Spirometry

Smokers or

Ex-Smokers

Patients

presenting with

Chest Infections

or 'Bronchitis'

Consider

COPD

History And

Functional

Assessment

Smokers

presenting with

Dyspnoea

Diagnosis

of COPD

Management of

COPD

· Risk factors especially smoking history

· Symptoms and pattern of development

· Past medical history

· Co-morbidities

· History of exacerbations or previous hospitalisations

for respiratory disease

· Appropriateness of current medical treatments

· Problems with current or previous therapies

· Inhaler techniques

· Impact of disease on patient’s life

· Social and family support

History & Functional

Assessment

COPD STAGES ASSESSED BY

SPIROMETRY

Stage I: Mild COPD:Individual may not be aware that his/her lung

function is abnormal.

Mild airflow limitation (FEV1/FVC < 70%; FEV1 ≥ 80% predicted)

and sometimes, but not always chronic cough and sputum

production.

Stage II: Moderate COPD:

Patients typically seek medical attention at this stage because of

chronic respiratory symptoms or an exacerbation of their disease.

Worsening airflow limitation (FEV1/FVC < 70%; FEV1 50% to

80% predicted), with shortness of breath typically developing on

exertion.

Stage III: Severe COPD:

Further worsening of airflow limitation (FEV1/FVC < 70%; FEV1

30% to 50% predicted), greater shortness of breath, reduced

exercise capacity, and repeated exacerbations which have an

impact on a patient’ quality of life.

Stage IV: Very severe COPD:

At this stage, quality of life is very appreciably impaired and

exacerbations may be life-threatening

Severe airflow limitation (FEV1/FVC < 70%; FEV1< 30%

predicted or FEV1 < 50% predicted plus chronic respiratory

failure).

Management of COPD

Management of

Stable COPD

Management of

Acute

Exacerbation of

COPD (AECOPD)

Management of Acute

Exacerbation Of COPD (AECOPD)

Patient presents to ED / AMAU following GP / self

referral

Patient assessed by ED/AMAU Officer and routine

investigations ordered CXR ECG ABG Bloods

(CBC, CRP, U+E, LFTS)

Administration of humidified O2

(FiO2 2L via nasal cannula or 28% via mask)

Maintain>88% SaO2 < 92%

On presentation

Check arterial blood gas and repeat if FiO2 increase is required. If in

respiratory failure with pH < 7.35 consider initiation of non- invasive

ventilation/ transfer to appropriate Dept.

Administer nebulised Beta 2 agonists and anticholinergics

Within 30 min

Within 4 hrs

Review laboratory results

Review CXR results

Administer antibiotics PO

Oral prednisone 40 mg (30 mg

if 60kg or less) if wheezy or

elevated inflammatory markers

PO Amoxycillin or

Clarithromycin or

doxycycline If infiltrate,

treat as pneumonia

TED stockings or LMWH for prophylaxis

(if admitted)

Refer to Respiratory Team/Nurse

within 24hrs of admission

COPD

Bundle

Consider COPD Outreach

Management of Stable COPD

Patient Education Self Management

and Support

Preventive Measures

PharmacologicalTherapy

SpecialistReferral

Avoidance of Risk Factors

Smoking Cessation Advice

Vaccination

Advice and Self Management Plans

Patient Held Record (Respiratory Passport)

Pulmonary Rehabilitation

Individualise Management

CONSIDER COPD OUTREACH

Inclusion Criteria

· FEV1 <80% predicted

· FEV1/FVC<70% predicted

· MMSE >7

· Sytstolic BP >100mmHg

· ABGs pH>7.35, pO2

>7.3kPa,pCO2>8kPa (on

room air)

· Total WCC 4-20*10/l

· 0-72hrs of presenting to

hospital

Exclusion Criteria

· Suspected malignancy

· Pneumothorax

· Pneumonia

· Uncontrolled LVF

· Acute ECG changes

· Requires full time care

· Insufficient home care

· Requires IV therapy

· Type 1 DM

Patient is diagnosed

with Acute

Exacerbation of

COPD and if

appropriate referred

to COPD Outreach

Team

Patient is re-assessed

and admitted for

medical treatment and

investigation for up to

48 hrs until early

supported discharge

with the COPD

Outreach team.

Patient is admitted to

medical ward and is

expected to require

medical treatment and

investigations for longer

than 48 hours

Patient is Discharged

Directly home from A&E

with COPD Outreach

Team and Care

package.

Normal spirometry result versus a COPD result

FVC (Forced Vital Capacity): maximum volume of air that can

be exhaled during a forced manoeuvre.

FEV1 (Forced Expired Volume in one second): volume

expired in the first second of maximal expiration after a

maximal inspiration.

FEV1/FVC: FEV1 expressed as a percentage of the FVC, gives

a clinically useful index of airflow limitation.

The ratio FEV1/FVC is between 70% and 80% in normal

adults; a value less than 70% indicates airflow limitation

and the possibility of COPD.

What is Spirometry?

Spirometry, as an objective measure of how an individual

inhales and exhales air as a function of time is the gold

standard for diagnosing, assessing and monitoring COPD.

The Forced Expiratory Volume in the first second of

maximal expiration after a maximal inspiration (FEV1) is

used to assess the severity of COPD and is a marker of

disease progression.

Figure 1 shows the difference in spirometry results

between a person with normal lungs and one with COPD.

Refer to Pulmonary

Rehabilitation

Programme

Assessment Clinic

Start Pulmonary

Rehabilitation

Programme

Reassessment at

Completion of

Pulmonary

Rehabilitation

Programme

Review at 6 Months

Review at I year

Referral

from

Hospital Respiratory

Service

General Practice

Multidisciplinary

Physiotherapist/

Respiratory Nurse

Respiratory Consultant

Supervison

See

Detailed

Programme

Measurable

Outcomes

Assessed

And Audited

PULMONARY REHABILITATION PATHWAY

Pulmonary Rehabilitation Assessment Form

Name: Date of Assessment:

DOB: Hospital No:

Address: Medical Card No:

Tel No:

Mobile No:

Consultant:

GP:

Respiratory Diagnosis:

Other/Past Medical History: Social History

Occupation:

Mobility:

Transportation:

Medications:

Baseline Respiratory Function:

Mob Distance

Stairs

Uphill

Orthopnoea

Cough

Sputum

Wheeze

Stress Incontinence

Other

Home O2: Y N L/min Portable O2 Y N L/min

BiPAP: Y N Make: IPAP: EPAP:

Home Nebs: Y N

Smoking History: Y N Ex Pack Years

BMI: BORG:

HEART RATE: SaO2:

CXR Report:

Health Service LOGO Pulmonary Rehabilitation Referral

Date of Referral: Consultant:

Name DOB MRN

Address: Phone Number:

Diagnosis: Lung Function Date:

FEV1 > 80% GOLD I - Mild

FEV1 > 50% - <80% GOLD II - Moderate

FEV1 >30% - < 50% GOLD III - Severe

FEV1 < 30% GOLD IV - Very severe

Inclusion Criteria (Please Tick) √

1.Dx chronic respiratory disease (e.g COPD, bronchiectasis, lung transplant candidates)

2. No evidence of unstable asthma, ischaemic heart disease, decompensate/unstable heart failure, severe or uncontrolled systemic arterial hypertension, neuromuscular or musculoskeletal disorders or other disabling diseases that could resist exercise training.

3. No suspected underlying malignancy

4. Motivated to attend a 8 week outpatient exercise and education programme in a group setting.

5. Has the ability to exercise independently with supervision.

Relevant Investigations. CXR_____________________________________________________________________ ABG _____________________________________________________________________ ECG _____________________________________________________________________ ECHO EF_______% PAP’s_____mmHg Other

Optimization of respiratory medication per ITS/ICGP guidelines Yes No. Please List medications :

Have you discussed pulmonary rehabilitation with patient? Yes No

Will transport be required? Yes No

Smoking status: Current Smoker Ex-smoker (≥12mths) Never Smoked

If smoker has patient been referred to Smoking Cessation Officer Yes No

LTOT: Yes No _____L 16 / 24 hr/day Portable Oxygen Yes No ____L

Referring Health Professional Name: Signature: Phone: Fax: Email:

COPD Outreach Supported Early Discharge Certain patients will continue to be assessed for suitability for early discharge within 72 hours of presenting to the ED/AMAU by the COPD outreach team. Patients who fulfil the criteria, have a diagnosis of COPD and give their CONSENT will be recruited for early supported discharge. Please refer if patient fits inclusion criteria.

COPD Acute Management Bundle

Patient presents to ED/ AMU following G.P. / Self Referral

Patient assessed by ED/AMU Clinician and appropriate investigations ordered CXR ECG ABGs Blood Tests

(FBC, U+E, LFTS, CRP (if available) Action Time completed or

reason for Variation Signed

Administration of humidified O2 (FiO2 2L via nasal cannula or 28% via mask) Maintain Sao2 of >88% < 92%

On presentation

Check arterial blood gas and repeat if FiO2 increase is required or hypercapnia. If in respiratory failure with pH < 7.35 consider initiation of non- invasive ventilation/ transfer to appropriate unit.

Within 30 minutes of presentation

Administer nebulised Beta 2 agonists and/or anticholinergics Within 30 minutes of presentation

Review laboratory results Within 2 hours of presentation

Review Chest x-ray Within 2 hours of presentation

Administer antibiotics po amoxicillin or clarithromycin or doxycycline If new infiltrate treat as pneumonia (see pneumonia bundle)

Within 4 hours of presentation

Oral prednisone 40 mg (30 mg if 60kg or less) Within 4 hours of presentation

Consider COPD Outreach (complete inclusion/exclusion criteria)

Within 4 hours of presentation

Refer to respiratory team/Nurse Within 24 hours of admission

Ted stockings or LMWH for prophylaxis (if admitted) Within 8 hours of admission

Respiratory Nurse Led Hospital Care

Action Time completed or reason for variation

Signed Date of pre-arranged appointments

Provide patient information On initial review

Consider early discharge On initial review Review inhaler technique and ensure patient is competent and familiar with maintenance medications

When patient is stable

Organise spirometry When patient is stable xxxx Administer Flu vaccination When patient is stable Refer to pulmonary rehabilitation

When patient is stable xxxx

Assess oxygen requirements Before discharge Refer to smoking cessation Before discharge xxxx Ensure appropriate OPD/GP/Rapid Access appointment is made

Before discharge xxxx

Give patient individualised self management plan

Before discharge

Copy of self management plan for ………………………………………………...

Please fix patient label here Name of respiratory nurse: ……………………………………………… Contact details: ………………………………………………

10 TIPS FOR QUITTING SMOKING 1. MOTIVATION

There is no 'magic cure'. The first step is to Really WANT to stop smoking. To help you to get motivated you could write a list of why you want to quit smoking – here are a few suggestions; Health Reasons: Ask a professional to explain exactly how the cigarettes are affecting your health, you may be surprised how much of the body is affected by smoking. Try and remember times when you have been unwell, maybe in hospital. Other Reasons may include the cost of smoking etc. When you Quit smoking, keep the list of reasons at hand to help you stay motivated.

2. PREPARE TO QUIT Set a date to quit smoking and stick to it. Pick a time when you are not under any extra stress. Allow time to prepare to quit.

3. ASK YOUR GP/ PHARMACIST ABOUT QUIT SMOKING MEDICATION If you are a regular dependent smoker it has been proven that these may assist you in quitting smoking. Always seek advice from a health professional before using any of these products.

If you have a medical card you can avail of these for free, if prescribed NICOTINE REPLACEMENT THERAPY (patches, gum, lozenge, inhaler) are available from the Chemist.

Medication – CHAMPIX or ZYBAN are also available but MUST be prescribed from your GP.

4. CHANGE YOUR ROUTINE AND PLAN AHEAD Think about the TIMES & SITUATIONS when you smoke and write them down. Examples could be that you smoke first thing in the morning, when on the phone, watching TV, with tea/ coffee, alcohol, with friends, when bored or stressed. PLAN AHEAD, the easiest way to deal with these situations or to avoid them.

5. SEEK SUPPORT Seek help from family and friends. Know who is supportive, and will encourage you to stay quit. The NATIONAL SMOKERS QUITLINE is open 7 days per Week from 8am – 10pm, Call 1850 201 203

6. LEARN TO DEAL WITH CRAVINGS A strong craving lasts for approx 3 -5 MINUTES. Learn the 4 D's. Delay for a few minutes and the urge will go away. Distract Yourself Keep busy & Move away from the situation that you are in. Drink water, juice, have fruit, gum or a boiled sweet to replace the 'hand to mouth' habit of smoking. Deep Breathe Take a few deep breaths, slowly breathing out to help you relax.

7. EXERCISE REGULARLY AND WATCH WHAT YOU EAT You may feel more hungry when you stop smoking. Avoid substituting cigarettes with high calorie foods. Opt for low calorie snacks that will fill you. Always have breakfast which will help to kick-start your metabolism. Keep to your exercise plan recommended by your physiotherapist.