COPD - Stable Management 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 management of stable COPD in primary care in Adults age 18+
  • pharmacological and non-pharmacological treatments

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

Mild/moderate/severe (stages 1 to 3)
  • Frequency
    • At least annual
  • Clinical assessment
    • Smoking status and desire to quit
    • Adequacy of symptom control:
      • breathlessness
      • exercise tolerance
      • estimated exacerbation frequency
    • Presence of complications
    • Effects of each drug treatment
    • Inhaler technique and compliance
    • Need for referral to specialist and therapy services
    • Need for pulmonary rehabilitation
    • CAT Score
  • Measurements to make
    • FEV1 and FVC
    • calculate BMI
    • MRC dyspnoea score
Very severe (stage 4)
  • Frequency
    • At least twice per year
  • Clinical assessment
    • Smoking status and desire to quit
    • Adequacy of symptom control:
      • breathlessness
      • exercise tolerance
      • estimated exacerbation frequency
    • Presence of cor pulmonale
    • Need for long-term oxygen therapy
    • Patient's nutritional state
    • Presence of depression
    • Effects of each drug treatment
    • Inhaler technique and compliance
    • Need for social services and occupational therapy input
    • Need for referral to specialist and therapy services
    • Need for pulmonary rehabilitation
    • CAT Score
  • Measurements to make
    • FEV1 and FVC
    • calculate BMI
    • MRC dyspnoea score
    • SaO2
The BODE Index
  • The BODE index has been developed in an attempt to qunatify prognosis in COPD
  • Those with a BODE score of IV have predicted mortality of 80% in next 5 years
  • Click here for more information
Self Management


Red Flags

Seek immediate or urgent specialist advice/treatment if:

Management

Principles that apply to all patients:
  • Diagnosis should be confirmed by quality assured spirometry - See COPD Diagnosing Care Pathway
  • Pharmacological treatments are not always the most effective
  • Patients who maintain physical activity will have better outcomes. This can be encouraged through early referral to Pulmonary Rehabilitation Programmes (see Pulmonary Rehabilitation Guidance)
  • Prior to changes in medication, check inhaler technique and concordance https://www.blf.org.uk/support-for-you/copd/health...
  • Any changes to medications should be reviewed after 4 weeks to assess impact on health status, with discontinuation or substitution of treatments given for breathlessness if no improvement
  • To assess the impact of COPD on the patient's wellbeing and daily life, consider the use of the COPD Assessment Test (CAT). Copies to download are available online at http://www.catestonline.org The CAT score is included in the CCG COPD review template.
  • Co-morbidities play an important part in mortality of COPD. Patients should be assessed for Coronary Artery Disease, Anxiety & Depression, and Osteoporosis.
  • If there is a past history or family history of asthma consider Asthma/COPD Overlap Syndrome (ACOS)- See COPD - Diagnosing Care Pathway
  • Inhaled steroids can increase the risk of pneumonia and indications for use have changed. They should only be prescribed when clearly indicated as per inhaler guidelines
All patients at all stages of COPD should be:
  • Offered self care education
  • Offered pneumococcal and influenza vaccinations
  • Offered smoking cessation where appropriate
  • Encouraged to have regular exercise/activity - 30 minutes 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 (See Treatment Algorithm)

Gold Approach to management

Use the GOLD grid to allocate a category A-D for each patient

GOLD-Categories.jpg#asset:7213

  • Assess breathlessness and symptoms
    • Choose the left column (A or C) if
      • CAT score <10 and mMRC score is 0-1
    • Choose the right column (D or B) if
      • CAT score ≥10 and mMRC is ≥2
  • Assess exacerbation risk
    • Choose the upper row (C or D) if
      • the patient has 2 or more exacerbations in the last12 months OR
      • the patient has been admitted with an exacerbation
    • Choose the lower row (A or B) if:
      • the patient has had 0 or 1 exacerbation in the last 12 months AND
      • there were no admissions to hospital with an exacerbation

Please use your local COPD Preferred Inhaler Guidelines to guide pharmacological therapy

Additional Management Information

Long Term Oxygen Therapy (LTOT)

  • Oxygen saturation should be checked 6 monthly in people with FEV1 <30% or <1.5 litres
  • Refer for home oxygen therapy assessment people with resting saturations 92% as per the Identification and Referral of COPD Patients for Home Oxygen Assessment guideline

Theophyllines

  • Not routinely used in COPD. If considering this treatment referral to specialist services is recommended. Changes in breathlessness and health status will require review after 4 weeks. Check theophylline level at 4 to 6 weeks

Mucolytics

  • These should not be routinely used in people with stable COPD. May be of use in people with chronic productive cough, review after 4 weeks and discontinue if no benefit

Osteoporosis prophylaxis

  • Should be considered in people requiring frequent courses of oral corticosteroids (>2 courses per year) and in people on high doses of ICS (2mg/day beclometasone or equivalent) with a second risk factor. The risks of developing osteoporosis should be discussed with the patient

Treatments considered unsuitable for COPD

  • Includes maintenance oral corticosteroids, prophylactic antibiotics, Alpha-1 antitrypsin replacement therapy, antioxidant therapies and antitussive therapy

Primary Care Review

  • It is strongly recommended that the CCG COPD template, linked to the Care Planning Template, is used during COPD patient reviews. Local templates may be used but should contain all of the components identified on the Primary Care Review Table
Click here to see the Management of COPD according to Gold Categories
Click here to see Guidelines for Managing Stable COPD in Primary Care (please note this contains the same information provided in this pathway in one document)
Self Management
Rescue Medication
  • Due to the risks associated with increasing antimicrobial resistance and long term steroid use, more attention should be applied when issuing prescriptions for rescue medication for COPD exacerbations as it is evident that some patients may be ordering rescue medication excessively.
  • Many cases of COPD exacerbations are viral – antibiotics are not indicated in absence of purulent sputum. If the patient presents with purulent sputum and increased shortness of breath and/or increased sputum volume then they should be treated promptly with antibiotics. Prednisolone and antibiotics should no longer be issued routinely to be held at home by patients in primary care as part of a self-management plan.
  • Each patient should assessed individually.

Referral

Referral Criteria

Wakefield

Referrals for Live Well Breathlessness Workshop for people who:

  • Experience breathlessness due to a chest condition and those who become breathless due to anxiety.

Referral criteria for Pulmonary Rehabilitation for Patients: (click here to see Wakefield referral pathway)

  1. Registered with a Wakefield CCG GP surgery
  2. Consent gained for referral / information given
  3. Patients diagnosed with a respiratory condition (MRC grade 3-4 and selected grade 5).
  4. All patients with an MRC score of 2 who are symptomatic and disabled by their condition, and who require a health care professional assessment and supervision of exercise training, rather than simple advice on lifestyle changes (i.e. not universally to everyone with an MRC score of 2)
  5. All patients who have either recently had an exacerbation of COPD requiring a hospital admission or whose functional baseline has significantly altered and is not following the expected recovery path
  6. Must be clinically stable
  7. On optimal medication
  8. Identifiable difficulties in activities of daily living.
  9. Motivated and willing to attend exercise programme
  10. Independently mobile
North Kirklees

Referral for Breathe Better workshop can be made for people who:

  • Have Advanced Chronic Respiratory Disease, known to CHFT respiratory team or on the caseload of Locala Community Matrons / Respiratory Specialist Nurse / COPD Respiratory Nurse - please see referral form for more detailed inclusion and exclusion criteria

Referral criteria for pulmonary rehabilitation - North Kirklees

  1. Patients with a respiratory diagnosis
  2. Must be clinically stable.
  3. On optimal medication.
  4. Identifiable difficulties in activities of daily living due to breathlessness (MRC grade 3-4 and selected grade 5).
  5. Patient motivated and consents to referral
  6. Independently mobile.
  7. Must be able to make own way to group (twice per week for 6 weeks) – PLEASE NOTE, TRANSPORT IS NOT PROVIDED
Wakefield & North Kirklees - 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
  • Assessment for oxygen therapy or long term nebuliser
  • Bullous lung disease
  • FEV1 <30% aged under 40 years or a family history of alpha1-antitrypsin deficiency
  • Rapid decline in FEV1
  • Assessment for lung volume surgery or lung transplantation
  • Dysfunctional breathing
  • Frequent infections
  • 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)
  • Symptoms disproportionate to lung function deficit

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
North Kirklees
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

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: 02.2018
  • Publication Date: 02.2018
  • Review Date: 02.2019
  • Ref No: RS8 - 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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