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Walker PP. Optimising the management of patients with COPD. Practitioner Mar 2019;263(1824):21-26

Optimising the management of patients with COPD

25 Mar 2019

AUTHORS

Dr Paul P Walker BMedSci (Hons) BM BS MD FRCP, Consultant Respiratory Physician, University Hospital Aintree and Honorary Senior Lecturer, University of Liverpool, Liverpool, UK

Competing interests: None

Article

Abstract

An estimated 1.2 million people are living with chronic obstructive pulmonary disease (COPD). Around 4.5% of people aged over 40 years have been diagnosed with COPD. COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age. Diagnosis is made using post-bronchodilator spirometry in patients with relevant clinical features. An FEV1/FVC ratio below 0.7 confirms the presence of persistent airflow limitation. However, the 2019 GOLD COPD guideline cautions against diagnosing COPD on the basis of a single post-bronchodilator FEV1/FVC measurement of between 0.6 and 0.7 because of biological variation. Use of a fixed FEV1/FVC ratio leads to overdiagnosis of COPD in older individuals and underdiagnosis in younger people so missing the chance for early intervention. Hence an increasing number of respiratory laboratories are using the lower limit of normal to report airflow obstruction. Referral is appropriate where there is diagnostic uncertainty. This can include situations where there is a disconnect between physiology (spirometry) and symptoms, where multiple conditions causing similar symptoms may overlap and where regular sputum production suggests a diagnosis of bronchiectasis.


The morbidity and excess mortality associated with lung disease has been brought into focus by the recent launch of the NHS Long Term Plan by NHS England1 with the prominent inclusion of respiratory medicine (see box 1).

Many of the recommendations and proposals impact on future care for people with COPD, in particular the organisation of care outside hospital, and align with the recent Taskforce for Lung Health report.2

Diagnosis

An estimated 1.2 million people are living with COPD making it the second most common lung condition after asthma.3 Around 4.5% of people aged over 40 years have been diagnosed with COPD. It is predominantly a condition of older age and most commonly diagnosed in the seventh to eighth decades. The hallmark of COPD diagnosis is opportunistic case finding based on clinical suspicion rather than screening.

COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) with symptoms such as breathlessness and wheeze, cough and phlegm, who has an associated risk factor; typically current, or a past history of, cigarette smoking. Other risk factors include passive environmental and occupational exposure to inhalants.

A diagnosis should also be suspected where a person with one or more risk factors develops a lower respiratory tract infection requiring treatment.

COPD is far more common in heroin and crack cocaine smokers and occurs at a younger age. A recent UK screening study shows a COPD prevalence of around 50% in current or former heroin and crack cocaine smokers attending drug centres.4

Diagnosis is made using spirometry in patients with relevant clinical features. Spirometry must be quality assured and performed by an individual who is trained, has ongoing support and supervision and who is doing the test regularly. A diagnosis of COPD should only be based on post-bronchodilator spirometry.

Taking into consideration the NICE asthma diagnostic guidance and current variability in spirometry services, many respiratory specialists believe that initial reversibility testing can be helpful, in particular to highlight asthma where there is reversibility of > 400 ml and where abnormal pre-bronchodilator spirometry normalises with a bronchodilator. Once a diagnosis is confirmed it is not recommended that reversibility is performed again unless there is a specific indication.

Interpretation of most spirometry is straightforward but sometimes it is more challenging and needs a clinician experienced in interpretation.

Whatever local model is chosen to deliver spirometry that expertise needs to be available.

Some services are increasing specialist involvement in reporting of first (diagnostic) spirometry in order to get the diagnosis right first time.

An increasing number of respiratory laboratories are using the lower limit of normal (LLN) to report airflow obstruction. This reduces overdiagnosis of COPD in older individuals and underdiagnosis in younger people (hence improving the chance for early intervention in the latter group) as shown in figure 2.

The 2019 international Global Obstructive Lung Disease (GOLD) COPD guideline6 recommends using a FEV1/FVC ratio of < 0.7 but specifically caution against diagnosing COPD in someone with a single post-bronchodilator FEV1/FVC measurement of between 0.6 and 0.7, because of biological variation. Using LLN makes spirometry more complex to interpret than using the traditional fixed cut-off for FEV1/FVC ratio of 0.7 and supports greater specialist input and oversight.

If an individual is diagnosed with COPD it is appropriate to perform a chest X-ray and a full blood count (for polycythaemia and eosinophil count) as recommended by NICE.7 At this point it is important to record MRC dyspnoea score, body mass index (BMI) and a measure of quality of life, such as the CAT score shown in figure 3.8

In December 2018, NICE updated its 2010 COPD guideline.7 The vast majority of the recommendations were unchanged or little changed but there were some important updates about treatment.

A full review of evidence-based treatment was published in the November 2017 edition of this journal9 and a detailed review of pulmonary rehabilitation in the January 2018 issue.10

Management

Antibiotics

In December 2018 NICE also published a guideline specifically on antibiotic prescribing in acute exacerbations of COPD.11 It recommends five days of treatment using amoxycillin, doxycycline or clarithromycin first and second line.

Antibiotics such as co-amoxiclav, levofloxacin and co-trimoxazole are reserved for specific organisms and circumstances. The guideline appropriately advises the use of antibiotics in circumstances where there is clear clinical evidence of an infection based on change in phlegm, in particular sputum colour but also an increase in volume.

It is particularly important that any clinician who prescribes and advises COPD patients about the use of emergency (rescue) packs emphasises that antibiotics are not required at the time of every exacerbation and use should be based on symptoms.

 

Inhaler technique

Inhaled therapy is the cornerstone of pharmacological treatment for COPD. There is evidence that instruction by a healthcare professional is a key component to an individual administering inhaled therapy correctly and that incorrect use of inhalers, in particular critical errors, are associated with more symptoms, poorer disease control, more exacerbations and more hospitalisations in COPD and asthma.12

Over the past few years, with a dramatic increase in the number and type of inhalers this has become more challenging and therefore arguably even more important. NICE emphasises that the smallest number of different devices should be prescribed.

 

Inhaler therapy

The key issue with respect to inhaler therapy in COPD is the use of inhaled corticosteroids (ICS). Unlike asthma, COPD is relatively poorly responsive to ICS and their role is to reduce exacerbation rate; hence, the recommendation for those patients with COPD who have two or more exacerbations per year and/or one or more episodes of hospitalisation.

The introduction of a number of long-acting beta-agonist/long-acting anti-muscarinic (LABA/LAMA) inhalers provides an alternative long-term inhaler option.

NICE has attempted to simplify inhaler prescription into three steps:

First, a short-acting bronchodilator, typically a short-acting beta-agonist (SABA), should be prescribed to all patients with COPD even if they are only used at the time of an exacerbation.

Second, for people with ongoing symptoms (breathlessness) and exacerbations, NICE recommends a LABA/LAMA with the option to use a LABA/ICS in those who have significant asthma. The latter includes a previous secure diagnosis of asthma, a higher blood eosinophil count, diurnal peak flow variation > 20% and substantial (> 400 ml) variation in FEV1 over time. The lack of a more precise definition for some of these markers of asthma is expected to cause some difficulty during implementation.

Third, if breathlessness and exacerbations continue then use of a LABA/LAMA/ICS combination is appropriate which can be prescribed as a triple combination inhaler. NICE has yet to publish complete guidance concerning triple therapy but this recommendation is a reflection of the current research evidence and GOLD guidelines.

The basis for using ICS in COPD is to reduce exacerbation rate. However, it is necessary to balance increased risk of pneumonia against any benefit seen in reductions in exacerbations and this should be discussed with the individual. It is now established that when patients with COPD have exacerbations and a blood eosinophil > 300 cells/µl they are likely to benefit from ICS and this is recommended by the GOLD guideline.6 However, it is less clear whether ICS should be prescribed in people with this higher eosinophil count and few exacerbations or how an eosinophil count of < 300 cells/µl should be used to guide treatment.

 

Oxygen

Long-term oxygen therapy reduces mortality in patients with COPD and chronic hypoxaemia. Ambulatory oxygen has a role in those who can walk further on formal testing using oxygen and are motivated to use it. However, oxygen is a potentially hazardous drug and there have been numerous safety alerts due to fires caused by ignition of oxygen, often related to smoking in the vicinity of oxygen. Relatively recently, a specific risk assessment was incorporated into oxygen assessment to attempt to reduce these risks.

The updated NICE guideline recommends that oxygen should only be prescribed to patients with COPD who do not smoke; a significant change from previous practice where it was often prescribed to smokers after a risk assessment.

Many COPD specialists are strongly opposed to this recommendation and the impact of this recent change is still far from clear. There are many other conditions where oxygen can be prescribed where this recommendation does not apply.

Discharge care bundles

The Best Practice Tariff (BPT) for COPD is payable by clinical commissioning groups to hospitals where specific measures concerning hospital COPD care are met. Hospitals have to submit details of every COPD hospitalisation to the National COPD Audit who report outcomes on which BPT payment is determined. The measures chosen are the proportion of people seen by a respiratory specialist within 24 hours of admission and use of a discharge care bundle; an example is shown in figure 4.

Fundamentally, this process is about delivering evidence-based interventions which are of proven benefit and is an outstanding example of using metrics to drive care quality improvement.

Previous publications on discharge bundles suggest an impact on COPD readmission14 and improvement in care quality.15 COPD discharge bundles emphasise checking and correcting inhaler technique as discussed earlier and promotion of self-management. The latter will not be successfully delivered by all, or perhaps even a majority of, patients with COPD but where successful it has a significant benefit including reducing rate of future hospitalisation.16

Referral for specialist review

There are a variety of reasons why specialist review might be sought. First, it is appropriate if there is diagnostic uncertainty. This can include situations where there is a disconnect between physiology (spirometry) and symptoms or where multiple conditions causing similar symptoms may overlap and it is unclear what treatment is best, for example, a patient with regular phlegm production where a diagnosis of bronchiectasis is being considered.

Second, referral is appropriate where certain treatments are being considered such as lung volume reduction, prescription of oxygen therapy and transplantation.

Finally, individuals who have, or are suspected of having, alpha-1-antitrypsin deficiency are likely to benefit from specialist input. Table 1 lists some of the potential reasons for seeking specialist input recommended in the 2018 NICE guideline.7 However, some of the other recommendations for referral suggested by NICE might be considered contentious by specialists (e.g. referral for consideration of long-term low-dose steroids) and few would consider specialist input necessary for referral for pulmonary rehabilitation.

Improving outcomes

The optimum way to improve COPD outcomes is to ensure that the diagnosis is made correctly and that patients are reviewed, at least annually, by a clinician trained to manage COPD.

Support with smoking cessation, delivery of pneumoccocal and annual influenza vaccination, pulmonary rehabilitation and provision of disease specific information to promote self-management are also key.

Optimisation of pharmacological therapy and management of comorbidity, in particular anxiety and depression, are vital. NICE recommends consideration of a cognitive behavioural component in the patient’s self-management plan to help manage anxiety and cope with breathlessness.

Furthermore, better organisation of care including joint working between primary and secondary care and use of admission prevention and early discharge schemes are important. Patients who are admitted should have early respiratory specialist review and a discharge care bundle.

REFERENCES

1 NHS England. The NHS Long Term Plan. NHS England. 2019  https://www.longtermplan.nhs.uk

2 Taskforce for Lung Health. A National Five Year Plan for Lung Health. Taskforce for Lung Health. (2018) www.blf.org.uk/taskforce/plan

3 British Lung Foundation. The Battle for Breath: The Impact of Lung Disease in the UK. British Lung Foundation. 2016 www.blf.org.uk/policy/the-battle-for-breath-2016

4 Burhan H, Young R, Byrne T et al. Screening heroin smokers attending community drug services for COPD. Chest 2019;155(2):279-87

5 Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. GOLD Committee. 2019    https://www.goldcopd.org/

6 British Lung Foundation. Out in the cold: Lung disease, the hidden driver of NHS winter pressure. British Lung Foundation. 2017 www.blf.org.uk/policy/out-in-the-cold

7 National Institute for Health and Care Excellence NG115. Chronic obstructive pulmonary disease in over 16s: Diagnosis and management. NICE. London. 2018 www.nice.org.uk/guidance/ng115

8 Jones PW, Harding G, Berry P et al. Development and first validation of the COPD assessment test. Eur Respir J 2009;34(3):648-54

9 Walker PP. Improving outcomes in COPD. Practitioner 2017;261(1809):13-17

10 Channell J, Walker PP. Pulmonary rehabilitation improves exercise capacity and quality of life. Practitioner 2018;262(1811):17-20

11 National Institute for Health and Care Excellence. NG114. Chronic obstructive pulmonary disease (acute exacerbation): Antimicrobial prescribing. NICE. London. 2018 www.nice.org.uk/guidance/ng114

12 Melani AS, Bonavia M, Cilenti V et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105(6):930-38

13 Rupple GL, Carlin BW, Hart M, Doherty DE. Office spirometry in primary care for the diagnosis and management of COPD: National Lung Health Education Programme Update. Respir Care 2018;63(2):242-52

14 Hopkinson NS, Englebretsen C, Cooley N et al. Designing and implementing a COPD discharge care bundle. Thorax 2012;67(1):90-92

15Turner AM, Lim WS, Rodrigo C et al. A care-bundles approach to improving standard of care in AECOPD admissions: results of a national project. Thorax 2015;70(10):992-94

16 Bucknall CE, Miller G, Lloyd SM et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ 2012;344:e1060