The COPD-X Plan:Australia and New Zealand guidelines for the management of

COPD

Presentation Authors: COPD National Program Executive Committee A/Professor Ian Yang, Professor Peter Frith, Professor Christine McDonald,

Dr Kerry Hancock, Dr Julia Walters, Mrs Liz Harper

Presenter: Dr Bajee Krishna Sriram

Affiliations

Overview

• Present Australian COPD clinical guidelines• Stepwise diagnosis and management of patients with COPD• Available resources for primary care

Action points: Register on www.copdx.org.au to receive the updated COPD-X

guidelines and the new handbook to be released soon Use Stepwise Management of Stable COPD Use COPD Action Plan Use COPD Assessment Tool (CAT) Use Lung Health Checklist Use Lung Foundation Australia resources for COPD

www.copdx.org.au

New GP Handbook coming soon:COPD-X Concise Guide for Primary Care

Register now on www.copdx.org.au to receive an email update as soon as it is available

Australian COPD-X guidelines

• C Case ID & Confirm diagnosis• O Optimise function• P Prevent deterioration• D Develop support

network & selfmanagement plan

• X eXacerbations management

• COPD-X Concise Guide for Primary Care (due October 2013)

Chronic Obstructive Pulmonary Disease

• A common preventable and treatable disease

• Characterised by persistent airflow limitationthat is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

• Exacerbations and comorbidities contribute to the overall severity in individual patients

Spirometry

Case Identification

Case Finding – General Practice and Pharmacy

Lung Health Checklist

Piko6 or COPD6

• Cough• Sputum• Chest infections• Dyspnoea

Confirm Diagnosis

www.copdx.org.au

Diagnosis of COPD

• Gold Standard Test – Spirometry

• Cough• Sputum• Chest infections• Dyspnoea

Spirometry (example of volume-time curve)

Expired volume (litres)

Forced vital capacityFVC 4.3 L

FEV1 3.5 LForced expiratory volume in 1 sec

Examples of spirograms and flow-volume loops

From: Johns and Pierce 2008: Spirometry (National Asthma Council)

Severity of disease (Australian guidelines)

Diagnosis: Post-bronchodilator airflow obstruction that is not fully reversible

Investigations

• Spirometry Pre- and post-bronchodilator• Gas transfer Detect emphysema physiologically• Chest X-ray Exclude other causes of dyspnoea• 6 min walk Measure exercise capacity &

desaturation• Sputum Microscopy, culture, sensitivity• Arterial Blood Measure gas exchange & acid-

base Gases (ABGs) status• CT chest Exclude other causes of dyspnoea

(not needed in all patients)

Optimise Function

PLEASE TICK IN THE BOX THAT APPLIES TO YOU (ONE BOX ONLY)

mMRC Grade 0. I only get breathless with strenuous exercise. mMRC Grade 1. I get short of breath when hurrying on the level or walking up a slight hill. mMRC Grade 2. I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level. mMRC Grade 3. I stop for breath after walking about 100 meters or after a few minutes on the level. mMRC Grade 4. I am too breathless to leave the house or I am breathless when dressing or undressing.

Global Strategy for Diagnosis, Management and Prevention of COPD

Modified MRC (mMRC)Questionnaire

www.catestonline.org

CoughSputumChest tightnessWalking up hillADLsLeaving the houseSleepEnergy levels

Scores11-20 medium impact> 20 high impact

Non-pharmacological interventions

• Consider referral to Pulmonary Rehabilitation for patients who display exertional dyspnoea and after an exacerbation

- Level 1 evidence for reducing dysnoea, fatigue, anxiety and depression and improving exercise capacity, emotional function and health related quality of life outcomes

- Level II evidence for reducing hospital admissions

Relievers -Short-acting β2-agonists (SABAs)

•Acute onset (1-3 min)

•Short duration of action (4hr)

•Relaxation of airway smooth muscle by stimulating β2-adrenoceptors

•Use as needed

•Salbutamol (100 mcg, 2-4 inhalations PRN)

•Terbutaline (500 mcg, 1-3 inhalations PRN)

LABAs

Long-acting β2-agonists (LABAs)- bd

• Slow onset – salmeterol (15-20 min)MDI 25 mcg AH 50 mcg

• Fast onset – eformoterol (1-3 mins)

• Long duration of action (12 h)

• Relaxation of airway smooth muscle by binding and occupying β2-adrenoceptors

6, 12 mcg TH12 mcg Aerolizer, 12 mcg bd

Once a day LABA

Once a day - Long-acting β2-agonists (LABAs)

- indacaterolDPI 150 mcg, 300 mcg150 to 300 mcg once daily

• Long duration of action (24hr)• Relaxation of airway smooth muscle by binding and

occupying β2-adrenoceptors

LAMA

Long-acting muscarinic antagonist (LAMA) (long-acting anticholinergic)

- Tiotropium (18mcg daily)

• Slow onset (30min)• Long duration of action (24hr)• Relaxation of airway smooth muscle by binding

and occupying muscarinic M3 receptors

Combination inhalers (ICS/LABA)

salmeterol/fluticasone

MDI 250/252 inhalations bdAH 500/501 inhalation bd

eformoterol/budesonide

TH 400/12 mcg1 inhalation bd

Preventer

+

Controller

Prevent Deterioration

www.copdx.org.au

Smoking Cessation

• Brief intervention• Counselling – behavioural intervention• Nicotine replacement therapy• Pharmacological agents

– Varenicline – Bupropion

RACGP smoking cessation guidelines www.racgp.org.au/your-practice/guidelines/smoking-

cessation

Immunisations

• Annual influenza immunisations

• Pneumococcal immunisation every five yearsor as per the Australian Immunisation Handbook

Long-term Oxygen Therapy for COPD

Position on continuous oxygen therapyContinuous oxygen therapy is indicated to improve survival and quality of life for:• PaO2 ≤ 55 mmHg at rest, or

• PaO2 56-59 mmHg with right heart failure, pulmonary hypertension or polycythaemia

Flow rate to maintain oxygen saturation >90% at restIncrease by 1L/min during:- Sleep- Exertion- Air travel

TSANZ guidelines: McDonald et al, MJA 2005: 182: 621-626

Develop a plan of care

www.copdx.org.au

Lung Foundation Resources

• Primary Care Respiratory Toolkit– Spirometry Calculator– Lung age estimator

• Stepwise Management of Stable COPD• COPD online, an interactive training

program for primary care nurses• Website listings

– Pulmonary Rehabilitation program locations– Patient support groups– Lungs in Action exercise maintenance classes

• Patient Resources (fact sheets, brochures, Better Living Guide, Getting Started on O2)

• Lung Health Checklist• Pulmonary Rehab Toolkit

• NEW (soon) – COPD-X: Concise Guide for Primary Care

Respiratory Education Team (Multi-disciplinary Management of COPD)

• COPD knowledge and symptom awareness• Symptom control• Inhaler technique, delivery devices• Written COPD action plan• Self-management education• COPD first aid• Palliative and Supportive Care• End of Life Discussions/ Advanced Care Planning

www.lungfoundation.com.au

Or Call 1800 654 301 to have the editable pdf emailed directly to you

Indigenous version also available

When to start antibiotics and prednisolone

Support Teams

• Patient Support Groups & Family, friends• GP , Practice Nurse• Respiratory nurse specialist• Respiratory educator• Allied Health: Physiotherapist , Occupational therapist, Social worker,

Psychologist, Dietitian, Speech therapist• Respiratory Specialist• Pharmacist – Home Medicine Reviews, Quality Use of Medicines

Checks, Inhaler Technique• Home Carers, Oxygen suppliers• Pulmonary Rehabilitation• Lungs in Action classes (post rehab)

Manage eXacerbations

www.copdx.org.au

Primary care management of exacerbations

Tests:• Oximetry • Spirometry (if required)• Chest x-ray (if clinically indicated)• Sputum MCSTreatment:•Bronchodilators e.g salbutamol 100mcg, 2-4 (up to 10) inhalations via spacer•Oral steroids e.g. prednisolone 30-50mg, 7-14 days•Antibiotics e.g. amoxycillin 500mg tds, 5 days or doxycycline, 100 mg bd, 5 days (or consider other antibiotics)

• When do you refer to hospital?

• What is NIV?

• Who is likely to require ICU admission?

• What about referral to pulmonary rehabilitation after an exacerbation?

New GP Handbook coming in October:COPD-X Concise Guidelines for Primary Care

• Visit www.copdx.org.au and register to receive COPD-X pdf. This will register you for updates.

• COPD-X Concise Guide for Primary Care is available in pdf in October. It contains key recommendations and grades the strength of recommendations and quality of evidence.

• Stepwise diagnosis and management of patients with COPD – also available to download as pdf from www.lungfoundation.com.au (single page summary)

Summary Actions

• COPD-x guidelines• Lung Foundation Australia resources

– COPD Action plan– Lung health checklist– Primary Care Respiratory Toolkit– COPD Online training for practice nurses– Database of Pulmonary Rehab programs– Database of Patient Support Groups– Database of Lungs in Action classes– Patient Education materials– 1800 654 301– www.lungfoundation.com.au