Copd Protocol Kingthorne Group Practice

The Oakwood Surgery Clinical Protocols

COPD QoF topic

Author Dr Dean Eggitt Created November 2012 Reviewed October 2014 (Dr Phillips and Dr Garth) Review Date October 2015 Introduction Indicators suggestive of COPD include the following  Over 35  Smokers or ex smokers  Exertional sob  Chronic cough  Reg sputum production  Frequent winter “bronchitis”  Wheeze

Patients with the above features should be considered for the diagnosis of COPD if no other diagnosis is in place to account for their symptoms. Diagnosis is made based upon clinical grounds with the aid of post bronchodilation spirometry, CXR, BMI and and FBC

Interpreting the Spirometry Diagnosis of COPD requires…

 FEV1/FVC <70% (Post Bronchodilator)

Mild > = 80 % pred fev1 stage 1 Moderate 50 - 79% pred fev1 stage 2 Severe 30 - 49% pred fev1 stage 3 Very severe <30% stage 4

Reversibility Testing COPD is not reversible. Reversibility testing is carried out at the time of spirometry to rule out the differential diagnosis of asthma.

 Preferred method - 4 puffs salbutamol via spacer device  If fev1 increases >400ml (or 20%), consider asthma

At diagnosis 1. Code the patient as one of the following (using the definitions above)

. Mild COPD (H36) . Moderate COPD (H37) . Severe COPD (H38) . Very Severe (H39)

2. Complete the EMIS WEB COPD template 3. Record the smoking status 4. Give smoking cessation advise if this is needed, and code this in the notes 5. Consider the need for alpha1-antitrypsin deficiency blood test if <40yrs or a positive family history 6. Discuss  The importance of medication concordance and inhaler technique  Annual flu vaccination process and pneumonia vaccination  Annual COPD review process and importance  Self management plans  Issue the patient with a COPD handbook (if available)  Review the need for community respiratory nurse referral of pulmonary rehab referral as per form and leaflet (attached)

Treatment Treatment is based upon a step wise approach and is aimed to relieve symptoms. When symptoms are not controlled, a step up is required. A step down may be considered where symptoms are very well controlled and the patient may be over treated or when a particular inhaled therapy is ineffective.

Inhaled therapy (See flow chart)

For dyspnoea on exertion or simple exercise limitation, start on…

1. Short acting beta 2 agonist OR Short acting antimuscarinic (if SABA ineffective)

a. Salbutamol or Ipratropium bromide

For when the patient is suffering from frequent exacerbations (2 or more per year) of COPD and FEV1>50% add in long term…

2. Long Acting antimuscarinic Tiotropium handihaler (NOT RESPIMAT)

3. Add LABA if still symptomatic

For when the patient is STILL suffering from frequent exacerbations of COPD, remains symptomatic or FEV1 < 50% add in long term…

4. Inhaled Steroid with long acting beta 2 agonist, as a combination inhaler Depending on patient preference… a. Seretide Accuhaler 500mcg 1 puff BD b. Symbicort 400/12 Turbohaler 1 puff BD c. Symbicort 200/6 Turbohaler 2 puffs BD

Refer to GP if  Uncertain diagnosis  Fev1 < 1 litre  Haemoptysis  Assessment for O2 therapy  Assessment for nebuliser therapy  Assessment for oral corticosteroid therapy  Rapid