COPD Management (Read Code H3) - Pennine GP Training



COPD Management (Read code H3)

Definition

A chronic progressive deterioration of small airway obstruction with little variation in lung function and incomplete reversibility. Spirometry essential.

Usually over the age of 35 with a history of greater than 10 pack years of smoking (daily smokes x years of smoking divided by 20).

Common (2x angina) but often undiagnosed.

Post bronchodilator FEV1 < 80% of predicted and FEV1/FVC ratio < 0.7 indicating an obstructive picture with a history consistent with COPD.

• Do not Read code as COPD (H3 or by severity as below) unless the diagnosis is confirmed by history and post bronchodilator spirometry. All FEV1 and FVC values should be Read coded!

• Diagnosis should only be made with postbronchodilator spirometry and coded as such for QOF

Grading of severity

On the basis of post bronchodilator FEV1/predicted in patients with an FEV1/FVC ratio 80%* |XaElV |

|Moderate airflow obstruction | 50–79% |XaElW |

|Severe airflow obstruction | 30 – 49% |XaElY |

|V. Severe airflow obstruction | 10 pack years smoking hx and > 35 years – if not re-consider the diagnosis.

▪ Objective assessment with post bronchodilator FEV1/FEV ratio < 0.7 with no significant reversibility. Record grade: mild, moderate or severe on the basis of percentage post bronchodilator FEV1 vs predicted.

▪ Record BMI

▪ CXR to exclude bullae, tumour, pulmonary oedema, bronchiectasis (CT may be required )

▪ Consider FBC if there is a clinical suspicion of anaemia or polycythaemia.

▪ Consider alpha-antrypsin deficiency if < 40 years old

When to refer

1. Uncertain diagnosis e.g. History or Examination: age 25, Pulse > 110, unable to speak in sentences or confused.

• SaO2 4 x seven day courses in a lifetime).

• Inhaled steroid > 1000mcg day beclomethasone.

If unable to have a DEXA then treat, 1st line = a bisphosphonate.

If steroid course likely to > 3 months then treat, 1st line = a bisphosphonate.

If able to have a DEXA and the T score above -1.5 treat with lifestyle measures +/- calcium supplementation. NB DEXA needs repeating every 3 years

If the T score is = -1.5 or lower then treat, 1st line = a bisphosphonate.

NB Consider repeat DEXA every 3 years

Another strategy for deciding who warrants a DEXA scan is to use Qfracture - (or FRAX via SystmOne) where a DEXA is indicated if risk >10%.

QOF summary points

COPD001 COPD register 3

COPD002 post-bronchodilator spirometry 5

if diagnosed after 1/4/11

(3/12 before to 12/12 after diagnosis)

COPD003 Annual review, including 9

MRC dyspnoea scale

COPD004 FEV1 within 12 months 7

COPD005 SpO2 if MRC score 3 or above 5

COPD007 fluvax in preceding 1st August 6

to 31st March

total 35

Reference:

NICE 2010





The management of chronic breathlessness in patients with advanced and terminal illness

BMJ 2015; 349 doi:  (Published 02 January 2015)



GPUpdate handbook 2015

Useful Read codes (Systm1)

COPD H3

Post bronchodilator spirometry XaXeg

Referral for spirometry XaK02

COPD annual review XaIet

MRC dyspnoea scale 1 XaIUi

MRC dyspnoea scale 2 XaIUl

MRC dyspnoea scale 3 XaIUm

MRC dyspnoea scale 4 XaIUn

MRC dyspnoea scale 5 XaIUo

Mild COPD XaElV

Moderate COPD XaElW

Severe COPD XaElY

Very severe COPD XaN4a

Oxygen saturation at periphery X770D

Admit COPD emergency XaJFu

Number of COPD exacerbations in

past year XaK8U

Summary reproduced from BNF 68 0/3 2015 p 184 3.1

[pic]

Example of COPD exacerbation info for patients

BRIG ROYD SURGERY

COPD Action Plan

WHAT ACTION TO TAKE IF YOUR SYMPTOMS (cough, sputum or shortness of breath) GET WORSE

1. RELIEVER TREATMENT

Via inhaler or nebuliser

Maximum dose ______ / ______ times per day

2. Check the colour of your sputum:

Cough sputum onto a white tissue

If your sputum colour has changed from clear or pale to a darker shade

e.g. yellow or green: start ANTIBIOTICS:

Please take your home supply

or obtain a prescription without delay from the surgery

3. PREDNISOLONE

If breathlessness is not improved by relievers, take 30mg once daily

(6 x 5mg tablets) for planned course (duration may vary).

4. Follow up

Let us know (same or next working day) if you have needed to use your standby treatment. We will usually want to review your chest and treatment after an episode like this

5. If you are not getting better with treatment or getting worse despite treatment, let us know (or out of hours NHS 111) as you may need an urgent assessment.

Further information for patients and carers:





Adapted from Primary Care Respiratory Society 2010

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