QUEST Integration – Chronic Obstructive Pulmonary Disease

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline Summary

• COPD is characterized by symptoms including cough, sputum production, and dyspnea on exertion
• The four components of COPD management include:
  1. Assessment and monitoring of COPD
  2. Reducing risk factors
  3. Managing stable COPD
  4. Managing exacerbations

Introduction

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by chronic airflow limitation and a range of pathological changes in the lung, some significant extra pulmonary effects and important comorbidities that may contribute to the severity of the disease in individual patients. The airflow limitation usually is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. This definition does not use the terms chronic bronchitis and emphysema, and excludes asthma (reversible airflow limitation). Symptoms of COPD include:

• Cough
• Sputum production
• Dyspnea on exertion

GOLD 2008 Update – Summary of Recommendations

• Including “previous tuberculosis” as a risk factor for COPD, and recognizing that a history of TB is associated with airflow obstruction in adults older than 40 years
• Recognizing that in patients with severe COPD, women have anatomically smaller airway lumens with disproportionately thicker airway walls than men. Women also exhibit emphysema that is less extensive and is characterized by smaller hole size and less peripheral involvement
• In patients with moderate to severe COPD, increases in lung function can be achieved following administration of inhaled anticholinergic plus sympathomimetic bronchodilators. Treatment with long-acting anticholinergic drugs improves the effectiveness of pulmonary rehabilitation
• Recognizing that pursed lip breathing may provide sustained improvement in exertional dyspnea and physical function
• Recognizing that inspiratory muscle training may provide additional benefits when used as part of a comprehensive pulmonary rehabilitation program
• In a large multicenter study, surgery was shown to reduce the frequency of COPD exacerbations and increase the time to first exacerbation
• In the use of glucocorticosteroids, therapy with oral prednisolone is preferable
• In the case of hospital discharge and follow-up, the following factors are shown to be predictive of readmission:
  • Prior hospital admission
  • Oral glucocorticosteroid use
  • Use of long-term oxygen therapy
  • Poor health related to quality of life
  • Lack of routine physical activity
• Including MDI formulation in the use of levalbuterol for COPD

Goals/desired outcomes

The purpose of this guideline is to increase awareness of COPD and consequently decrease morbidity and mortality. The goals of effective COPD management include the following:

• Prevent disease progression
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality
• Prevent or minimize side effects from treatment
• Cessation of cigarette smoking should be included as a goal throughout the management program

Diagnosis

A diagnosis of COPD should be considered in any individual who presents characteristic symptoms and a history of exposure to risk factors for the disease, especially cigarette smoking (see key indicators below). The diagnosis should be confirmed by spirometry, and where spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expiratory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but has poor specificity because it can be caused by other lung diseases and by poor performance. In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made to provide access to standardized spirometry.

Key indicators for considering a COPD diagnosis include:

• Chronic cough: May be intermittent and may be unproductive
• Chronic sputum production: Any pattern of chronic sputum production may indicate COPD
• Dyspnea that is:
  • Progressive (worsens over time)
  • Persistent (present every day)
  • Usually worse with exercise
  • Described by the patient as an “increased effort to breathe”, “heaviness”, “hunger”, or “gasping”
• History of exposure to risk factors, especially:
  • Tobacco smoke
  • Occupational dusts and chemicals
  • Smoke from home cooking and heating fuel
  • Outdoor air pollution
• When performing spirometry, measure:
  • Forced Vital Capacity (FVC) and
  • Forced Expiratory Volume in one second (FEV 1)

  Calculate the FEV 1 /FVC ratio. Spirometric results are expressed as percentage predicted using appropriate normal values for the person’s sex, age and height.

Differential diagnosis

A major differential diagnosis is asthma. In some patients with chronic asthma, a clear distinction from COPD is not possible using current imaging and physiological testing techniques and it is assumed that asthma and COPD coexist in these patients. In these patients, current management is similar to that of asthma. Other potential diagnoses usually are easier to distinguish from COPD.

Table 1 – Classification of COPD by Severity

Components of COPD management

The following four components comprise a COPD management program intended to increase awareness of COPD and consequently decrease morbidity and mortality:

1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD
4. Manage exacerbations

Component 1: Assess and monitor disease

A detailed medical history of a new patient known or thought to have COPD should assess:

• Exposure to risk factors, including intensity and duration
• Past medical history, including asthma, allergy, sinusitis or nasal polyps, respiratory infections in childhood, tuberculosis infection, oxidative stress and other respiratory diseases, as well as lung growth and development
• Demographic factors and family history of COPD or other chronic respiratory disease
• Pattern of symptom development
• History of exacerbations or previous hospitalizations for respiratory disorder
• Presence of comorbidities, such as heart disease, malignancies, osteoporosis, and musculoskeletal disorders that also may contribute to restriction of activity
• Appropriateness of current medical treatments
• Effect of disease on patient’s life, including limitation of activity, missed work and economic impact, effect on family routines and feelings of depression or anxiety
• Social and family support available to the patient
• Possibilities for reducing risk factors, especially smoking cessation

In addition to spirometry, the following tests may be considered for the assessment of a patient with Moderate (Stage II), Severe (Stage III), and Very Severe (Stage IV) COPD:

• Bronchodilator reversibility testing to rule out a diagnosis of asthma and guide initial treatment decisions
• Chest X-ray is seldom diagnostic in COPD but valuable to exclude alternative diagnoses, e.g., pulmonary tuberculosis
• Arterial blood gas measurement should be performed in stable patients with FEV1 <50% predicted or with clinical signs suggestive of respiratory failure or right heart failure. The major clinical sign of respiratory failure is cyanosis. Clinical signs of right heart failure include ankle edema and an increase in the jugular venous pressure
• Alpha-1 antitrypsin deficiency screening to be performed when COPD develops in Caucasian patients younger than 45, or in patients with a strong family history of COPD

COPD is usually a progressive disease. Lung function can be expected to worsen over time, even with the best available care. Symptoms and lung function should be monitored to follow the development of complications, to guide treatment, and to facilitate discussion of management options with patients.

Component 2: Reduce risk factors

The most important risk factor for COPD is cigarette smoking. Pipe, cigar and other types of tobacco smoking popular in many countries are also risk factors for COPD. Smoking cessation is the single most effective – and cost-effective – intervention to reduce the risk of developing COPD and slow its progression. At every possible opportunity, individuals who smoke should be encouraged to quit. Even a brief, 3-minute period of counseling to urge a smoker to quit can be effective, and at a minimum this should be done for every smoker at every visit. More intensive strategies increase the likelihood of sustained quitting.

Pharmacotherapy (nicotine replacement and/or bupropion) is recommended when counseling is not sufficient to help patients stop smoking. Special consideration should be given before using pharmacotherapy in people smoking fewer than 10 cigarettes per day, pregnant women, adolescents, and those with medical contraindications (unstable coronary artery disease, untreated peptic ulcer, recent myocardial infarction or stroke for nicotine replacement and history of seizures for buproprion).

Smoking prevention: Encourage comprehensive tobacco-control policies and programs with clear, consistent and repeated nonsmoking messages. Work with government officials to pass legislation to establish smoke-free schools, public facilities, and work environments and encourage patients to keep smoke-free homes.

For brief strategies to help the patient willing to quit, follow the five A’s:

1. Ask – Systematically identify the tobacco-use of every patient. Implement an office-wide system to ensure that every patient be asked about his/her tobacco-use status, and that information is recorded in the medical record. Repeated assessment is not necessary in the case of an adult who has never smoked or has not smoked for many years, if this information is clearly documented in the medical record.
2. Advise – Strongly urge all tobacco users to quit. In a clear, strong, and personalized manner, urge every smoker to quit.
3. Assess – Determine willingness to make a quit attempt. Ask every tobacco use if he or she is willing to make an attempt to quit at this time (e.g., within the next 30 days).
4. Assist – Aid the patient in quitting. Help the patient devise a plan to quit smoking. Set a quit date. Encourage treatment therapies except in special circumstances. Give key advice on successfully quitting: total abstinence, limiting or abstaining from drinking alcohol during the quitting process and considering the potential influence of other smokers in the household.
5. Arrange – Schedule follow-up contact. Schedule follow-up contact, either in person or via telephone. Timing should occur soon after the planned quit date, preferably during the first week. Second follow-up contact is recommended within the first month. Congratulate success, review circumstances for smoking, elicit recommitment, assess treatments and consider referral.

*Recommended pharmacotherapies for smoking cessation include: nicotine-replacement therapy, bupropion SR, and varenicline (Chantix).

See the Smoking Cessation guideline for more information.

Occupational exposures: Emphasize primary prevention, which is best achieved by elimination or reduction of exposures to various substances in the workplace. Secondary prevention, achieved through surveillance and early detection, is also important.

Indoor and outdoor air pollution: Implement measures to reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings.

Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors altogether during pollution episodes. Air cleaners directed at indoor or outdoor pollutants have not been shown to have health benefits.

Component 3: Manage stable COPD

Management of stable COPD should be guided by the following general principles:

• Determine disease severity on an individual basis by taking into account the patient’s symptoms, airflow limitation, frequency and severity of exacerbations, complications, respiratory failure, comorbidities and general health status
• Implement a stepwise treatment plan that reflects this assessment of disease severity
• Choose treatments according to national and cultural preferences, the patient’s skills and preferences, and the local availability of medications

Patient education can help improve skills, ability to cope with illness and health status. It is an effective way to accomplish smoking cessation, initiate discussions and understanding of advance directives and end-of-life issues, and improve responses to acute exacerbations.

Pharmacologic treatment can improve and prevent symptoms, reduce the frequency and severity of exacerbations, improve health status and improve exercise tolerance. See Figure 1 – Therapy [PDF].

Bronchodilators: These medications are central to symptom management in COPD.

• Give “as-needed” to relieve intermittent or worsening symptoms, or on a regular basis to prevent or reduce symptoms
• The choice between beta2-agonists, anticholinergics, methylxanthines and combination therapy depends on the availability of medications and each patient’s individual response in terms of both symptom relief and side effects
• Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators
• Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects
• Theophylline is effective in COPD, but due to its potential toxicity, inhaled bronchodilators are preferred when available

Glucocorticosteroids: Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic patients with FEV1 <50% predicted (Stage III: Severe and Stage IV: Very Severe) and repeated exacerbations

Regular treatment with inhaled glucocorticosteroids may relieve symptoms in this carefully selected group of patients but does not modify the long-term decline in FEV1. The dose-response relationships and long-term safety of inhaled glucocorticosteroids in COPD are not known. Long-term treatment with oral glucocorticosteroids is not recommended.

Short-term treatment with a combined inhaled glucocorticosteroid and long-acting beta2-agonist resulted in greater control of lung function and symptoms than combined anticholinergic and short-acting beta2-agonist.

An inhaled glucocorticosteroid combined with a long-acting beta2-agonist is more effective than the individual components.

Withdrawal from treatment with inhaled glucocorticosteroids can lead to exacerbations in some patients.

Vaccines: Influenza vaccines reduce serious illness and death in COPD patients by 50 percent. Administer once a year at the beginning of the flu season. Pneumococcal polysaccharide vaccine is recommended for COPD patients >65 years old and for COPD patients < 65 years old with FEV1 <40% predicted.

Antibiotics: Not recommended except for treatment of infectious exacerbations and other bacterial infections. Based on the current available evidence, antibiotics should be given to:

• Patients with exacerbations of COPD with three of the following cardinal symptoms: increased dyspnea, increased sputum volume, increased sputum purulence
• Patients with exacerbations of COPD with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms
• Patients with a severe exacerbation of COPD that requires mechanical ventilation (non-invasive)

Mucolytic (mucokinetic, mucoregulator) agents: Patients with viscous sputum may benefit from mucolytics, but overall benefits are very small. Widespread use is not recommended.

Antitussives: Regular use is not recommended in stable COPD.

Vasodilators: Nitric oxide is contraindicated in stable COPD.

Non-pharmacologic treatment includes rehabilitation, oxygen therapy, and surgical interventions.

Rehabilitation programs should include, at a minimum:

• Exercise training
• Nutrition counseling
• Education

Patients at all stages of disease benefit from exercise training programs, with improvements in exercise tolerance and symptoms of dyspnea and fatigue. Benefits can be sustained even after a single pulmonary rehabilitation program, whether it is conducted in an inpatient, outpatient or home setting. The minimum length of an effective rehabilitation program is two months; the longer the program continues, the more effective the results.

Oxygen therapy: The long-term administration of oxygen (>15 hours per day) to patients with chronic respiratory failure increases survival and has a beneficial impact on hemodynamics, hematological characteristics, exercise capacity, lung mechanics and mental state. There is no evidence of benefit from using short burst oxygen for symptomatic relief before or after exercise.

Surgical treatments: Bullectomy and lung transplantation may be considered in carefully selected patients with Stage IV: Very Severe COPD. Lung-volume reduction surgery (LVRS) remains an experimental palliative surgical procedure not recommended for widespread use.

Several studies in high-risk COPD patients suggest that there is a threshold beyond which the risk of surgery is prohibitive. Surgery should be postponed if an exacerbation is present. Surgery in patients with COPD needs to be differentiated from that aimed to improve function and symptoms for COPD. This includes bullectomy, lung volume reduction surgery and lung transplantation.

Ventilatory support: Noninvasive ventilation (using either negative or positive pressure devices) is now widely used to treat acute exacerbations of COPD. However, there is no convincing evidence that mechanical ventilatory support has a role in the routine management of stable COPD.

Component 4: Manage exacerbations

COPD is often associated with exacerbations of symptoms. Many exacerbations are caused by infection of the tracheobronchial tree or an increase in air pollution; however, the cause of about one-third of severe exacerbations cannot be identified.

A COPD exacerbation is defined as: an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.

How to assess the severity of an exacerbation:

• Spirometric tests are not routinely recommended because they are not accurate during an acute exacerbation
• Pulse oximetry: May be used to evaluate need for supplemental oxygen therapy
• Chest X-ray: Chest radiographs (posterior/anterior plus lateral) identify complications such as pneumonia and alternative diagnoses that can mimic the symptoms of an exacerbation
• ECG: Aids in the diagnosis of right ventricular hypertrophy, arrhythmias, and ischemic episodes
• Other laboratory tests:
  • Sputum culture and antibiogram to identify infection if there is no response to initial antibiotic treatment
  • Biochemical tests to detect electrolyte disturbances, poor glucose control, and metabolic acid-base disorder

Home management

Bronchodilators: Increase the dose and/or frequency of current bronchodilator therapy. If not already in use, add anticholinergics until symptoms improve.

Glucocorticosteroids: If baseline FEV1 <50% predicted, add 30-40 mg oral prednisolone per day for 7-10 days to the bronchodilator regimen. Therapy with oral prednisolone is preferable.

Antibiotics: When symptoms of breathlessness and cough are increased and sputum is purulent and increased in volume, provide antibiotic coverage of the major bacterial pathogens involved in exacerbations, taking into account local patterns of antibiotic activity.

Hospital management

Patients with the characteristics listed below should be hospitalized. Indications for referral and the management of exacerbations of COPD in the hospital depend on local resources and the facilities of the local hospital.

Indications for hospital admission for exacerbations:

• Marked increase in intensity of symptoms, such as sudden development of resting dyspnea
• Severe background COPD
• Onset of new physical signs (e.g., cyanosis, peripheral edema)
• Failure of exacerbation to respond to initial medical management
• Significant comorbidities
• Frequent exacerbations
• Newly occurring arrhythmias
• Diagnostic uncertainty
• Older age
• Insufficient home support

Early outpatient pulmonary rehabilitation after hospitalization for COPD exacerbation results in exercise capacity and health status improvements at three months.

Home care or hospital care for end-stage COPD patients?

The risk of dying from an exacerbation of COPD is closely related to the development of respiratory acidosis, the presence of serious comorbidities, and the need for ventilatory support. Patients lacking these features are not at high risk of dying, but those with severe underlying COPD often require hospitalization in any case. Attempts at managing such patients entirely in the community have met with limited success, but returning them to their homes with increased social support and a supervised medical care program after an initial emergency room assessment has been much more successful. However, detailed cost-benefit analyses of these approaches have not been reported.

Additional reference documents

• COPD Care Guide 2009 [PDF]
• Therapy at Each Stage of COPD [PDF]
• Update to Therapy at Each Stage of COPD [PDF]
• GOLD Report 2008 (Global Initiative for COPD) [PDF]

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Sources

1. Global Initiative for Chronic Obstructive Lung Disease. (2008). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: Updated 2008.

References

1. National Collaborating Center for Chronic Conditions. (2004). Chronic obstructive pulmonary disease: National clinical guideline on the management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax, 59(Suppl1):1-232.

Revision History