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CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
COPD is primarily a respiratory disorder characterised by slowly progressive airflow obstruction that is not fully reversible; there is additional systemic illness. The person with COPD becomes increasingly breathless, even at rest, ultimately requiring palliative care. COPD is the fifth most common cause of death in the UK. Smoking is the predominant cause of COPD, although not all smokers are affected. An occupational cause warrants secondary referral. Stopping smoking is the most important way to improve outcomes.
NICE NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management; 2018 (Updated 2019) https://www.nice.org.uk/guidance/NG115
GOLD (Global Initiative for Obstructive Lung Disease) 2021 Global strategy for Prevention, Diagnosis and Management of COPD (Also available as pocket guide and teaching slide set) https://goldcopd.org/gold-reports/
Practice nurses should be alert to patients who may be at risk of COPD, e.g. at new patient medicals or when patients consult for other reasons, and offer advice and assessment of respiratory function. See also Smoking cessation
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Diagnosis of COPD is a clinical judgement, based on the history and physical examination, supported by the results of spirometry or post-bronchodilator spirometry showing respiratory obstruction that is not completely reversible. Consider a diagnosis of COPD in a person aged over 35 years who has:
Spirometry is an essential investigation for COPD diagnosis. It allows more sensitive measurement of lung function than peak-flow measurement. Demonstrating reversibility in COPD is not necessary except where the history is not clear. The main objective of reversibility testing is to demonstrate the substantial increase (400 ml or more) in FEV1 (forced expiratory volume in 1 second) that occurs in patients with asthma in response to bronchodilator treatment.
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Determining disease severity
Airflow obstruction in COPD is measured with spirometry. Measure annually to assess disease progression.
FEV1 alone does not determine quality of life in COPD. NICE recommends use of the MRC dyspnoea scale to measure COPD’s effect on daily activities. Frequency of exacerbations (see below) is another factor.
Inhaled medication, short- and long-acting, is added stepwise, in line with NICE guidance, as COPD progresses and symptoms worsen. Long-term oxygen therapy (LTOT) may be necessary in severe disease. Pulmonary rehabilitation can improve exercise tolerance, confidence and quality of life in moderate/severe COPD and should be available to all appropriate patients. End-of-life support should be offered to patients and families as necessary.
An exacerbation of COPD is:
Additional medication is often necessary (often patient has a supply ready at home, and a self-management plan), and sometimes admission to hospital. It is important to minimise the frequency and impact of exacerbations by:
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Outcomes Strategy for COPD
Among the aims of the Outcomes Strategy for COPD are to:
The Quality and Outcomes Framework (QOF) requires all patients with COPD to have at least an annual review, carried out by a suitably qualified individual. Be aware of QOF indicators, and ensure correct application of Read codes.
NICE guidance (NG115)
Assess (at least annually at stages 1-3, at least twice a year at stage 4):
and additionally at Stage 4
Monitor (at stages 1-3)
and, additionally at Stage 4
The review is also an opportunity to:
NICE NG115 Chronic obstructive pulmonary disease in adults: diagnosis and management; 2018 (updated 2019).
NICE CG91 Depression with a chronic physical health problem: recognition and management; 2009 https://www.nice.org.uk/guidance/CG91
Primary Care Respiratory Society UK www.pcrs-uk.org
Information on COPD British Thoracic Society https://www.brit-thoracic.org.uk/clinical-information/copd/
British Lung Foundation (runs Breathe Easy groups) https://www.blf.org.uk/Page/chronic-obstructive-pulmonary-disease-COPD
SPIROMETRY: measuring lung function
Diagnosis of COPD is confirmed by spirometry. Spirometry is carried out using a spirometer, a machine that measures:
The machine records the results of the patient’s efforts. FVC is a measure of lung volume. FEV1 is a measure of the speed of exhalation, i.e. how quickly full lungs can be emptied. Normal lungs will achieve 80% in 1 second, obstructed lungs will achieve <80% in 1 second.
A guide to performing quality assured diagnostic spirometry; PCC 2013 https://www.brit-thoracic.org.uk/media/70454/spirometry_e-guide_2013.pdf
Predicted values The readings obtained are compared with those predicted for an individual of the patient’s age, height, sex and ethnic group. When lungs are healthy, the readings are similar to or exceed the predicted values Significant airways obstruction is indicated when the:
Many spirometers carry out the necessary calculations.
To calculate % predicted (Actual measurement/predicted value) x 100 eg, if actual FEV1 = 3.5 litres, and predicted FEV1 = 4.0 litres, (3.5/4.0) x 100 = 87.5% = % predicted
To calculate FEV1/FVC ratio (Actual FEV1/actual FVC) x 100 eg, if FEV1 = 3.0 litres, and FVC = 4.0 litres Ratio = (3/4) x 100 = 75%
Flow-volume curves Some spirometers produce a graph of lung function. The volume of air breathed out (in litres) is plotted against time (in seconds), to give a flow–volume curve. This spirometry trace may be: a) normal – when lungs are healthy, the trace rises rapidly at the start and then slows steadily, with no irregularities b) obstructive – a flattened curve indicates slow exhalation of a normal lung volume c) restrictive – a small curve of normal shape indicates a normal expiratory rate but reduced lung volume d) combined – a flattened curve with low volumes indicates that both obstruction and restriction are present.
Training for ARTP/BTS Certificate of Competence in Spirometry Association for Respiratory Technology and Physiology www.artp.org.uk
Education for Health Warwick www.educationforhealth.org (also accredited spirometry module)
Primary Care Training Centre Bradford www.primarycaretraining.co.uk
European Respiratory Society. ERS HERMES self-assessment course in adult respiratory medicine https://www.ersnet.org/events/adult-hermes-self-assessment-2021/ Check https://www.ersnet.org/events/ for further courses