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Chronic obstructive pulmonary disease

Implementing NICE guidance

June 2010

NICE clinical guideline 101

What this presentation covers

Background

Scope

Key priorities for implementation

Discussion

Find out more

Background

• Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variationsrequiring a change in treatment

• An estimated 3 million people have chronic pulmonary disease (COPD) in the UK, though many remain undiagnosed

• COPD is predominantly caused by smoking and is characterised by airflow obstruction that:

- is not fully reversible- does not change markedly over several months- is usually progressive in the long term

Scope

The scope for the guideline update was to examine:

a) Diagnosis and severity classification:

•spirometry and post-bronchodilator values

•multidimensional severity assessment indices (for example, the BODE index)

b) Management of stable COPD and prevention of disease progression

•long-acting bronchodilators: beta2 agonists and anticholinergics (tiotropium, formoterol fumarate, salmeterol) as monotherapy and in combination, both with and without inhaled corticosteroids

•mucolytic therapy (carbocisteine and mecysteine hydrochloride)

BODE = body mass index, airflow obstruction, dyspnoea and exercise tolerance

Definition of COPD

• Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)

• It is no longer necessary to have an FEV1 < 80% predicted for definition of airflow obstruction

• If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough

FEV1 = forced expiratory volume in 1 secondFVC = forced vital capacity

Diagnose COPD

Consider a diagnosis of COPD for people who are:• over 35, and• smokers or ex-smokers, and• have any of these symptoms:

- exertional breathlessness

- chronic cough

- regular sputum production,- frequent winter ‘bronchitis’ - wheeze

[2004]

Diagnose COPD: 2

• The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry [new 2010]

• All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the

interpretation of the results [2004]

Diagnose COPD: 3

• Assess severity of airflow obstruction using reduction in FEV1

NICE clinical

guideline 12 (2004)

ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101

(2010)

Post-bronchodilator

FEV1/FVC

FEV1 % predicted

Post-bronchodilato

r

Post-bronchodilator

Post-bronchodilator

< 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)*

< 0.7 50–79% Mild Moderate Stage 2 (moderate)

Stage 2 (moderate)

< 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe)

< 0.7 < 30% Severe Very severe Stage 4 (very severe)**

Stage 4 (very severe)**

* Symptoms should be present to diagnose COPD in people with mild airflow obstruction** Or FEV1 < 50% with respiratory failure

[new 2010]

Stop smoking

• Encouraging patients with COPD to stop smoking is one of the most important components of their management

• All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity

• Record a smoking history, including pack years smoked

• Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [2010]

[2004]

Promote effective inhaled therapy

In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy:

•if FEV1 ≥ 50% predicted: either LABA or LAMA

•if FEV1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA

Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS,irrespective of their FEV1

ICS = inhaled corticosteroidLABA = long-acting beta2 agonist

LAMA = long-acting muscarinic agonist[new 2010]

Use of inhaled therapies

SABA or SAMA as required*Breathlessness and exercise limitation

Exacerbations or persistent breathlessness

Persistent exacerbations or breathlessness

LABA LAMADiscontinue

SAMA________

Offer LAMA in preference to regular

SAMA four times a day

LABA + ICS in a combination

inhaler________

Consider LABA + LAMA if ICS

declined or not tolerated

LAMADiscontinue

SAMA________

Offer LAMA in preference to

regular SAMA four times a day

FEV1 ≥ 50% FEV1 < 50%

LABA + ICS in a combination

inhaler________

Consider LABA + LAMA if ICS

declined or not tolerated

LAMA + LABA + ICS in a combination

inhaler

Offer Consider* SABAs (as required) may continue at all stages

Provide pulmonary rehabilitation

Pulmonary rehabilitation

An individually tailored multidisciplinary programme of care to optimise patients’ physical and social performance and autonomy

Tailor multi-component, multidisciplinary interventions to individual patient’s needs

Hold at times that suit patients, and in buildings with good access

Offer to all patients who consider themselves functionally disabled by COPD

Make available to all appropriate people, including those recently hospitalised for an acute exacerbation

[new 2010]

Use non-invasive ventilation (NIV)

• Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy

• NIV should be delivered by staff trained in its application, experienced in its use and aware of its limitations

• When starting NIV, make a clear plan covering what to do in the event of deterioration and agree ceilings of therapy

[2004]

Managing exacerbations

• Minimise impact of exacerbations by:

- giving self-management advice on responding promptly to symptoms of exacerbation

- starting appropriate treatment with oral steroids and/or antibiotics

- use of non-invasive ventilation when indicated

- use of hospital-at-home or assisted-discharge schemes

• The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations

[2004]

Multidisciplinary working

• COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists

• Consider referral to specialist departments (not just respiratory physicians)

[2004]

Specialist department Who might benefit?

Physiotherapy People with excessive sputum

Dietetic advice People with BMI that is high, low or changing over time

Occupational therapy People needing help with daily living activities

Social services People disabled by COPD

Multidisciplinary palliative care teams

People with end-stage COPD (and their families and carers)

Discussion

• How can we improve identification and diagnosis of people over 35 who have a risk factor?

• How does our use of spirometry compare with the recommendations?

• How will our prescribing practice need to change?

• What pulmonary rehabilitation services are available?

• How do we minimise the risk of exacerbations for our patients?

Find out more

Visit www.nice.org.uk/CG101 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report •audit support

NICE is developing a Quality Standard for COPD which will be published in 2011