J43.0/1/2/8/9/J44.0/1/8/9
DESCRIPTION
COPD is characterised by persistent respiratory symptoms (dyspnoea, chronic cough and sputum production), and airflow limitation. Spirometry is required to diagnose COPD, where the post bronchodilator FEV1/FVC ratio is <0.7. COPD is likely to worsen over time, even with optimal care.
Regular follow-up is necessary to monitor lung function, symptoms, exacerbations, co-morbidities, and the need for treatment regimen changes.
COPD can be graded on severity of symptoms and frequency of exacerbations to assist in treatment selection and to monitor treatment success:
| GOLD grade | mMRC breathlessness score | Exacerbations in past year |
| A | 0–1 | <2 |
| B | ≥2 | <2 |
| C | 0–1 | ≥2 |
| D | ≥2 | ≥2 |
| Grade | Exacerbations in past year |
| 0 | Dyspnea with strenuous exercise |
| 1 | Dyspnea when hurrying on level ground or walking up a slight hill |
| 2 | Walks slower than people of same age group, due to dyspnea |
| 3 |
Stops for breath after walking 91m, or after a few minutes on level ground |
| 4 | Too breathless to leave the house, or dyspnea when dressing/undressing |
Url link to the modified Medical Research Council (mMRC) dyspnea scale calculator:
https://www.mdcalc.com/mmrc-modified-medical-research-council-dyspnea-scale
GENERAL MEASURES
Patients with clinical COPD must undergo spirometry to confirm and grade the severity of obstruction.
Patients should be screened for ongoing smoking and advised to stop at each visit. Smoking cessation and avoidance of noxious respiratory particles should form the mainstay of management.
MEDICINE TREATMENT
Note: Correct inhaler technique should be demonstrated and checked regularly.
Management of acute exacerbations
Progression of disease (measured by symptoms and deterioration in lung function) in COPD is variable, but is greater in patients who experience COPD exacerbations which are defined as:
- worsening of dyspnoea,
- increased cough,
- increased sputum production or purulence or,
- greater than usual day to day variability of symptoms.
Severe exacerbations are defined as being sufficiently severe to prompt use of an oral corticosteroid course and/or an antibiotic. COPD exacerbations are not always associated with significant decreases in PEF or FEV1, and are defined by symptoms and, when severe, measures of respiratory failure. Most are precipitated by viral and/or bacterial infection, and are more common in winter.
Patients should be admitted if there is a marked increase in dyspnoea, symptoms disturb eating or sleeping, change in mental status or poor social circumstances. Causes of worsening symptoms other than an acute exacerbation of COPD such as cardiac failure, pulmonary embolus, or pneumonia must be considered.
If available, check blood gases for the presence of hypoxaemia and hypercapnia. In some patients with long-standing lung disease the drive to respiration switches from hypercapnia (increases in PaCO2) to hypoxaemia (level of respiratory failure). In such patients, relief of hypoxaemia with uncontrolled oxygen therapy may result in hypoventilation, with consequent rise in PaCO2 to dangerous levels and associated respiratory acidosis leading to coma and death. For this reason, hypoxaemia should be corrected using controlled use of supplemental oxygen, preferably starting with a nasal cannula 1-2 litres/minute.
If the patient’s arterial PaCO2 does not rise, the FiO2 may be increased until a PaO2 of 8 kPa is reached (or oxygen saturation of 90%). The FiO2 must be reduced or removed if worsening hypercapnia occurs; these patients might require non-invasive ventilation or intubation for mechanical ventilation.
Where blood gases are not readily available, the patient’s clinical status should be reviewed regularly to check for increasing drowsiness, headache, or confusion, which may precede coma.
Where resources for mechanical ventilation are scarce, oxygen saturation targets for patients with long-standing COPD and limited effort tolerance may be relaxed if the patient is improving clinically.
- Salbutamol, nebulisation, 5 mg.
- Nebulise continuously (refill the nebuliser reservoir every 20 minutes) at a flow rate of 6–8 L/minute.
If a poor response to nebulised salbutamol:
ADD
- Ipratropium bromide 0.5 mg (UDV) with the first refill of the nebuliser reservoir.
- Patients who fail to respond within 1 hour must be discussed with a specialist. (Patients with COPD have fixed airway disease and unlike asthmatics, PEF is not a reliable measure of their disease).
Once clinically stabilised, nebulise with:
- Salbutamol, nebulisation 5 mg OR fenoterol 1.25–2.5 mg.
- Repeat 4–6 hourly.
AND
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 40 mg immediately.
Follow with:
- Prednisone, oral, 40 mg daily for 5 days.
OR
In patients who cannot use oral therapy:
- Hydrocortisone, IV, 100 mg 6 hourly until patient can take oral medication.
Once oral medication can be taken, follow with:
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 30 mg daily for 5 days.
- Monitor response and clinical signs.
Acute infective exacerbation of chronic bronchitis:
- Amoxicillin, oral, 500 mg 8 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
- Doxycycline, oral, 100 mg 12 hourly for 5 days.
Non-responsive to first course of antibiotic therapy or in patients with a moderate to severe exacerbation and who have increased sputum purulence plus ≥ 1 of the following symptoms should receive an antibiotic:
- increased dyspnoea,
- increased sputum volume
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
- Azithromycin, oral, 500 mg daily for 3 days.
Chronic therapy
GRADE A
As initial therapy:
- Short acting β2-agonist (SABA) e.g.:
- Salbutamol, MDI, 200 mcg 6 hourly as needed (educate on correct inhaler use - use a large volume spacer if inhaler technique remains poor).
If no response in symptoms or GRADE B:
ADD
- Long acting β2-agonist (LABA), e.g.:
- Formoterol, inhalation 12 mcg 12 hourly.
GRADE C and D (frequent exacerbations (≥2 per year)):
- Short acting β2-agonist (SABA) e.g.:
- Salbutamol, MDI, 200 mcg 6 hourly as needed using a large volume spacer.
AND
- LABA/ICS combination, e.g.:
- Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.
AND
Refer COPD patients for additional assessment and management.
Patients on protease inhibitors:
Replace salmeterol/fluticasone with:
- Beclomethasone, inhalation, 400 mcg 12 hourly.
AND
- Formoterol, inhalation, 12 mcg 12 hourly.
If inadequate control with above therapy:
- Theophylline, slow release, oral, 200 mg at night. Specialist consultation.
- Ongoing use of theophylline should be re-evaluated periodically. If there is no benefit after 12 months discontinue theophylline.
Corticosteroids
Oral corticosteroids are not recommended for stable COPD.
For acute exacerbations: J44.1
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 30 mg daily for 5 days.
Pre-operative assessment for surgical procedures:
Patients with chronic lung disease are at an increased risk of post-operative pulmonary complications. Risk is increased with increasing severity of pulmonary disease, and with upper abdominal or thoracic surgery.
Patients undergoing elective surgery must be optimised pre-operatively by following the recommended treatment for their disease. Clinical assessment is sufficient with further investigations such as spirometry, CXR and ABGs reserved for patients with clinically severe disease/ unstable disease or where the diagnosis is uncertain. COPD patients should be wheeze free without dyspnoea on moderate exertion (carrying shopping walking up a flight of stairs) or a history of frequent exacerbations. As COPD is a disease characterised by fixed airway obstruction some patients may have continuous wheezing and will require further pre-operative assessment.
Peri-operative oral corticosteroids may be used to gain optimal control but are not advocated for routine use:
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 30 mg daily for not longer than 5 days.
AND
Inhaled therapy must be continued and may be administered via nebulisation peri-operatively:
- SABA, e.g.:
- Salbutamol MDI, 200mcg, 30 minutes pre-intubation.
Prophylaxis (Z25.1)
- Annual influenza vaccination. See Adult vaccination.
REFERRAL
- Assessment for long-term home-based oxygen therapy, if COPD with PaO2 <7.3 kPa and non-smoker for at least 3 months,
- Recent onset of respiratory failure or signs of cor pulmonale.
- Symptoms that appear disproportionate to the level of airflow obstruction, as judged by spirometry or clinical evaluation (absence of hyperinflation or unusual pattern of symptoms).
- Onset <40 years of age.
- COPD with a history of little or no smoking.
- Recurrent exacerbations, i.e. ≥2 per year.
- Failure to respond to treatment.