GPAC: Guidelines and Protocols Advisory Committee

Chronic Obstructive Pulmonary Disease (COPD)

Effective Date: January 1, 2005

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope and Standard of Care

1. Diagnosis by spirometry (FEV₁ less than 80% and FEV₁/FVC < 0.7 postbronchodilator)

2. Smoking cessation

3. Education and self-management

4. Active lifestyle and rehabilitation

5. Immunization for influenza and pneumococcus

6. Pharmacotherapy

7. Acute exacerbations (AECOPD) require more intensive management

8. Oxygen therapy

9. Referral to a specialist

10. Practice management

11. End of Life Care

Rationale

References

Appendices

Scope:

The guideline provides strategies for the improved diagnosis and management of adults with chronic bronchitis and emphysema (chronic obstructive pulmonary disease).

COPD is a respiratory disorder most commonly caused by smoking. COPD involves progressive airway obstruction with breathlessness, cough and sputum production and increasing frequency and severity of exacerbations.

STANDARD OF CARE

Accurate diagnosis
Smoking cessation
Education and self-management
Structured exercise and pulmonary rehabilitation
Immunization
Optimal maintenance therapy
Special attention to exacerbations
End of Life Care
Clinical review at least twice a year

CARE SUMMARY

A. Diagnosis: COPD is underdiagnosed

RECOMMENDATION 1: Diagnosis by spirometry (FEV₁ less than 80% and FEV₁/FVC* < 0.7 postbronchodilator)

Spirometry testing for patients at high risk should include:

• Smokers or ex-smokers 40 years or older;
• Patients with persistent cough or sputum production;
• Patients with frequent respiratory infections;
• Patients with unexplained shortness of breath; and
• Chest X-ray may suggest COPD or be used to rule out other diagnoses, but definitive diagnosis requires spirometry.

Note: COPD and asthma commonly coexist

• Asthmatic patients will have a 12% or greater improvement in FEV₁ (and >180 ml in adults from the baseline 15 minutes after use of an inhaled short-acting beta₂-agonist.
• In some situations a corticosteroid trial may be appropriate to differentiate COPD from asthma.

If clinical uncertainty remains, refer to a specialist.

*FEV₁: Forced expiratory volume in 1 sec., FVC: forced vital capacity

B. Management of COPD

A management strategy including pharmacotherapy and non-pharmacotherapeutic approaches can improve symptoms, activity levels and quality of life even in patients with severe COPD. The following table of severity can help guide the management of the disease.

Table 1: Canadian Thoracic Society COPD classification by symptoms/disability

Therapy should be based on a stepwise approach as below (modified from Figure 1 of Reference #6)

RECOMMENDATION 2: Smoking cessation

• Smoking is the most important cause of and contributing factor to COPD progression.
• Smoking cessation is effective in preventing disease progression even in long-term smokers.
• Effective strategies exist to aid in smoking cessation.
• Even minimal intervention should be offered to every smoker.
• Smoking cessation should be reinforced at every contact.

RECOMMENDATION 3: Education and self-management

Education of the patients and family can improve coping skills and quality of life and reduce the likelihood of hospitalization. The physician should:

• Reinforce lifestyle modifications such as smoking cessation and exercise;
• Refer the smoker with COPD to the BC Smokers Helpline (see patient guide);
• Help the patient identify resources and a support team (e.g. respirologist, pharmacist, nurse, dietician as appropriate); and
• Refer the patient to a pulmonary rehabilitation program where available.

RECOMMENDATION 4: Active lifestyle and rehabilitation

Clinically stable COPD patients who remain limited in their activity due to their symptoms despite optimal therapy should be referred to an exercise training program. Formal pulmonary rehabilitation programs that include patient education and exercise can reduce symptoms, and improve exercise endurance and quality of life.

RECOMMENDATION 5: Immunization for influenza and pneumococcus

• Annual influenza vaccination
• Pneumococcal vaccination at least once and possibly every 5 years

RECOMMENDATION 6: Pharmacotherapy *

• First line therapy should be a short-acting inhaled beta₂-agonist and regular use of inhaled anticholinergics for symptom control (see footnote).
• Introduce long-acting beta₂-agonist if symptoms persist.
• Add inhaled corticosteroid if asthmatic, or if COPD with more frequent exacerbations (3 or more per year), or FEV₁ < 50%.
• If indications for both a long-acting beta₂-agonist and an inhaled corticosteroid exist, then a combination product containing both may be an option.
• Theophylline may be useful in some individuals with persistent symptoms despite optimal inhaled therapy. A therapeutic trial of 2-3 weeks may be considered.

* Current BC PharmaCare Program Limited Coverage Criteria can be found at: www.health.gov.bc.ca/pharme/

RECOMMENDATION 7: Acute exacerbations (AECOPD) require more intensive management

Acute exacerbations are characterized by sustained (48 hrs or more) worsening of shortness of breath and coughing, with or without sputum. The most common cause is a viral or bacterial infection.

Therapies should include:

• Therapy with short-acting beta₂-agonists and anticholinergic bronchodilators;
• Oral steroids (e.g. prednisone 25-50 mg/day) for 5-10 days in most moderate to severe COPD patients; and
• Antibiotic use based on risk factors (see Appendix A).

Severe AECOPD complicated by acute respiratory failure is a medical emergency. Consider consultation with an emergency specialist and/or a respirologist.

RECOMMENDATION 8: Oxygen therapy

The goal of oxygen therapy is to maintain PaO₂ ≥ 60 mmHg or SpO₂ ≥ 90% at rest, on exertion and during sleep. (PaO₂ refers to partial pressure of oxygen in arterial blood, SpO₂ to % oxygen saturation) See Appendix B for Medical Indications for Home Oxygen.

RECOMMENDATION 9: Referral to a specialist

• Uncertain diagnosis
• Severe or recurrent exacerbations
• Complex comorbidities
• Young patient with limited smoking history
• Assessment for home oxygen
• Surgical options

RECOMMENDATION 10: Practice management

Physicians are encouraged to:

• Identify all patients with COPD;
• Monitor key clinical indicators of COPD using a flow sheet (attached);
• Use recall systems to ensure that patients are seen at appropriate intervals;
• Review patient records to ensure that goals of care are met; and
• Consider comorbidities.

RECOMMENDATION 11: End of Life Care

Advance planning allows patients to plan for end of life care. Making decisions about the intensity of end of life care is a highly individualized process and requires continuous review as COPD progresses.

Prior to initiating end of life care:

• Address the precipitating factors;
• Explore all active therapeutic options; and
• Consider comorbidities.

End of life care :

• Manage all symptoms (including those of co-morbid conditions, e.g. chronic pain) and address function and quality of life issues;
• Review need for home oxygen and treatment for severe dyspnea including opioids, neuroleptics and benzodiazepines;
• It is important to ensure that advanced care planning, encompassing financial and health care decisions (e.g. Representation Agreement) has been carried out;
• Decisions need to be made and documented as to whether and when to pursue hospital admission and the level of intervention. Assure that BiPAP (bilevel positive airway pressure device) is not overlooked; and
• Consultation with a respirologist may be helpful.

The BC Palliative Care Consultation Line 1 877 711-5757 offers advice from a palliative care physician on symptom management 24 hours per day, 7 days per week.

Detailed strategies to assist physicians with end of life care can be found at the American College of Chest Physicians web site: www.chestnet.org

Rationale

This guideline has been developed following review of the recommendations of the Canadian Thoracic Society for the management of chronic obstructive pulmonary disease (COPD)^1,2 and other international strategies for the management of COPD^3,4,5,6,7. It is adapted for family physicians in British Columbia using the chronic care management approach.

Approximately 73,000 patients in British Columbia have been diagnosed with COPD. It is a major cause of morbidity and mortality. Women account for about 47% of the cases⁸. Most patients (95%) who develop chronic bronchitis and emphysema are smokers. Smoking cessation, even in long-term smokers, is the cornerstone of treatment. Accurate diagnosis is required, and exercise, rehabilitation and pharmacological management are important components of a disease management strategy.

A chronic disease and self-management approach directed by health professionals can significantly improve health status and reduce hospital admissions for exacerbations by 40%⁹.

Patients with COPD require education regarding disease process, treatment and prognosis with particular attention to advance care planning and end of life care.¹⁰

The Cochrane review concluded that "Tiotropium reduced COPD exacerbations and related hospitalisations compared to placebo and ipratropium. It also improved health related quality-of-life and symptom scores among patients with moderate and severe disease, and may have slowed decline in FEV₁. Additional long-term studies are required to evaluate its effect on mortality and change in FEV₁ to clarify its role in comparison to, or in combination with, long-acting beta 2-agonists and to assess its effectiveness in mild and very severe COPD.¹¹

Patients receiving tiotropium experienced fewer exacerbations and improved quality of life compared to those receiving ipratropium in a small clinical trial (356 patients treated). The trial showed a trend to increased mortality in the treatment group.¹² The increase was not statistically significant. More trials are required to determine effects on survival.

References

1. O'Donnell DE Aaron S Bourbeau J et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease-2003. Can Respir J 2003; 10:11A-65A.
2. O'Donnell DE Hernandez P Aaron S et al. Canadian Thoracic Society COPD Guidelines: Summary of highlights for family doctors. Can Respir J 2003; 10:183-185.
3. Sin DD McAlister, FA Man SFP and Anthonisen NR. Contemporary Management of Chronic Obstructive Pulmonary Disease. Scientific Review. JAMA 2003;17:2301-2312.
4. Man SFP McAlister FA Anthonisen NR Sin DD. Contemporary management of chronic obstructive pulmonary disease. Clinical applications. JAMA 2003;290:2313-2316.
5. Calverley PMA and P Walker. Chronic obstructive pulmonary disease. Lancet 2003;362:1053-61.
6. Celli BR. A 62 year-old woman with chronic obstructive pulmonary disease. JAMA 2003;290:2721-2729.
7. National Institute for Clinical Evidence. Chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical guideline 12 February 2004. Available at: www.nice.org.uk/CGO12NICEguideline.
8. British Columbia Ministry of Health 2004. Chronic Disease Management Data.
9. Bourbeau J Julien M Maltais F et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease. Arch Intern Med 2003; 163:585-591.
10. Patients' perspectives on Physician Skill in End-of-Life Care. Curtis JR Weinrich MD Carline JD et al. Chest 2002; 122:356-362.
11. Barr RG, Bourbeau, J Camargo CA Jr. and FSF Ram. Inhaled tiotropium for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 3, 2005.
12. Vincken W, van Noord JA, Greefhorst AP, Bante TA, Kesten S, Korducki L, et al. Dutch/Belgium Tiotropium Study Group. Improved health outcomes in patients with COPD during 1 yr's treatment with tiotropium. European Respiratory Journal 2002;19:209{16}.

Appendices

Appendix A: Antibiotic treatment recommendations for acute exacerbations of COPD (AECOPD)

Appendix B: Medical Indications for Home Oxygen

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Revised Date: November 14, 2007

This guideline is based on scientific evidence current as of the revised date.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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