1. Current management of COPD and when to refer?
Dr Maxine Hardinge Consultant Respiratory Medicine
Oxford University Hospitals NHS Foundation Trust

2. Aims of treatment – reducing risk and reducing symptoms
Inhaled therapy – new Oxfordshire guidance
Severe COPD – home oxygen therapy, palliative measures, surgical interventions
Out-patient referrals - who to refer and who is being referred?

3. GOLD 2014: Treatment goals for stable COPD
Relieve symptoms
Improve exercise tolerance
Improve health status
REDUCE
SYMPTOMS
AND
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
REDUCE
RISK
COPD, chronic obstructive pulmonary disease; GOLD, Global initiative for chronic Obstructive Lung Disease
Reference: GOLD. COPD guidelines Available at (Accessed December 2014)
Date of preparation: February 2015; ULT0046

4. NICE 2010: Use of inhaled therapies
Who should be treated with LABA/ICS or LABA/LAMA?
* SABAs (as required) may continue at all stages
Offer
Consider

5. “Value” in COPD Triple Therapy £35,000-£187,000/QALY LABA £8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in “at risk” population
London respiratory team, NHS London

6. Getting the basics right
Diagnosis – quality assured spirometry
Vaccination
Smoking cessation
Physical activity – pulmonary rehabilitation
Diet
Self management
Depression/ anxiety

7. Smoking cessation – a treatment for COPD
Stopping smoking is only intervention in COPD that can
reduce all four core symptoms (cough, wheeze, breathlessness and chest pain)1 and simultaneously
slow the decline in lung function 1
reduce COPD readmissions 2
mortality 3
1 Scanlon PD et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir Crit Care Med 2000;161:
2 Borglykke A et al. The effectiveness of smoking cessation groups offered to hospitalised patients with symptoms of exacerbations of chronic obstructive pulmonary disease (COPD). Clin Respir J 2008;2:
3 Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD);

8. Smoking cessation data (PHE)
Smoking prevalence in Oxfordshire in 2013 was 14.7% (12% in 2010)
Numbers setting a quit date
2013/14:  6065
2014/15:  3319
Percentage of successful 4 week quitters self-report
2013/14: 60%
2014/15: 58%
Percentage of successful 4 week quitters CO monitor validated
2013/14: 46%
2014/15: 43%
Cost per quitter 2013/14 £181.1

9. NICE 2010: Pulmonary rehabilitation
Offer to all appropriate people with COPD
those who consider themselves functionally disabled by COPD (usually MRC grade 3 and above)
including those who have had a recent hospitalisation for an exacerbation – early post discharge pulmonary rehabilitation

10. Oxon PR outcomes

11. Pulmonary rehabilitation programme
45% of patients invited to assessment attend
Of those 77.23% who started the course managed to complete it (starter to completion rate has improved considerably from the previous years: : 59.5%, : 64.6% and : 66.66%)
Therefore, just over 30% of all the referrals we receive complete course

13. Self management
Need to take a variety of approaches tailored to individual

14. Pharmacological management
Bronchodilators – single or dual
Role of ICS
Theophyllines
Mucolytics
Long term oral steroids
Macrolides - azithromycin

18. Severe COPD – additional treatments
Home oxygen therapy
Long term oxygen therapy
Ambulatory oxygen therapy
Surgical interventions
Lung volume reduction by endobronchial valves or surgery
Bullectomy
Transplantation

19. End of Life Care in COPD:
Severe AFO FEV1 < 30% predicted
Respiratory failure
BMI < 19
Housebound or MRC grade 5
2 or more admissions in previous year
Required NIV for AECOPD
“Surprise question”
Symptom relief
Fan therapy
Breathing control/pacing advice
Dietary advice
Depression/anxiety
Morphine
Benzodiazepines
Home oxygen therapy if resting O2 sats< = 92%
Advance care planning
Support for carers

20. NICE 1.1.8 Referral for specialist advice (2004, 2010)
should be made when clinically indicated
may be appropriate at all stages and not solely in most severely disabled patients

21. Referrals for specialist advice
Diagnostic uncertainty:
Is it all COPD? Symptoms disproportionate to lung function deficit
Is it asthma or COPD?
Assessment for additional treatments;
oxygen therapy, pulmonary rehabilitation, transplantation, nebulisers, long term steroids or antibiotics
Advice about management of recurrent exacerbations
Advice about management of breathlessness
Significant disease in young person:
Alpha 1 antitrypsin deficiency
cannabis

22. Who is being referred? 69 year old woman
COPD diagnosed following hospital admission Sept 2015
Fostair and salbutamol. Tried Carbocisteine twice – rash both times.
O2 sats 95%
‘extremely SOB and afraid to out. Please advise on breathlessness’
What is her spirometry?
Why tried carbocisteine if problem is breathlessness?
Why isn’t she on a LAMA?
Has she done PR?
Is she still smoking?
Is her CXR normal?
FEV1 0.7L (51% pred), FVC 1.1L (64%)
Thoracic kyphoscoliosis
CXR normal

23. Who is being referred? 63 yr old woman COPD breathlessness grade 4
Continues to smoke
On maximal therapy
Requires frequent courses of oral steroids
O2 sats 93%
What is her spirometry?
Has she has a CXR or Hb recently?
If recurrent exacerbations what’s growing in her sputum?
Is she eosinophilic and would long term low dose steroids be appropriate?
Has she been to PR?
What's been tried for her smoking?
O2 sats 90-91%
No CXR or Fbc since 2010
Dry powder inhalers – try MDI/ mist
Declined PR or smoking advice
Sputum culture ? PSA
Discussion about smoking – prognosis and oxygen

24. Summary Treatments as risk reduction and symptom treatment
New inhaler guidance
Smoking cessation is a treatment for COPD
Championing exercise and PR
Tailoring self-management
Referrals – overview of COPD severity and problem which needs addressing