COPD

in
Primary Care
BY
N. OPPONG

Introduction
COPD is characterised by airflow
obstruction which is usually progressive,
not fully reversible and does not change
markedly over several months.
Predominantly caused by smoking.
Airflow obstruction is defined as FEV1
<80% predicted and FEV1/FVC <0.7.
Significant airflow obstruction may be
present before the individual is aware of
it.

Introduction
COPD

is an important cause of
morbidity and mortality (>30,000
deaths / year in the UK).
Estimated 3 million people in the UK
suffering from the disease (900,000
diagnosed).
June 2006: Announcement by
Secretary of State for Health that a
new NSF will be developed to
improve standards of care and
increase choice for patients with
COPD.

Presenting Features 1
Over 35 years
Smokers or ex-smokers
Breathlessness on exertion
Chronic cough
Regular sputum production
Frequent winter bronchitis
Wheeze
Exclude features of other diseases
including Asthma, Bronchiectasis, CCF and
Lung Cancer

Presenting Features 2
On examination the following may be
present:
Hyper inflated chest
Use of accessory muscles of respiration
Wheeze or quiet breath sounds
Peripheral oedema
Raised JVP
Cyanosis
Cachexia

Blue Bloaters & Pink Puffers

Investigations
Spirometry is crucial to demonstrate
airflow obstruction. Can be used for
screening.
Also as part of initial assessment at
diagnosis:
Chest X-ray to exclude other pathology
Full blood count to exclude anaemia or
polycythaemia
BMI
Other invs. that may be necessary: serial
peak flow measures, CT thorax, ECG,
Echo, sputum culture, alpha-1-antitrypsin

Differentiating Asthma & COPD

COPD

Asthma

Smoker or exsmoker

Nearly all

Possibly

Symptoms under
age 35

Rare

Often

Chronic productive
cough

Common

Uncommon

Breathlessness

Persistent and
progressive

Variable

Night time waking

with DIB

Uncommon

Common

Significant diurnal or Uncommon

daily variability

Common

Assessment of COPD Severity

Multidimensional using:
Severity of airflow obstruction: FEV1 5080% = mild, FEV1 30-49% = moderate,
FEV1 <30% = severe
Degree of breathlessness. Measure MRC
Dyspnoea Score.
Exercise limitation and disability
Assessment of productive cough
frequency of exacerbations
BMI
Signs of failing lung: Cor Pulmonale,
SaO2 92%

MRC Dyspnoea Score

1 Not troubled by breathlessness except on
strenuous exercise
2 Short of breath when hurrying or walking
up a slight hill
3 Walks slower than contemporaries on level
because of breathlessness, or has to stop
for breath when walking at own pace.
4 Stops for breath after walking about 100
metres or after few minutes on the level.
5 Too breathless to leave the house or
breathless when dressing or undressing

Management

Management 1

COPD care should be delivered by a

multidisciplinary team including resp. nurse,
physiotherapists, dieticians, palliative care teams,
social services, occupational therapists, etc

All Patients
Smoking cessation: NRT and oral bupropion
combined with support schemes can improve quit
rates.
Influenza and pnuemococcal vaccination.
Exercise advice
Dietary advice: both over and underweight

Mgt 2 - Symptomatic Patients

Intermittent breathlessness
Short-acting 2-agonists such as Terbutaline and
Salbutamol. OR
Short-acting anticholinergic agent such as Ipratropium
Persistent breathlessness
Long-acting 2-agonists given twice daily eg. Formoterol
and Salmeterol. Main side-effects are tremors and
palpitations.
Long-acting anticholinergic agent eg. Tiotropium can be
given once daily. Main side-effect is dry mouth.
Oral theophyllines: reserved for patients intolerant to
inhaled therapy because of side-effects, drug interactions
and need for monitoring.
Cough
Mucolytic agents (carbocisteine or mecysteine) for
distressing viscid sputum.
Physiotherapy may help.

Management 3
Patients with a disability
Patients with a restriction in their
daily activities should be referred for
pulmonary rehabilitation.
Patients with the failing lung
Refer for secondary care or palliative
care assessment

Management 4
Patients with exacerbations of COPD
FEV1 50% and with 2 or more
exacerbations in a year offer a trial of
inhaled steroid and LABA combination. Eg.
Formoterol 12mcg / budesonide 400mcg
(Symbicort) or salmeterol 50mcg /
fluticasone 500mcg (Seretide).
With prolonged dosing consider
osteoporosis screening.
Self management plans should be
discussed with patients including the
provision of standby antibiotics and oral
steroids.

Referral for diagnostic help

Diagnostic uncertainty
Suspected severe and deteriorating COPD
Age < 40 yrs or alpha-1-antrypsin
deficiency
Onset of cor pulmonale or presence of
significant co-morbidities
Red flag symptoms to exclude lung
cancer: haemoptysis, clubbing
Patients experiencing frequent infections
or exacerbations
Requests for second opinion

Referral for therapeutic help

Assessment for pulmonary rehabilitation
for patients with functional disability
Assessment for lung surgery: volume
reduction / transplantation
Assessment for long term oxygen therapy:
FEV1 30%, SaO2 92%
Assessment for ambulatory oxygen
therapy: patients who desaturate on
exercise
Assessment for nebulised therapy

Follow Up
Once

or twice yearly
Smoking status and desire to quit
Adequacy of symptom control
Presence of complications
Effects of drug treatment
Inhaler technique
Need for referral to specialist or
therapy services
Need for pulmonary rehabilitation
Measure FEV1, FVC, MRC score, BMI

Pulmonary Rehabilitation
A multidisciplinary programme of care for
patients with chronic respiratory
impairment (MRC dyspnoea score 3)
Individually tailored and designed to
optimise each patients physical and social
performance and autonomy
Involves exercise, disease education,
nutritional, psychological and behavioural
intervention
Despite its proven benefits, it is available
to only about 2% of suitable patients

Oxygen
Initiated by specialist service
From Feb 1, 2006 provision of oxygen
made by the Home Oxygen Therapy
Service led from secondary care.
Criteria for assessment
FEV1 <30%
Cyanosis
Polycythaemia
Cor pulmonale
SaO2 92% when stable
GPs can still order oxygen usually as part
of short term arrangements whilst
awaiting assessment

Exacerbations
A sustained worsening of the patients
symptoms from their usual stable state
Beyond normal day to day variations
Acute in onset
Requires treatment change
Triggers
Weather
Viral epidemics eg. winter flu and other
infections
Smoky environment
High pollen levels

Exacerbations
Cost of exacerbations:
Mild self managed - 15
Moderate GP managed - 95
Severe requiring admission - 1,658
Frequent exacerbations associated with:
Faster lung function decline, up to 25%
each year
Worsening health status
50% of those who survive their first
admission with COPD will be readmitted
within 6 months. 10% die during
admission and a third will die within 6
months.

Exacerbations
Self Management
In an exacerbation, the earlier treatment is
started the better:
Take maximal bronchodilator therapy
Oral steroids if symptoms persist
Antibiotics if sputum goes yellow or green
In flu epidemics, when alerted by public health
lab, oseltamivir should be used within 48 hrs of
onset of flu-like illness.
Indications for in-patient assessment
Worsening hypoxaemia
Unremitting severe breathlessness
Confusion, drowsiness
New onset of peripheral oedema or cyanosis
Chest pain and fever

End of Life Issues

Indicators for end of life criteria:
FEV1 <30%
Recurrent acute exacerbations of COPD (>2 per
year)
Frequent admissions to hospital for acute COPD
Progressive shortening of time period between
admissions
Severe co-morbidities eg. heart failure, diabetes
etc
Dependence on oxygen
Severe unremitting dyspnoea at rest (MRC
dyspnoea score 5)
Inability to carry out normal activities of daily
living, inability to self care

End of Life Issues

For these patients consider:
Completion of DS1500 form for DLA
Clear management plan in consultation
with patient and carer
Referral to specialist services: resp. nurse,
palliative care, district nurse
Provide alert card / patient held record for
emergency services eg. OOH service.
Include preferred place of death.
Liverpool Care Pathway: for the last 48
hrs of life