COPD - NICE guideline

NICE guideline of Chronic Obstructive Pulmonary Disease

1. 0
Chronic obstructive
pulmonary disease
Implementing NICE guidance
2
nd
Edition July 2011
NICE clinical guideline 101

2. NICE Pathway
The NICE COPD pathway covers the management of
COPD in adults in primary care and secondary care and
shows recommendations on:
• When to consider referral
• Diagnosis
• Managing stable COPD
• Managing exacerbations
• Palliative Care
Click here to go to
NICE Pathways
website

4. What this presentation covers
Background
Scope
Definition
Recommendations
Costs and savings
Discussion
NICE COPD quality standard
Find out more

5. Epidemiology
• About 3 million people have chronic obstructive pulmonary
disease (COPD) in the UK
• Nearly 900,000 people in England and Wales are
diagnosed as having COPD and an estimated 2 million people
have COPD which remains undiagnosed
• Symptoms usually develop insidiously making it difficult to
determine the true prevalence of the disease
• Most patients are not diagnosed until they are in
their fifties

6. Background
•COPD is predominantly caused by smoking and is
characterised by airflow obstruction that:
- is not fully reversible
- does not change markedly over several months
- is usually progressive in the long term
•Exacerbations often occur, where there is a rapid and
sustained worsening of symptoms beyond normal day-
to-day variations requiring a change in treatment

7. Scope
The scope for the guideline update was to examine:
a) Diagnosis and severity classification:
•spirometry and post-bronchodilator values
•multidimensional severity assessment indices (for example, the
BODE index)
a) Management of stable COPD and prevention of disease progression
•long-acting bronchodilators: beta
2
agonists and anticholinergics
(tiotropium, formoterol fumarate, salmeterol) as monotherapy and in
combination, both with and without inhaled corticosteroids
•mucolytic therapy (carbocisteine and mecysteine hydrochloride)
BODE = body mass index, airflow obstruction,
dyspnoea and exercise tolerance

8. Definition of COPD
• Airflow obstruction is defined as reduced FEV
1
/FVC ratio (< 0.7)
• It is no longer necessary to have an FEV
1
< 80% predicted for definition of
airflow obstruction
• If FEV
1
is ≥ 80% predicted, a diagnosis of COPD should only be made in
the presence of respiratory symptoms, for example breathlessness or cough
• COPD produces symptoms, disability and impaired quality of life which
may respond to pharmacological and other therapies that have limited or no
impact on the airflow obstruction.
FEV
1
= forced expiratory volume in 1 second
FVC = forced vital capacity

9. Natural History
•The Fletcher-Peto Diagram, illustrating the
effects of smoking on rate of decline in FEV
1

10. Diagnose COPD
Consider a diagnosis of COPD for people who are:
•over 35, and
•smokers or ex-smokers, and
•have any of these symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production,
-frequent winter ‘bronchitis’
-Wheeze
•And no clinical features of asthma
[2004]

11. Diagnose COPD: Spirometry
•Perform spirometry if COPD seems likely [2004]
•The presence of airflow obstruction should be confirmed by
performing post-bronchodilator spirometry [new 2010]
•Consider alternative diagnoses or investigations in:
- older people without typical symptoms of COPD
where the FEV1/FVC ratio is < 0.7
- younger people with symptoms of COPD where the
FEV1/FVC ratio is ≥ 0.7 [new 2010]
•All health professionals involved in the care of people with COPD
should have access to spirometry and be competent in the
interpretation of the results [2004]

12. Differentiating COPD from
asthma
Clinical features COPD Asthma
Smoker or ex-smoker Nearly all Possibly
Symptoms under age 35 Rare Often
Chronic productive cough Common Uncommon
Breathlessness Persistent and
progressive
Variable
Night time waking with breathlessness
and or wheeze
Uncommon Common
Significant diurnal or day to day
variability of symptoms
uncommon Common
[2004]

13. Differentiating COPD from
asthma: 2
• If diagnostic uncertainty remains, the following findings should be
used to help identify asthma:
- FEV
1
and FEV
1
/FVC ratio return to normal with drug therapy
- a very large (>400ml) FEV
1
response to
bronchodilators or to 30mg prednisolone daily for 2 weeks
- serial peak flow measuremenst showing significant (20% or
greater) diurnal or day-to-day variability
- remaining diagnostic uncertainty may be resolved by referral
for more detailed investigations
[2004]

14. Diagnose COPD: assessment
of severity
•Assess severity of airflow obstruction using reduction in FEV
1
NICE
clinical
guideline 12
(2004)
ATS/ERS 2004 GOLD 2008 NICE clinical
guideline 101
(2010)
Post-
bronchodilator
FEV
1
/FVC
FEV
1
%
predicted
Post-
bronchodilato
r
Post-
bronchodilator
Post-
bronchodilator
< 0.7 80% Mild Stage 1 (mild)Stage 1 (mild)*
< 0.7 50–79% Mild Moderate Stage 2
(moderate)
Stage 2
(moderate)
< 0.7 30–49% Moderate Severe Stage 3 (severe)Stage 3 (severe)
< 0.7 < 30% Severe Very severe Stage 4 (very
severe)**
Stage 4 (very
severe)**
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction
** Or FEV
1
< 50% with respiratory failure
[new 2010]

15. Patient with COPD
Palliative care
Smoking Breathlessness &
exercise limitation
Frequent
exacerbations
Respiratory
failure
Cor
pulmonale
Abnormal
BMI
Chronic
productive
cough
Anxiety &
depression
Managing stable COPD
Assess symptoms/problems
Manage those that are present as below
Patients with COPD should have access to the wide range
of skills available from a multidisciplinary team

16. Managing stable COPD: Stop
smoking
•Encouraging patients with COPD to stop smoking is one of the
most important components of their management
•All COPD patients still smoking, regardless of age, should be
encouraged to stop, and offered help to do so, at every
opportunity
•Record a smoking history, including pack years smoked
•Offer nicotine replacement therapy, varenicline or bupropion
(unless contraindicated) combined with a support programme to
optimise quit rates [2010]
[2004]

17. Managing stable COPD:
Promote effective inhaled
therapy
In people with stable COPD who remain breathless or have
exacerbations despite using short-acting bronchodilators as
required, offer the following as maintenance therapy:
•if FEV
1
≥ 50% predicted: either LABA or LAMA
•if FEV
1
< 50% predicted: either LABA+ICS in a combination inhaler,
or LAMA
Offer LAMA in addition to LABA+ICS to people with COPD who remain
breathless or have exacerbations despite taking LABA+ICS,
irrespective of their FEV
1
ICS = inhaled corticosteroid
LABA = long-acting beta
2
agonist
LAMA = long-acting muscarinic agonist
[new 2010]

18. Managing stable COPD:
inhaled therapies
SABA or SAMA as required*
Breathlessness and
exercise limitation
Exacerbations
or persistent
breathlessness
Persistent
exacerbations or
breathlessness
LABA LAMA
Discontinue
SAMA
________
Offer LAMA in
preference to regular
SAMA four times a day
LABA + ICS in a
combination
inhaler
________
Consider LABA +
LAMA if ICS
declined or not
tolerated
LAMA
Discontinue
SAMA
________
Offer LAMA in
preference to
regular SAMA four
times a day
FEV
1
≥ 50% FEV
1
< 50%
LABA + ICS
in a combination
inhaler
________
Consider LABA +
LAMA if ICS
declined or not
tolerated
LAMA + LABA + ICS
in a combination
inhaler
Offer Consider
* SABAs (as required)
may continue at all stages

19. Managing stable COPD: Oral
corticosteroids
• Maintenance use of oral corticosteroid therapy in COPD is not
recommended
• Some patients with advanced COPD may require maintenance
oral corticosteroids when these cannot be withdrawn following an
exacerbation
• The does of oral corticosteroids should be kept as low as possible
• Any patient treated with long term corticosteroid therapy should be
monitored for the development of osteoporosis and given
appropriate prophylaxis. Patients over the age of 65 should be
started on prophylactic treatment without the need for
monitoring

20. Managing stable COPD:
Oxygen
• Clinicians should be aware that inappropriate oxygen therapy in
people with COPD may cause respiratory depression
• Use appropriate oxygen therapy:
•Long-term oxygen therapy
•Ambulatory
•Short burst

21. Managing stable COPD:
Cor pulmonale
• A diagnosis of cor pulmonale should be considered if patients
have:
- Peripheral odema, raised venous pressure, systolic
parasternal heave, a loud pulmonary second heart sound.
• Assess need for oxygen
•Use diuretics
[2004]

22. Managing stable COPD:
provide pulmonary
rehabilitation
Pulmonary
rehabilitation
An individually tailored
multidisciplinary programme of
care to optimise patients’
physical and social
performance and autonomy
Tailor multi-component,
multidisciplinary
interventions to individual
patient’s needs
Hold at times that
suit patients, and in
buildings with good
access
Offer to all patients who
consider themselves
functionally disabled by
COPD
Make available to all
appropriate people, including
those recently hospitalised
for an acute exacerbation
[new 2010]

23. Multidisciplinary working
•COPD care should be delivered by a multidisciplinary team that includes
respiratory nurse specialists
•Consider referral to specialist departments (not just respiratory physicians)
[2004]
Specialist departmentWho might benefit?
Physiotherapy Advice about excessive sputum
Dietetic advice People with BMI that is high, low or
changing over time
Occupational therapy People needing help with daily living
activities
Social services People disabled by COPD
Multidisciplinary palliative
care teams
People with end-stage COPD (and their
families and carers)

24. Follow-up of patients with
COPD
• Follow-up of patients should include:
-Highlighting the diagnosis in the case record
-Recording the values of spirometric tests
-Offering stop smoking advice
-Recording the opportunistic measurement of spirometric
parameters
• Patients should be reviewed at least once per year
• For most patients with stable severe disease regular hospital
review is not necessary
[2004]

25. Managing exacerbations
•Minimise impact of exacerbations by:
- giving self-management advice on responding
promptly to symptoms of exacerbation
- starting appropriate treatment with oral steroids
and/or antibiotics
- use of non-invasive ventilation when indicated
- use of hospital-at-home or assisted-discharge schemes
•The frequency of exacerbations should be reduced
by appropriate use of inhaled corticosteroids and
bronchodilators, and vaccinations
[2004]

26. Use non-invasive ventilation (NIV)
•Use NIV as the treatment of choice for persistent hypercapnic
ventilatory failure during exacerbations not responding to medical
therapy
•NIV should be delivered by staff trained in its application,
experienced in its use and aware of its limitations
•When starting NIV, make a clear plan covering what to do in the
event of deterioration and agree ceilings of therapy
[2004]

27. Palliative care
• Palliative care depends on good understanding of patients’:
- Perception of their quality of life
- Satisfaction with current functioning
- Expectations
• Opioids, benzodiazepines, tricyclic antidepressants, major
tranquilisers and oxygen can be used for the palliation of
breathlessness in patients with end stage COPD unresponsive to
other medical therapy
• Providers of care should adopt an effective and equitable
standardised approach to palliative care such as that provided by
the Liverpool care pathway or equivalent
[2004]

28. Costs per 100,000 population
Costs are based on recommendations which have the
most significant resource impact: 1.2.2.5 - 1.2.2.9
Costs per annum
£
Current cost of prescribing 524,291
Future cost of prescribing 624,812
Incremental cost of prescribing 100,521
Estimated 5% reductions in hospital admissions 30,302
Estimated cost of implementation 70,219

29. Discussion
•How can we improve identification and diagnosis of people over
35 who have a risk factor?
•How does our use of spirometry compare with the
recommendations?
•How will our prescribing practice need to change?
•What pulmonary rehabilitation services are available?
•How do we minimise the risk of exacerbations for our patients?

30. NHS Lung Improvement
Visit the NHS Lung Improvement Programme
webpages (www.improvement.nhs.uk/lung) for further
practical support consistent with implementing the
recommendations in this guideline

31. NHS Evidence
Visit NHS Evidence for
the best available
evidence on all
aspects of respiratory
diseases, including
COPD
Click here to go to
the NHS Evidence
website

32. Find out more
Visit www.nice.org.uk/CG101 for:
•the guideline
•the quick reference guide
•‘Understanding NICE guidance’
•costing report
•audit support
•baseline assessment tool

33. NICE quality standard
COPD
July 2011

34. Quality standards
A quality standard is a set of specific, concise
statements that:
•act as markers of high-quality, cost-effective patient
care across a pathway or clinical area, covering
treatment and prevention
•are derived from the best available evidence such as
NICE guidance or other NHS evidence accredited
sources
•are produced collaboratively with the NHS and social
care, along with their partners and
service users

35. COPD quality standard
•This quality standard covers Assessment, diagnosis
and clinical management of chronic obstructive
pulmonary disease (COPD) in adults.
•It does not include prevention, screening or case
finding.
•The quality standard consists of 13 quality
statements.

36. Quality statement 1
People with COPD have one or more indicative
symptoms recorded, and have the diagnosis confirmed
by post bronchodilator spirometry carried out on
‑
calibrated equipment by healthcare professionals
competent in its performance and interpretation.
Quality measure
Process:
a)Proportion of people with COPD who have
one or more indicative symptoms recorded.
b) Proportion of people with COPD who have
the diagnosis confirmed by post bronchodilator
‑
spirometry

37. Quality statement 2
People with COPD have a current individualised
comprehensive management plan, which includes high-
quality information and educational material about the
condition and its management, relevant to the stage of
disease.
Quality measure
Process: Proportion of people with COPD who
have a current individualised comprehensive
management plan, which includes high-quality
information and educational material about the
condition and its management, relevant to the
stage of disease.

38. Quality statement 3
People with COPD are offered inhaled and oral
therapies, in accordance with NICE guidance, as part of
an individualised comprehensive management plan.
Quality measure
Process:
a) Proportion of people with COPD who are
offered inhaled and oral therapies in
accordance with NICE guidance.
b) Proportion of people with COPD who receive
their inhaled and oral therapies as part of an
individualised comprehensive management
plan.

39. Quality statement 4
People with COPD have a comprehensive clinical and
psychosocial assessment, at least once a year or more
frequently if indicated, which includes degree of
breathlessness, frequency of exacerbations, validated
measures of health status and prognosis, presence of
hypoxaemia and comorbidities.
Quality measure
Process: Proportion of people with COPD who
had a comprehensive clinical and psychosocial
assessment in the previous 12 months which
includes degree of breathlessness, frequency of
exacerbations, validated measures of health
status and prognosis, presence of hypoxaemia
and comorbidities.

40. Quality statement 5
People with COPD who smoke are regularly encouraged
to stop and are offered the full range of evidence-based
smoking cessation support.
Quality measure
Process:
Proportion of people with COPD who smoke
who are offered the full range of evidence-based
smoking cessation support.

41. Quality statement 6
People with COPD meeting appropriate criteria are
offered an effective, timely and accessible
multidisciplinary pulmonary rehabilitation programme.
Quality measure
Process:
Proportion of people with COPD meeting
appropriate criteria who receive an effective,
timely and accessible multidisciplinary
pulmonary rehabilitation programme.

42. Quality statement 7
People who have had an exacerbation of COPD are
provided with individualised written advice on early
recognition of future exacerbations, management
strategies (including appropriate provision of antibiotics and
corticosteroids for self-treatment at home) and a named
contact.
Quality measure
Process: Proportion of people who have had an
exacerbation of COPD who are given
individualised written advice on early
recognition of future exacerbations,
management strategies (including appropriate
provision of antibiotics and corticosteroids for
self-treatment at home) and a named contact.

43. Quality statement 8
People with COPD potentially requiring long-term oxygen
therapy are assessed in accordance with NICE guidance
by a specialist oxygen service.
Quality measure
Process:
Proportion of people with COPD with oxygen
saturation less than or equal to 92% when
stable, who are assessed for LTOT in
accordance with NICE guidance by a specialist
oxygen service.

44. Quality statement 9
People with COPD receiving long-term oxygen therapy are
reviewed in accordance with NICE guidance, at least
annually, by a specialist oxygen service as part of the
integrated clinical management of their COPD.
Quality measure
Process: Proportion of people with COPD
receiving LTOT, who have had a review in the
previous 12 months by a specialist oxygen
service in accordance with NICE guidance, as
part of the integrated clinical management of
their COPD.

45. Quality statement 10
People admitted to hospital with an exacerbation of
COPD are cared for by a respiratory team, and have
access to a specialist early supported-discharge scheme
with appropriate community support.

46. Quality statement 10 continued
Quality measure
Process:
a) Proportion of people with COPD admitted to
hospital with an exacerbation who are cared for by a
respiratory team
b) Proportion of people with COPD admitted to
hospital with an exacerbation, and who meet the
criteria for early supported discharge, who are placed
on a specialist early supported discharge scheme with
appropriate community support.

47. Quality statement 11
People admitted to hospital with an exacerbation of
COPD and with persistent acidotic ventilatory failure
are promptly assessed for, and receive, non invasive
‑
ventilation delivered by appropriately trained staff in
a dedicated setting.

48. Quality statement 11 continued
Quality measure
Process:
a)Proportion of people admitted to hospital with
an exacerbation of COPD and with persistent
acidotic ventilatory failure, who are promptly
assessed for NIV, and for whom any subsequent
delivery is promptly undertaken.
b) Proportion of people admitted to hospital and
receiving NIV for an exacerbation of COPD and
persistent acidotic ventilatory failure, who have it
delivered by appropriately trained staff in a
dedicated setting.

49. Quality statement 12
People admitted to hospital with an exacerbation of COPD
are reviewed within 2 weeks of discharge.
Quality measure
Process:
Proportion of people discharged from hospital
following an admission with an exacerbation of
COPD, who are reviewed within 2 weeks of
discharge.

50. Quality statement 13
People with advanced COPD, and their carers, are
identified and offered palliative care that addresses
physical, social and emotional needs.
Quality measure
Process:
Proportion of people with advanced COPD, and
their carers, who receive palliative care that
addresses physical, social and emotional needs.

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