Think of the diagnosis of COPD



Think of the diagnosis of COPD163639513652500Perform spirometry if COPD seems likelyAirflow obstruction is:FEV1 < 80% predictedANDFEV1:FVC ratio < 0.7FEV1Severity24339554445000Over age 35, Smoker or ex-smokerHave any of:Exertional dyspnoeaChronic coughRegular sputum productionFrequent winter bronchitisWheezeand have no features of asthma≥ 80%Mild50% – 79%Moderate30% – 49%Severe< 30%Very Severe(or FEV1 <50% with respiratory failure)MRC dyspnoea scale 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 metres or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing , Referral for Specialist Advice May be appropriate if any of the following apply Diagnostic uncertainty Consider for lung volume reduction or transplantation Severe COPD The patient requests a second opinion Dysfunctional breathing Patient aged under 40 years Family history of alpha-1 antitrypsin deficiency Assessment for nebuliser therapy Assessment for oral corticosteroid therapy Bullous lung disease Rapid decline in FEV1 Symptoms disproportionate to lung function deficit Frequent respiratory tract infections Haemoptysis Palliative careLong Term Oxygen TherapyIndications Severe airflow obstruction (FEV1 < 30%) Cyanosis Polycythaemia Peripheral oedema A raised jugular venous pressure or Oxygen saturations ≤ 92% breathing air when stableDetailed Prescribing information for drug types (see over for algorithm for order of preference)LAMASingle agent LAMA inhalerCombination inhaler LAMA + LABAUmeclidinium Incruse? Ellipta 1 ODAnoro? (Umeclidinium + Vilanterol) Ellipta 1 ODAclidinium Eklira? Genuair 1 BDDuaklir? (Aclidinium + Formoterol) Genuair 1 BDGlycopyrronium Seebri? Breezhaler 1 ODUltibro? (Glycopyronnium + Indacaterol) Breezhaler 1 ODTiotropiumBraltus? Zonda 1 OD orSpiriva? Respimat 2 ODSpiolto? (Tiotropium + Olodaterol) Respimat 2 ODLABASingle agent LABA inhalerCombination inhaler LABA + ICSVilanteroln/aRelvar? (Vilaneterol + Fluticasone Furoate) Ellipta 1 ODIndacaterolOnbrez? Breezhaler 1 ODn/aOlodaterolStriverdi? Respimat 2 ODn/aFormoterolOxis? Turbohaler 2 ODDuoresp? Spiromax 160/4.5 2 BD / Symbicort? Turbohaler 200/6 2 BD (Formoterol + Budesonide) or Fostair? 100/6 MDI (Formoterol + Beclometasone) 2 BDor Symbicort? 200/6 MDI (Formoterol + Budesonide) 2 BDSalmeterolSerevent? MDI 2 OD / Accuhaler 1 ODSeretide? 50/500 (Salmeterol + fluticasone) Accuhaler 1 BDABBREVIATIONS: SABA: Short acting beta-2 agonist; LABA: Long acting beta-2 agonist, LAMA: Long acting antimuscarinic; ICS: Inhaled corticosteroid; MDI: Metered dose inhaler, OD=Once daily, BD=Twice dailyThis guidance adapted from: Global Strategy for Diagnosis, Management, and Prevention of COPD (GOLD) Update 2015COPD Management of chronic obstructive pulmonary disease in adults in primary and secondary care NICE 2010 Stable COPD Treatment Algorithm and Preferred Inhalers793102690465Before embarking on new or changing inhaled medication, consider the following interventions:Check inhaler techniqueLifestyle advice (smoking cessation, diet and exercise). Address psychological issuesVaccination: Influenza (annual) and PneumococcalComorbidities; including osteoporosis, depression and coexisting cardiovascular diseasePulmonary rehabilitation if functionally disabled - consider re-referral for repeat rehabilitation coursesUse of TeleMedicine, Gold Standards Framework, Palliative Care and consider DNACpR Status00Before embarking on new or changing inhaled medication, consider the following interventions:Check inhaler techniqueLifestyle advice (smoking cessation, diet and exercise). Address psychological issuesVaccination: Influenza (annual) and PneumococcalComorbidities; including osteoporosis, depression and coexisting cardiovascular diseasePulmonary rehabilitation if functionally disabled - consider re-referral for repeat rehabilitation coursesUse of TeleMedicine, Gold Standards Framework, Palliative Care and consider DNACpR Status-673102045335Prescribing for COPD is based on assessment of risk of exacerbations (based on previous exacerbations and/or FEV1) and the patient’s symptomsThe treatment recommendations in the following table outline the preferred inhaler therapy for each category of COPD patient, as defined in GOLD 2015The preferred inhaler therapies listed are based on (i) ease of use of inhaler device; (ii) evidence of safety and efficacy from clinical trials; (iii) cost.Where required, combination inhaler devices (e.g. ICS/LABA, LAMA/LABA or ICS/LABA/LAMA) should be prescribed in preference to separate devices.00Prescribing for COPD is based on assessment of risk of exacerbations (based on previous exacerbations and/or FEV1) and the patient’s symptomsThe treatment recommendations in the following table outline the preferred inhaler therapy for each category of COPD patient, as defined in GOLD 2015The preferred inhaler therapies listed are based on (i) ease of use of inhaler device; (ii) evidence of safety and efficacy from clinical trials; (iii) cost.Where required, combination inhaler devices (e.g. ICS/LABA, LAMA/LABA or ICS/LABA/LAMA) should be prescribed in preference to separate devices.Fewer Symptoms (CAT < 10, MRC < 1)More Symptoms (CAT ≥ 10, MRC ≥ 2)Low exacerbation risk<2 exacerbationsno admissions for exacerbations and FEV >50%Low risk, fewer COPD symptoms(GOLD category A)Low exacerbation risk, more COPD symptoms(GOLD category B)SABALAMA (or LABA if LAMA contraindicated)LAMA + LABAUse combination if single agent ineffectiveSalbutamol MDI, easyhaler or easi-breathe 2 PRNIncruse? Ellipta 1 ODAnoro? Ellipta 1 ODEklira? Genuair 1 BDDuaklir? Genuair 1 BDHigh exacerbation risk≥ 2 exacerbationsHistory of admissions for exacerbations orFEV ≤50%High exacerbation risk, fewer COPD symptoms(GOLD category C)High exacerbation risk, more COPD symptoms(GOLD category D)FEV1 <50%, < 2 exacerbations per year and no admissionsLAMA + LABAAny FEV1 > 2 exacerbations per year or at least one admissionLABA + ICSLAMA + LABA + ICSAnoro? Ellipta 1 ODRelvar? Ellipta 1 ODTrelegy? Ellipta 1 ODDuaklir? Genuair 1 BDFostair? 100/6 MDI 2 BDTrimbow? MDI 2 BDABBREVIATIONS: SABA: Short acting beta-2 agonist; LABA: Long acting beta-2 agonist, LAMA: Long acting antimuscarinic; ICS: Inhaled corticosteroid; MDI: Metered dose inhaler, OD=Once daily, BD=Twice daily. Page 2 of 2 ................
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