Academy of Medicine Malaysia Malaysian Thoracic SocietyMinistry of Health Malaysia

QUICK REFERENCE FOR HEALTHCARE PROVIDERS

MANAGEMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE

[2nd Edition]

2

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERS

Diagnosis and Assessment of COPDA diagnosis of COPD should be considered in any individual with symptoms of chronic cough, sputum production or dyspnoea and a history of exposure to risk factors for the disease, especially cigarette smoking.

The diagnosis should be confirmed by spirometry showing a post-bronchodilator FEV1/

FVC ratio of less than 70%.

COPD severity should be assessed based on the severity of spirometric abnormality, symptoms, exercise capacity, complications and the presence of co-morbidities.

Table 1: Classification of COPD Severity Based on Spirometric Impairment and Symptoms

COPD stage Severity

Classification by post-bronchodilator spirometric values

Classification by symptoms and disability

I Mild FEV1/FVC < 0.70FEV1 > 80% predicted

Shortness of breath when hurrying on the level or walking up a slight hill (MMRC 1)

II Moderate FEV1/FVC < 0.7050% < FEV1 < 80% predicted

Walks slower than people of the same age on the level because of breathlessness; or stops for breath after walking about 100 m or after a few minutes at own pace on the level (MMRC 2 to 3)

III Severe FEV1/FVC < 0.7030% < FEV1 < 50% predicted

Too breathless to leave the house or breathless when dressing or undressing (MMRC 4)

IV Very severe

FEV1/FVC < 0.70FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Presence of chronic respiratory failure or clinical signs of right heart failure

*Should there be disagreement between FEV1 and symptoms, follow symptoms

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MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERS

Managing Stable COPDObjectives of managing stable COPD:1. Prevent disease progression2. Relieve symptoms3. Improve exercise tolerance4. Improve lung function and general health5. Improve quality of life7. Prevent exacerbations8. Prevent and treat complications9. Reduce mortality.

Figure 1: Algorithm for Managing Stable COPD

COPD severity

Pulmonary rehabilitation

Clinical features

Infrequentsymptoms SABA/SAAC combination as needed

Mild

SABA as needed

Persistentsymptomsb LAAC or LABA

Moderate Severe Very severe

For all patients: education, smoking cessation, avoidance of exposure, exercise, mantain ideal BMI, vaccination, short-acting bronchodilatora as needed

LAAC and/or LABA

If symptoms persist, add ICS/LABA combination to LAAC or replace LABA with ICS/LABA combination

± theophylline

Frequentexacerbationsc

(≥ 1 per yr)

Consideralternative

caused

LAAC or ICS/LABA combination

or LAAC + ICS/LABA combination± theophylline

Respiratoryfailure

Consider alternativecaused

LAAC + ICS/LABA combination± theophylline

Long-term oxygen therapy Consider lung transplantation/LVRS

Notes for Figure 1 (Please refer to the bottom of the next page)

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MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERS

Figure 2: Algorithm for Managing Stable COPD in Resource-Limited Settings

COPD severity

Pulmonary rehabilitation

Clinical feature

Infrequentsymptoms SABA/SAAC combination as needed

Mild

SABA as needed

Persistentsymptomsb

SABA/SAACcombination

regularly

Moderate Severe Very severe

For all patients: education, smoking cessation, avoidance of exposure, exercise, maintain ideal BMI, vaccination, short-acting bronchodilatora as needed

Frequentexacerbationsc

(≥ 1 per yr)

Consideralternative

caused

SABA/SAAC combination regularly + ICS + theophylline

(Consider referring to a tertiary centre to obtain long-acting bronchodilators)

Respiratory failureConsider alternative

caused

SABA/SAAC combination regularly + ICS + theophylline

Long-term oxygen therapy Consider lung transplantation/LVRS

SABA/SAAC combination regularly

If symptoms persist, add theophylline and/or ICS

Clinical features

Notes:1. SABA – Short-acting β2 agonist; SAAC – Short-acting anticholinergic; LAAC – Long-acting anticholinergic;

LABA – Long-acting β2 agonist; ICS – Inhaled corticosteroid; LVRS – lung volume reduction surgery

2. ICS dose per day should be at least 500 µg of fluticasone or 800 µg of budesonide

a. All COPD patients, irrespective of disease severity, should be prescribed SABA or SABA/SAAC combination (Berodual®/Combivent®) as needed. SABA has a more rapid onset of bronchodilatation than SAAC.

b. Defined as need for rescue bronchodilators more than twice a week.

c. Frequent exacerbation is defined as one or more episodes of COPD exacerbation requiring systemic corticosteroids ± antibiotics and/or hospitalisation over the past one year

d. Consider alternative causes - it is less common for patients with mild COPD to have frequent exacerbations; similarly, respiratory failure is uncommon in patients with mild to moderate COPD severity. Hence, in such patients, an alternative cause should be explored even if the COPD diagnosis is firmly established.

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MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERS

Table 2: Evidence-based Interventions in Stable COPD

Intervention Outcome Level of evidence*

Smoking cessation FEV1 decline, mortality I

Influenza vaccination COPD exacerbations, all-cause mortality (in patients aged ≥ 65 years during influenza season)

II-1

Pneumococcal vaccination community-acquired pneumonia II-2

Inhaled short-acting β2-agonists

post-bronchodilator FEV1,

dyspnoeaI

Inhaled long-acting β2-agonists

post-bronchodilator FEV1, symptoms,

QoL, COPD exacerbationsI

Inhaled short-acting anticholinergic

post-bronchodilator FEV1, dyspnoea I

Inhaled long-acting anticholinergic (tiotropium)

post-bronchodilator FEV1, symptoms,

exercise tolerance, QoL, COPD exacerbations, mortality

I

Inhaled corticosteroids FEV1, QoL, COPD exacerbations I

Inhaled long-acting β2-agonist and

inhaled corticosteroid combination [Seretide Accuhaler (salmeterol 50 µg/fluticasone 500 µg) twice daily, and Symbicort Turbuhaler (budesonide/formoterol 320/9 µg) twice daily]

post-bronchodilator FEV1, QoL,

COPD exacerbationsI

Oral theophylline Small FEV1, symptoms II-1

Long-term oxygen therapy mortality

(in patients with respiratory failure)I

Pulmonary rehabilitation

dyspnoea, exercise capacity, QoL, anxiety and depression associated

with COPD

I

number of hospitalisations and days in hospital

II-1

peripheral muscle strength II-2

Lung volume reduction surgery FEV

1, exercise tolerance, QoL,

mortalityI

* Refer to Table 4↓ : reduces, ↑ : increases or improves, QoL : quality of life

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MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERS

Managing Acute Exacerbations of COPDObjectives of managing exacerbations of COPD: • Relievesymptomsandairflowobstruction• Maintainadequateoxygenation• Treatanyco-morbidconditionsthatmaycontributetotherespiratorydeterioration• Treatanyprecipitatingfactorsuchasinfection

Table 3: Evidence-based Interventions in Acute Exacerbations of COPD

Intervention Outcome Level of evidence*

Inhaled short-acting β2-agonists FEV

1, dyspnoea I

Inhaled short-acting anticholinergic FEV1, dyspnoea I

Intravenous aminophylline FEV1, dyspnoea II-1

Systemic corticosteroids FEV1, shorten recovery time,

hypoxaemia I

Antibiotics

short-term mortality, treatment failure, sputum purulence(in patients with purulent sputum and increased dyspnoea or increased sputum volume, and in patients requiring ventilatory support)

II-1

Supplemental oxygen hypoxaemia III

Non-invasive ventilation intubation, mortality, length of hospital stay (in acute respiratory failure) I

* Refer to Table 4↓ : reduces, ↑ : increases or improves

Table 4: US / Canadian Preventive Services Task Force Level of Evidence Scale

I Evidence obtained from at least one properly randomized controlled trial

II - 1 Evidence obtained from well-designed controlled trials without randomization

II - 2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II - 3 Evidence obtained from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence

III Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees

7

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERSFi

gure

3: A

lgor

ithm

for M

anag

ing

Acut

e Ex

acer

batio

ns o

f COP

D: H

ome

Man

agem

ent

Patie

nt wi

th AE

COPD

None

• Inh

aled s

hort-

actin

g bron

chod

ilator

(SAB

A +

SAAC

) from

pMDI

via a

spac

er de

vice o

r ne

bulis

er de

pend

ing on

seve

rity

Good

resp

onse

toini

tial tr

eatm

ent

• Di

scha

rge w

ith fo

llow-

up •

Chec

k inh

aler te

chniq

ue •

Arran

ge ap

propri

ate in

vesti

gatio

ns if

this i

s a

new

prese

ntatio

n •

Refer

to sp

ecial

ist if

nece

ssary

Home

Man

agem

ent

• Inc

rease

dose

and f

reque

ncy o

f inha

led sh

ort-ac

ting b

ronch

odila

tor (S

ABA +

SAA

C) fro

m pM

DI•

Oral

predn

isolon

e 30-4

0 mg d

aily f

or 7-1

4 day

s (if t

here

is sig

nifica

nt dy

spno

ea or

base

line F

EV1 <

50%

predic

ted)

• Or

al an

tibiot

ics if

patie

nt ha

s 2 ou

t of 3

cardi

nal s

ympto

ms (ie

, puru

lent s

putum

, incre

ased

sputu

m vo

lume,

increa

sed d

yspn

oea)

Obta

in rel

evan

t hist

ory: U

nderl

ying C

OPD

seve

rity (if

know

n), co

-morb

iditie

s, pre

sent

treatm

ent re

gimen

Hosp

ital a

sses

smen

t or a

dmiss

ion in

dicate

d

Admi

nister

initia

l trea

tmen

t: •

Inhale

d sho

rt-ac

ting b

ronch

odila

tors

(SAB

A + S

AAC)

from

pMDI

via a

sp

acer

devic

e or n

ebuli

ser

• Or

al pre

dniso

lone (

or int

raven

ous

hydro

cortis

one i

f pati

ent u

nable

to

swall

ow or

vomi

ts)•

Start

initia

l dos

e of a

ntibio

tics

(if ap

propri

ate)

• Su

pplem

ental

oxyg

en th

erapy

(pr

eferab

ly via

Ventu

ri mas

k) if

Sp

O 2 < 90

%, ai

m for

SpO

2 90-93

%

Refer

to ne

arest

hosp

ital

or

patie

nt’s u

sual

hosp

ital

Failu

re to

impro

ve

Indica

tions

for h

ospit

al as

sess

ment

or ad

miss

ion:

• Ma

rked i

ncrea

se in

inten

sity o

f sym

ptoms

such

as

sudd

en de

velop

ment

of dy

spno

ea•

Unde

rlying

seve

re CO

PD•

Deve

lopme

nt of

new

phys

ical s

igns e

.g., c

yano

sis,

perip

heral

oede

ma•

Haem

odyn

amic

instab

ility

• Re

duce

d aler

tness

• Fa

ilure

of ex

acerb

ation

to re

spon

d to i

nitial

med

ical

mana

geme

nt •

Signif

icant

co-m

orbidi

ties

• Ne

wly o

ccurr

ing ca

rdiac

arrhy

thmias

• Ol

der a

ge•

Insuff

icien

t hom

e sup

port

Any i

ndica

tion f

or ho

spita

l ass

essm

ent o

r adm

ission

?

8

MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE QUICK REFERENCE FOR HEALTH CARE PROVIDERSFi

gure

4: A

lgor

ithm

for M

anag

ing

Acut

e Ex

acer

batio

ns o

f COP

D: H

ospi

tal M

anag

emen

t

Patie

nt w

ith A

ECOP

D

Good

resp

onse

• Di

scha

rge

with

follo

w-up

• Ch

eck i

nhale

r tec

hniqu

e •

Refe

r to

spec

ialist

if th

is is

a ne

w pr

esen

tatio

n

Hom

e M

anag

emen

t•

Incr

ease

dos

e an

d fre

quen

cy o

f inha

led

shor

t-acti

ng b

ronc

hodil

ator

(SAB

A +

SAAC

) fro

m

pMDI

• Or

al pr

ednis

olone

30-

40 m

g da

ily fo

r 7-1

4 da

ys•

Ensu

re a

dequ

ate

supp

ly of

ora

l ant

ibiot

ics if

starte

d

Failu

re to

impr

ove

Hosp

ital M

anag

emen

t•

Cont

rolle

d su

pplem

enta

l oxy

gen

ther

apy t

o m

ainta

in Pa

O 2 > 8

kPa

or

Sp

O 2 > 9

0% w

ithou

t wor

senin

g hy

perc

apnia

or p

recip

itatin

g ac

idosis

•

Inha

led sh

ort-a

cting

bro

ncho

dilat

ors f

rom

pM

DI vi

a a

spac

er d

evice

or

nebu

liser

• Co

nside

r int

rave

nous

am

inoph

ylline

if ina

dequ

ate

resp

onse

to in

haled

sh

ort-a

cting

bro

ncho

dilat

ors

• Sy

stem

ic co

rtico

stero

ids fo

r 7-1

4 da

ys•

Antib

iotics

(if a

ppro

priat

e)•

Mon

itor f

luid

balan

ce a

nd n

utrit

ion•

Cons

ider s

ubcu

tane

ous h

epar

in•

Clos

ely m

onito

r con

dition

of t

he p

atien

t•

Cons

ider i

nvas

ive o

r non

-inva

sive

vent

ilatio

n

Indi

catio

ns fo

r hos

pita

l adm

issi

on:

• M

arke

d inc

reas

e in

inten

sity o

f sym

ptom

s su

ch a

s sud

den

deve

lopm

ent o

f dy

spno

ea•

Unde

rlying

seve

re C

OPD

• De

velop

men

t of n

ew p

hysic

al sig

ns e

.g.,

cyan

osis,

per

ipher

al oe

dem

a•

Haem

odyn

amic

insta

bility

• Re

duce

d ale

rtnes

s•

Failu

re o

f exa

cerb

ation

to re

spon

d to

ini

tial m

edica

l man

agem

ent

• Si

gnific

ant c

o-m

orbid

ities

• Ne

wly o

ccur

ring

card

iac a

rrhyth

mias

• Ol

der a

ge•

Insu

fficien

t hom

e su

ppor

t

• Ob

tain

relev

ant h

istor

y: Cu

rrent

sym

ptom

s, re

cent

trea

tmen

t fro

m o

ther

doc

tors

, COP

D se

verit

y, pr

eviou

s epis

odes

(A

ECOP

D/ho

spita

l adm

ission

/ICU

adm

ission

/inva

sive

or n

on-in

vasiv

e ve

ntila

tion)

• Ex

amine

for d

ange

r sign

s: Re

spira

tory

dist

ress

, tac

hyar

rhyth

mia,

cyan

osis,

hea

rt fa

ilure

, exh

austi

on.

• Ar

rang

e ap

prop

riate

inve

stiga

tions

: ABG

(not

e th

e Fi

O 2), F

BC, B

USEC

r, LF

T, blo

od g

lucos

e, C

XR, E

CG, s

putu

m C

&S

Adm

inis

ter i

nitia

l tre

atm

ent:

• Co

ntro

lled

oxyg

en th

erap

y if S

pO2 <

90%

, aim

for S

pO2 9

0-93

%•

Inha

led sh

ort-a

cting

bro

ncho

dilat

ors (

SABA

+ S

AAC)

from

pM

DI vi

a a

spac

er d

evice

or n

ebuli

ser

• Or

al pr

ednis

olone

(int

rave

nous

hyd

roco

rtiso

ne if

patie

nt u

nable

to sw

allow

or v

omits

)•

Star

t ant

ibiot

ics if

patie

nt h

as 2

out

of 3

card

inal s

ympt

oms (

i.e, p

urule

nt sp

utum

, incr

ease

d sp

utum

volum

e, in

crea

sed

dysp

noea

)

No in

dicat

ion fo

r hos

pital

adm

ission

Adm

it to

hosp

ital