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At the heart of general practice since 1960

November 2008: Reducing exacerbations in patients with COPD

What are the diagnostic criteria for COPD?

How should exacerbations be managed?

When should patients be referred for specialist advice?

What are the diagnostic criteria for COPD?

How should exacerbations be managed?

When should patients be referred for specialist advice?

More than 27,000 people die from chronic obstructive pulmonary disease (COPD) each year in the UK. It is estimated that there are around 1.5 million adults with COPD, thus a GP practice with approximately 7,000 patients will have up to 200 patients with COPD on its practice list.1

Numerous advances have been made over the past two decades that have improved the diagnosis and management of this debilitating condition. A variety of treatments that improve patient-centred outcomes are now available and the current focus on strategies for long-term review will help the translation of this knowledge into improved patient care.

There are now several guidelines that address the diagnosis and management of COPD, including the 2004 NICE guideline2 and the international Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline,3 which is a regularly updated ‘living' guideline, last updated in 2007. In addition, a National Service Framework (NSF) for COPD is due to be published in 2009.

Diagnosis

The diagnosis of COPD is based on the presence of typical symptoms and airflow obstruction on spirometry. Cough (often productive), wheeze and breathlessness (usually occurring on activity) are typical presenting symptoms.

COPD is unusual in individuals under 45 and is almost always associated with a significant smoking history – typically more than 10 pack-years' exposure and frequently in excess of 20 pack-years.

The diagnosis of COPD is confirmed by demonstrating the presence of airflow obstruction after bronchodilation, although the presence of airflow obstruction does not exclude a diagnosis of asthma.

Spirometry

Airflow obstruction is the hallmark feature of COPD and represents an inability to empty the lungs quickly under force. In healthy individuals ?70% of the volume of the lungs can be expelled in the first second of forced expiration and if this is not seen then the patient has airflow obstruction.

Spirometry is a relatively straightforward test but should be performed and interpreted by a trained individual. Modern handheld spirometers report a value for forced expiratory volume in the first second (FEV1) and the forced vital capacity (FVC).

COPD is invariably the diagnosis in smokers who have symptoms and an FEV1 /FVC ratio <70% after administration of a bronchodilator. The FEV1 expressed as a percentage of the predicted value (provided in the spirometry printout) gives an approximate measure of disease severity (see box 1, attached).

The use of spirometry in primary care has been shown to increase the number of patients correctly diagnosed with COPD and leads to more effective treatment.4 The upcoming NSF for COPD may recommend screening of all patients with a high risk of COPD.

Health promotion

The most important general health promotion strategy when managing patients with COPD is smoking cessation, which is the only intervention proven both to reduce decline in FEV1 and extend life expectancy.5 There is evidence that diagnosis of COPD improves quit rates.6

As with all individuals with chronic lung disease, annual influenza vaccination is recommended for patients with COPD and pneumococcal vaccination is also suggested in light of the higher incidence of bacterial infections.

Formal exercise programmes (pulmonary rehabilitation) have been shown to improve walking distance, activity level and wellbeing in patients with COPD and regular exercise should be encouraged. Weight management is also important, as patients with COPD who are underweight die earlier and those who are overweight are more breathless as they have to work harder to move.

Breathing control techniques, such as diaphragmatic breathing and pursed lip breathing, may assist some patients.

The diagnosis of COPD can also have a major psychological effect on an individual. The national network of self-help ‘Breathe Easy' groups affiliated to the British Lung Foundation can provide valuable support.

Management of symptoms

The focus of COPD management is on the alleviation of symptoms (primarily breathlessness and its effect on exercise capacity) and reduction of exacerbations. Interventions to increase life expectancy are limited to smoking cessation and the provision of long-term oxygen therapy for patients who have chronic hypoxia.

Patients with more severe disease and ongoing symptoms should take both a long-acting anticholinergic7 and a combination long-acting beta-agonist/inhaled corticosteroid.8

There is little evidence that delivery of drugs by a nebuliser is superior to delivery by an inhaler. Moreover, recent large, long-term clinical trials have shown benefits from using these inhalers, such as a reduction in exacerbation rate, that have not been demonstrated by short-acting bronchodilators. A therapeutic trial of oral theophylline may be indicated in some patients.

Pulmonary rehabilitation has been shown to improve a number of clinically important outcomes, including improvement in walking distance, activity level, health status, breathlessness and a reduction in hospitalisations, and should be a mainstay of treatment for all patients with COPD who are able to enter a programme.9 Rehabilitation programmes have been shown to be effective in all disease severities regardless of where the programmes are carried out. It is important to optimise medication before commencing a pulmonary rehabilitation programme.

Ambulatory oxygen should be considered for patients with COPD who have exertional breathlessness and a significant fall in oxygen level on exercise. Assessment is increasingly performed by specialist oxygen services. Patients who require ambulatory oxygen should continue to use this during pulmonary rehabilitation.

Mucolytics may lead to a reduction in exacerbation frequency in patients with regular exacerbations.

Surgery to reduce the extent of emphysema and lung transplantation are only appropriate for a small number of patients with COPD, who will need to be assessed in secondary care.In very severe disease, the use of low-dose opiates may be useful to alleviate symptoms.

Exacerbations

Exacerbations are common in COPD. Patients with more frequent exacerbations have a poorer quality of life and a more rapid decline in lung function.10

Many exacerbations are associated with bacterial and particularly viral infections, although there is also an association with a change in atmospheric pollution.

Reassuringly, the number of exacerbations associated with pulmonary emboli appears low.11

There are many different definitions of a COPD exacerbation but the original Anthonisen criteria are simple and practical (see box 2, attached).12

Exacerbations can be treated with a 5-7 day course of a broad-spectrum antibiotic such as an aminopenicillin or macrolide. Alternatives include an oral cephalosporin or newer quinolone.

Microbiological assessment of sputum can be useful, particularly if there is an initial lack of response to treatment. Multiple consecutive courses of different antibiotics is rarely helpful.

A seven-day course of an oral corticosteroid (such as 30mg prednisolone) has been shown to speed up recovery time from an exacerbation.13

As part of an overall self-management plan, it is appropriate for some patients to be given a ‘pack' of antibiotics and steroids to be kept at home and started if symptoms of an exacerbation develop. These packs are usually accompanied by written instructions concerning when to commence treatment.

In the longer term, inhaled corticosteroids, long-acting beta agonists, long-acting anticholinergics and pulmonary rehabilitation have all been shown to reduce exacerbation rates.

Monitoring and referral

Until recently many patients with COPD were not subject to regular review, and management often lacked coordination or was predominantly reactive. The forthcoming NSF for COPD is likely to recommend how and when to monitor patients, and the NICE guideline contains recommendations on the follow-up of patients with COPD.2

The British Thoracic Society has produced guidance setting out criteria for referral to secondary care (see box 3, attached).14

Authors

Dr Paul Walker
BMedSci, BM BS, MRCP
consultant in respiratory medicine

Dr Abdul Ashish
MBBS, MRCP
specialist registrar in respiratory medicine, University Hospital Aintree, Liverpool

Key points Box 1: Summary of how to interpret spirometry Box 2: Anthonisen criteria for diagnosis of a COPD exacerbation Box 3: British Thoracic Society criteria for referral

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