COPD - Diagnosing Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The diagnosis of COPD in primary care in Adults age 18+

This guidance does not cover:

  • Acute presentation of Lower Respiratory Tract Infection.
  • Patients presenting with potential exacerbation of COPD without prior diagnosis should be managed as per appropriate clinical guidance and an assessment and diagnosis confirmed during a period of stability

Assessment

History and Examination

  • Consider a diagnosis of COPD in those over 35 years If any of the following indicators are present:
    • Smoker or Ex-smoker
    • Breathlessness that is progressive over time, worse with exercise, persistent
    • Chronic cough that may be intermittent or unproductive
    • Chronic sputum production
    • Occupational exposure to dust or fumes
    • and have no clinical features of asthma - See Clinical Features of Asthma & COPD

If considering COPD, perform quality controlled Spirometry (see investigations)

If in doubt about diagnosis consider the following pointers

  • Asthma may be present if:
  • there is a >400ml increase in FEV1 in response to bronchodilators
  • serial peak flow measurements show significant diurnal or day to day variability of 15% or more
  • there is a >400ml increase in FEV1 in response to (plain) prednisolone, at least 30mg daily for 2 weeks
  • Clinically significant COPD is not present if FEV1/FVC ratio returns to normal with drug therapy
  • Refer for more detailed investigations if needed
Read Codes

COPD code on SytsmOne/EMIS

  • Mild = XaEIV / H36
  • Moderate = XaEIW / H37
  • Severe = XaEIY / H38
  • Very Severe = XaN4a / H39

Differential Diagnoses

Asthma and COPD Overlap Syndrome (ACOS)

  • A significant proportion of patients who present with symptoms of a chronic airways disease have features of both asthma and COPD
  • Patients with features of both asthma and COPD experience frequent exacerbations, have poor quality of life, a more rapid decline in lung function and higher mortality than asthma or COPD alone
  • Concurrent clinician diagnosed asthma and COPD has been reported in between 15% and 20% of patients
  • Distinguishing asthma from COPD can be problematic, particularly in smokers and older adults
  • ACOS is characterised by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD
  • ACOS is therefore identified by the features that it shares with both asthma and COPD
  • Please also see referral criteria
Read Codes
  • ACOS code on SytsmOne Xac33 / EMIS H3B

Red Flags

Seek immediate or urgent specialist advice/treatment if:

Investigations

  • If considering COPD, perform quality controlled Spirometry – Performance of Spirometry
  • Airflow obstruction is defined as post bronchodilator FEV1 /FVC <0.7
  • At diagnosis post bronchodilator recording is defined as measurement 20 minutes after administration of 400mcg salbutamol via a large volume spacer during a period of stability (i.e. no chest infection for 6 weeks)

Management

If History and Spirometry confirm COPD:

  • Chest x-ray
  • Full blood count
  • Body Mass Index
  • MRC dyspnoea score
  • Enter diagnosis in electronic record including classification (below), MRC Dyspnoea Score, and number of exacerbations in past 12 months
  • Start treatment in line with ABCD classification - See COPD Stable Management Care Pathway
  • Refer to Pulmonary Rehabilitation programme – See Pulmonary Rehabilitation Referral (Wakefield)
  • Provide self management plan and commence self care education

Severity classification of COPD based on airflow limitation (FEV1 % predicted)

  • Mild (GOLD 1)
    • FEV1/FVC < 70%
    • FEV1 > or equal to 80% predicted
  • Moderate (GOLD 2)
    • FEV1/FVC < 70%
    • FEV1 between 50% and 80% predicted
  • Severe (GOLD 3)
    • FEV1/FVC < 70%
    • FEV1 between 30% and 50% predicted
  • Very Severe (GOLD 4)
    • FEV1/FVC < 70%
    • FEV1 < or equal to 30% predicted

All patients at all stages of COPD should be:

  • Offered pneumococcal and influenza vaccinations
  • Offered smoking cessation where appropriate
  • Encouraged to have regular exercise/activity - 30minutes of light exercise 5 times per week
  • Encouraged to enroll on a Pulmonary Rehabilitation Programme (MRC 2-4) or referred for Physiotherapist assessment (MRC 5)
  • Offered a short acting beta agonist for "as required" use
  • Categorized and managed according to the GOLD grid
Self Management
  • Wakefield - Live Well provide a Breathlessness workshop for patients who experience breathlessness due to a chest condition and those who become breathless due to anxiety please click her for further information
  • North Kirklees - Kirkwood Hosptice provide a Breathe Better workshop for people who gave Advanced Chronic Respiratory Disease please click here for further information


Referral

Referral Criteria

Refer to specialist if:

  • Persistent symptoms and or 4 or more exacerbations despite treatment
  • Diagnostic uncertainty ( e.g. suspected pulmonary hypertension)
  • Suspected very severe COPD (onset of cor pulmonale),
  • FEV1 <30% aged under 40 years or a family history of alpha1-antitrypsin deficiency
  • Atypical symptoms (e.g. haemoptysis, weight loss, night sweats or signs of bronchiectasis or structural lung disease)
  • Few features of either Asthma or COPD
  • Co-morbidities present
  • Asthma COPD Overlap Syndrome (ACOS) guidelines for COPD diagnosing
  • Symptoms disproportionate to lung function deficit
Wakefield
North Kirklees

Referral Instructions

  • e-Consultation is available for this speciality
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type
Wakefield
  • Referrals to Pulmonary Rehabilitation via a completed referral form which should be faxed to:: 01977 668748
  • Breathlessness Workshop - Self or professional referrals can be made using the attached referral form which should be sent to:
    • Live Well Wakefield, Agbrigg & Belle Vue Community Centre, Montague Street, Agbrigg, WF1 5BB.
    • Telephone: 01924 255363
    • Fax: 01924 255363
    • Email: swy-tr.livewellwakefield@nhs.net
North Kirklees

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Decision Making aid COPD which can be printed off for the patient if required

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 02.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: RS2 - 02.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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