The management of COPD in a primary care setting

Management of COPD in primary care is now essential, says Dr Kevin Gruffydd-Jones.

It is estimated that 3 million people suffer from COPD in the UK, with 25,000 patients dying each year of the disease.

NICE produced excellent evidence-based guidelines on the management of COPD in 2004, and the British Thoracic Society followed this with a 'practical pointers' booklet.

However, a recent survey of GPs showed that just over half of respondents were not aware of the NICE guidelines or found them difficult to follow.

In order to try and fill this knowledge gap, the General Practice Airways Group (GPIAG) has produced a guide to managing COPD in primary care.

Most GPs will ask about how to diagnose COPD and what is the role of reversibility testing using spirometry.

There has undoubtedly been confusion caused between the advice of NICE that reversibility testing is seldom needed to diagnose COPD, and the requirements of the quality framework for COPD which state that reversibility testing should be carried out.

The following typical case studies might help highlight the issues.

Cough and wheeze

Mr Woodbine is a 60-year-old lorry driver who smokes 20 cigarettes per day and presents with gradually worsening cough and wheeze on exertion.

The only positive finding on examination is of a hyper-inflated chest.

His chest X-ray shows emphysematous changes and the spirometry, an obstructive picture.

The NICE guidelines are correct in stating that for many patients like Mr Woodbine the diagnosis of COPD can be made from the history of progressive shortness of breath or cough in the absence of sinister features such as weight loss (usually in a smoker or ex-smoker); from the physical examination and chest X-ray, minimising the chance of missing an alternative diagnosis such as cardiac failure or lung cancer; from the obstructive pattern on spirometry - FEV1 <80% and FEV1/FVC ratio <70%. There is no need for reversibility testing in this instance.

However, the following case study is also not uncommon in primary care.

Mr Smith is a 60-year-old lorry driver who was diagnosed as having asthma 10 years ago (although there is no record of any objective testing having been carried out).

He has been attending the practice asthma clinic since that time and is slowly developing worsening shortness of breath and wheezing.

The practice nurse wants to know whether to code him as asthma or COPD for the quality figures.

Once any alternative cause of his breathlessness and wheezing, for example a cardiac cause or lung cancer, has been excluded, then the differential diagnosis is between asthma and COPD. Table 1, below left, shows the features in the clinical history for both conditions.

Where diagnostic doubt remains, the following findings might distinguish the asthmatic patient: more than 400ml increase in FEV1 20 minutes post salbutamol, or two weeks post-prednisolone 30mg per day; or more than 20 per cent diurnal variation in serial peak flow measurements.

In some situations, where a diagnosis of asthma is a strong possibility, then reversibility testing might give useful information on which to base the diagnosis. It is also worth noting that from April the quality framework will allow patients to be coded as having both COPD and asthma.

Treatment dilemma

Sometimes GPs are confused by all the treatments available for COPD and have problems deciding which one to use.

The NICE guidelines emphasise that COPD is not just a disease of the lungs but a multi-system disorder causing muscle wasting, anxiety and depression and which causes disruption to everyday life.

The emphasis has switched in the assessment of COPD from using lung function alone to using a more patient-centred approach (see chart, left).

All patients with COPD should be encouraged to stop smoking and be given advice on exercise, diet and influenza or pneumococcal immunisation.

Symptomatic patients

In symptomatic patients the cornerstone of management of breathlessness in COPD is inhaled bronchodilation. Bronchodilators improve breathlessness, exercise capacity and quality of life. Short-acting bronchodilators such as salbutamol, terbutaline or ipratropium are given for relief of intermittent breathlessness.

Patients who remain symptomatic in spite of short-acting bronchodilators should be given regular long-acting bronchodilators (such as salmeterol, formoterol or tiotropium).

Mucolytic therapy (mecysteine, carbocysteine) should be considered for patients with chronic productive cough.

Patients with a disability

Patients with a disability who are unable to carry out activities because of symptoms should be referred for pulmonary rehabilitation.

Pulmonary rehabilitation addresses the multi-system nature of COPD using a multi-disciplinary rehabilitation team. It has been shown to improve quality of life, improve walking distance and reduce in-patient stays for COPD exacerbations. Unfortunately, it is not yet widely available in the UK.

Exacerbations

Patients who exacerbate need hospital admission and/or oral steroids.

Patients with FEV1 equal to or less than 50 per cent predicted and with two or more exacerbations per year should be prescribed inhaled steroids at moderate/high doses in combination with a long-acting beta-2 agonist).

Patients should be screened for depression by asking if during the last month they have often been bothered by feeling depressed or helpless, or if during the last month they have been bothered by having little interest or pleasure in doing things. A positive answer should prompt a formal assessment and treatment with antidepressants.

Providing the patient with a self-management plan might help to reduce the chance of hospital admission. Advice should be given on how to recognise an attack, when to use standby antibiotics and/or oral steroids and when to call for professional help.

Patients with 'failing lung'

These patients have cor pulmonale or oxygen saturation measured by pulse oximetry of 92 per cent or less in air.

Patients with a 'failing lung' should be referred to secondary or intermediate care for assessment for long-term oxygen therapy, surgical intervention or consideration of palliative care. The presence of severe dyspnoea on exercise alone might prompt referral for assessment for ambulatory oxygen therapy. Further details of these treatment steps can be found in the GPIAG Guide to COPD Management in Primary Care.

- Dr Gruffydd-Jones is a GPSI in respiratory medicine in Box, Wiltshire, and a member of the General Practice Airways Group

- The General Practice Airways Group (GPIAG) is an independent GP-led primary care charity dedicated to achieving optimal respiratory health for all.

TABLE 1: FEATURES IN THE CLINICAL HISTORY DIFFERENTIATING COPD AND
ASTHMA
COPD ASTHMA
Smoker or ex-smoker Nearly all Possibly
Symptom onset under age 35 Rare Often
Chronic productive cough Common Uncommon
Breathlessness Persistent and
progressive Variable
Night-time waking breathlessness
and/or wheeze Uncommon Common
Significant diurnal or day-to-day
variation in symptoms Uncommon Common
Past history or family history of atopy
(atopic eczema, allergic rhinitis) Less common Common

REFERENCES

- NICE COPD Guidelines: Full Guidelines. Thorax 2004; 59 Supplement 1 or short version, www.nice.org.uk

- British Thoracic Society COPD Consortium. 'Practical Pointers' to the Guidelines. www.brit-thoracic.org.uk/copd

- The GPIAG Guide to COPD Management in Primary Care can be downloaded via the website www.gpiag.org, or, for a print copy, send a large (C5) SAE (postage charge 64p) to GPIAG Publications, Smithy House, Waterbeck, Lockerbie, DG11 3EY.

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