of 65 on prophylactic treatment without
monitoring
Oral theophylline
NICE Clinical Guideline 101, June 2010
•
Use theophylline only after a trial of short-acting and long acting bronchodilators,
or in patients who are unable to use inhaled therapy
– Use a slow-release formulation
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Use with caution in the elderly
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Assess effectiveness of the treatment by improvements in:
– Symptoms
– Activities of daily living
– Exercise capacity
– Lung function
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Reduce the dose if interacting drugs are prescribed
– Examples antibiotics used to treat exacerbations
Mucolytics
NICE Clinical Guideline 101, June 2010
• Consider in patients with a chronic cough productive of sputum
• Continue if there is symptomatic improvement (eg reduction in cough
frequency and sputum production)
• Do not routinely use to prevent exacerbations in people with stable COPD
What about beta-blockers?
• BNF 60 Sept 2010
– “When there is no suitable alternative, it may be necessary for a
patient with well controlled asthma, or COPD (without significant
reversible airways obstruction) to receive treatment with a betablocker for a co-existing condition (eg heart failure, post-MI)”...a
cardioselective beta-blocker should be initiated at a low dose by a
specialist, and the patient monitored for adverse effects
• DTB 2011, 49(1): 2-5
– “Observational studies indicate that cardioselective beta-blockers can
be used in patients with COPD with mild to moderate airflow
obstruction without impairing lung function or response to betaagonists, and such use may reduce hospitalisation and mortality”
Long term oxygen therapy (LTOT)
NICE Clinical Guideline 101, June 2010
• Inappropriate O2 therapy in people with COPD may cause respiratory
depression
• Pulse oximetry should be available in all healthcare settings
• Indicated if PaO2 < 7.3kPa when stable or < 8kPa when stable and one of:
– Secondary polycythaemia
– Nocturnal hypoxaemia (SaO2 < 90% for > 30% of the time)
– Peripheral oedema
– Pulmonary hypertension
• Patients should breaths supplemental O2 at least 15 hours per day,
preferably 20 hours per day
•
Assess need for O2 therapy in people with:
– Very severe COPD (FEV1 < 30% predicted)
– Cyanosis
– Polycythaemia
– Peripheral oedema
– Raised JVP
– O2 saturations ≤ 92% when breathing air
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Consider assessment in those with severe COPD (FEV1 30-49% predicted)
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Assessment should comprise two arterial blood gas measurements at least 3
weeks apart
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Review annually, including pulse oximetry
Ambulatory and short burst oxygen
NICE Clinical Guideline 101, June 2010
• Ambulatory oxygen therapy:
– People on LTOT who wish to continue O2 away from home
– People with exercise desaturation whose exercise capacity and/or
dyspnoea improve with O2
– Only after specialist assessment
• Short-burst oxygen therapy:
– Only for severe breathlessness not relieved by other treatments
– Only if improvement documented
Pulmonary hypertension and cor pulmonale
NICE Clinical Guideline 101, June 2010
•
Consider cor pulmonale if patients have:
– Peripheral oedema
– Raised JVP
– Systolic parasternal heave
– A loud pulmonary 2nd heart sound
•
Assess patients with cor pulmonale for LTOT
•
Oedema associated with cor pulmonale can usually be controlled symptomatically with
diuretic therapy
•
The following are not recommended for the treatment of cor pulmonale:
– ACE inhibitors
– Calcium channel blockers
– Alpha-blockers
– Digoxin (unless there is AF)
Pulmonary rehabilitation
NICE Clinical Guideline 101, June 2010
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Includes multicomponent, multidisciplinary interventions, which are tailored to
the individual patient’s needs including:
– Physical training
– Disease education
– Nutritional, psychological and behavioural intervention
•
Should be made available to all appropriate people with COPD including those
who have had a recent hospitalisation for an acute exacerbation
•
Should be offered to all patients who consider themselves functionally disabled by
COPD (usually MRC grade ≥ 3)
•
Is not suitable who:
– Are unable to walk
– Have unstable angina
– Have had a recent MI
Other issues in management
NICE Clinical Guideline 101, June 2010
• Offer pneumococcal and annual influenza immunisation
• Consider bullectomy, lung volume reduction surgery or lung
transplantation in selected patients
• Do not use alpha-1 antitrypsin replacement therapy in patients with
deficiency
• Review patients with COPD at least annually and twice yearly in those with
very severe COPD
Palliative care in end-stage COPD
NICE Clinical Guideline 101, June 2010
• Use opiates appropriately for the palliation of breathlessness in end-stage
COPD
• Use benzodiazepines, tricyclics, major tranquillisers and O2 where
appropriate
• Involve multidisciplinary palliative care teams
Multidisciplinary management
NICE Clinical Guideline 101, June 2010
•
“...breaking down historic demarcation of roles...competencies are more important
than professional boundaries”
•
Guidance on activity of multidisciplinary team and specifically:
– Respiratory nurse specialists
– Physiotherapy
– Identifying and managing anxiety and depression
– Nutritional factors
– Palliative care
– Assessment for occupational therapy
– Social services
– Advice on travel
– Education
– Self-management
Managing exacerbations of COPD
Management of exacerbations
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Definition of an exacerbation
Assessment and need for hospital treatment
Investigation of an exacerbation
Hospital-at-home and assisted discharge schemes
Pharmacological management
Non-invasive ventilation
Invasive ventilation
Respiratory physiotherapy
Monitoring recovery
Discharge planning
Definition of an exacerbation
NICE Clinical Guideline 101, June 2010
• A sustained worsening of the patient’s symptoms from his or her usual
stable state that is beyond normal day-to-day variations, and is acute in
onset
• Commonly reported symptoms are:
– Worsening breathlessness
– Cough
– Increased sputum production
– Change in sputum colour
Self-management of exacerbations
NICE Clinical Guideline 101, June 2010
• Give self-management advice to respond promptly to the symptoms of an
exacerbation by:
– Start oral corticosteroids if increased breathlessness interferes with
activities of daily living
– Start antibiotics if sputum is purulent
– Adjust bronchodilator therapy to control symptoms
– Contact a healthcare professional if they do not improve
• Give patients a course of antibiotics and corticosteroids to keep at home
for use as part of a self-management plan
– Monitor appropriate use
Investigation and management of exacerbations
NICE Clinical Guideline 101, June 2010
• Diagnosis is made clinically and does not depend on the results of
invesigations
• In primary care
– Routine sputum culture is not recommended
– Pulse oximetry valuable if clinical features of severe exacerbation
• More extensive investigations in patients managed in hospital
• Use hospital-at-home and assisted-discharge schemes as an alternative for
patients who would otherwise need to be admitted or stay in hospital
Treat in hospital or at home?
NICE Clinical Guideline 101, June 2010
Treat at home
Treat in hospital
Able to cope at home
Yes
No
Breathlessness
Mild
Severe
General condition
Good
Poor / deteriorating
Level of activity
Good
Poor / confined to bed
Cyanosis
No
Yes
Worsening peripheral oedema
No
Yes
Level of consciousness
Normal
Impaired
Already receiving LTOT
No
Yes
Good
Living alone / not coping
Acute confusion
No
Yes
Rapid rate of onset
No
Yes
Significant comorbidity
No
Yes
SaO2 <90%
No
Yes
Social circumstances
Drug management of exacerbations
NICE Clinical Guideline 101, June 2010
• Use nebuliser or hand-held inhalers for inhaled therapy
– Change to hand-held inhalers as soon as condition stablises
– Always state driving gas for nebulised therapy
• Oral corticosteroids
– Use in all admitted to hospital
– Consider in community if significant increase in breathlessness
– Prednisolone 30mg daily for 7-14 days
Drug management of exacerbations
NICE Clinical Guideline 101, June 2010
• Antibiotics
– More purulent sputum
– Consolidation on CXR
– Clinical signs or pneumonia
• IV theophylline only if inadequate response to nebulised bronchodilators
• Doxapram only if non-invasive ventilation (NIV) unavailable or
inappropriate
Other aspects of management of exacerbations
NICE Clinical Guideline 101, June 2010
• Oxygen therapy
– Monitor saturation if can’t do blood gases
– Give oxygen if necessary
– All healthcare professionals involved in care should have access to
pulse oximeters
• Non-invasive ventilation (NIV)
• Invasive ventilation and intensive care
– Treatment of choice for persistent hypercapnic ventilatory failure
during exacerbations
• Respiratory physiotherapy
• Monitoring recovery
• Discharge planning
Summary - managing exacerbations
• Frequency of exacerbations should be reduced by:
– Effective inhaled therapy
– Vaccinations
• Impact of exacerbations should be minimised by:
– Giving self-management advice on responding promptly to the
symptoms of an exacerbation
– Starting appropriate treatment with oral steroids and/or antibiotics
– Use of non-invasive ventilation when indicated
– Use of hospital-at-home or assisted-discharge schemes