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Patient Oriented Evidence that Matters

Introduction COPD POEM PDF
The COPDX Plan
Confirm diagnosis & assess severity
Optimise function
Prevent deterioration
Develop support network & self-management plan
eXacerbations manage appropriately
Review of drug use in COPD
Appendix One - Resources and contacts

O Optimise function
Follow up treatment | Review of medication | Inhaled steroids | Spacers

Initial treatment depends on severity of COPD

FEV1 is the strongest indicator of prognosis and best guide to initial treatment in COPD. However, functional impairment and spirometry results are not always clearly related and both must be taken into account.

COPD severity guide
Severity FEV1* Symptoms
At risk Normal Age >35yrs with past or current history of >10 pack years** smoking.
Occupational exposure.
Strong family history.
Mild 60% - 80% No symptoms or breathless on strenuous exercise only
(MRC 1)***.
Dyspnoea when hurrying on the level or walking up a slight hill (MRC 2).
Moderate 40% - 60% Has to walk slower than most people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level (MRC 3).
Stops for breath after walking about 100 yards or after a few minutes on the level (MRC 4).
Severe 30% - 40% Too breathless to leave the house or breathless when dressing (MRC 5).
Very severe <30% Permanent respiratory distress.
* percentage of predicted value.
** one pack year = 20 cigarettes per day for one year.
*** refers to grading of dyspnoea on the Medical Research Council (MRC) dyspnoea scale.

MRC Dyspnoea Scale
Grade One I only get breathless with strenuous exercise.
Grade Two I get short of breath when hurrying on the level or up a slight hill.
Grade Three I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level.
Grade Four I stop for breath after walking 100 yards or after a few minutes on the level.
Grade Five I am too breathless to leave the house or I am breathless on dressing.

The MRC scale is a useful validated score of dyspnoea in COPD (Bestall, 1999).

The following guide to initial treatment is suggested. At follow up, treatment will need to be tailored to the needs and responses of individual patients.

Guide to initial treatment
At risk Mild Moderate Severe Very Severe
    Oxygen and/or surgery## may be indicated.
    Tiotropium - special authority. Trial of inhaled corticosteroids. Possibly theophylline.
    Regular inhaled short acting bronchodilator (ipratropium or beta agonist or combination of both) if responsive.
Pulmonary rehabilitation.
LABA may be beneficial but not currently funded for this indication.
  Intermittent inhaled short acting bronchodilator
(ipratropium or beta agonist) before exercise.
Smoking cessation# - counselling plus NRT.
Annual spirometry & questions regarding cough, sputum, dyspnoea.
# Smoking cessation is the only intervention which slows disease progression. Other interventions are aimed at optimising function or decreasing number of exacerbations.
## Surgical options may include bullectomy and lung volume reduction. Lung transplantation is usually reserved for younger patients e.g. those with alpha-1 antitrypsin deficiency.

Follow up treatment tailored to response of individual patients

In order to assess the response to treatment and enable appropriate modification we need objective measurement of change. However, treatment often does not produce measurable changes in spirometry so objective measurements of symptoms and well-being also need to be recorded.

Objective measures include:
  • FEV1 or PEFR
  • Dyspnoea on the MRC scale
  • Frequency and severity of cough and sputum
  • Exercise capacity such as distance able to walk
  • Number of exacerbations
  • Smoking status
Other important areas to consider include:
  • Ability to sleep, fatigue
  • Psychosocial functioning
  • Adherence to medication and use of inhalers
  • Vaccinations due - influenza, pneumococcus
  • Participation in pulmonary rehabilitation
  • Self-management plan up to date
  • Evidence of complications - sleep apnoea, osteoporosis, gastro-oesophageal reflux, aspiration
  • Evidence of comorbidities such as heart failure

Review of medication

The response to medication is slow in COPD so a trial of at least four weeks is needed to assess response to treatment changes.

Evidence about the effectiveness of medications for COPD is often equivocal and international drug funding authorities interpret this evidence in different ways. For example inhaled corticosteroids are unlicensed for use in COPD in the UK except when combined with Long Acting Beta Agonists (LABAs), and LABAs are not funded for use in COPD in New Zealand.

bpacnz suggest the following pragmatic hierarchical approach to medication use in COPD in New Zealand, however there are other valid approaches which you might decide to use for individual patients after reading the review of medication that appears later in this POEM.

A hierarchical approach to medication use in COPD
Intermittent symptoms Short acting inhaled beta-2 agonist as needed
(e.g. salbutamol 200mcg PRN).
Persistent symptoms Regular short acting inhaled beta-2 agonist and ipratropium
(e.g. salbutamol 200-400mcg plus ipratropium 40mcg QID).
Severe COPD Regular tiotropium 18mcg daily with inhaled beta-2 agonist as needed.
Frequent exacerbations Trial of inhaled corticosteroids
(e.g. Fluticasone 250-500mcg BD).
Availability of prednisone and antibiotic at home.

The reduction in exacerbation rates achieved by inhaled corticosteroids is very modest and the results come from one study only. They should be discontinued in individual patients who do not show benefit. Because of the equivocal evidence of efficacy and the potential for side effects, inhaled corticosteroids are not approved for COPD in many countries (Cooper, 2005). Side effects include easy bruising, cataract formation and possible contribution to osteoporosis.

People with COPD are at high risk of osteoporosis because of smoking, vitamin D deficiency, low BMI, hypogonadism, sedentary lifestyle and the use of oral steroids. Although oral steroids are a known risk factor the situation with ICS is less clear. A higher risk does seem likely at high doses.

What should I do about people with COPD who have been on inhaled steroids for a long time without a documented response?

A dilemma occurs with people who have been on inhaled corticosteroids (ICS) for a prolonged period of time when a search of the notes does not reveal a documented response to them. In most people the dose can be reduced and if the patient remains stable they can be discontinued. However, there is some evidence that withdrawing the steroids can result in increased breathlessness and reduced exercise tolerance (O'Brien, 2001).

We suggest that the need for ICS is reviewed for patients with COPD when presenting for repeat medications, paying particular attention to those on high daily doses of ICS (Fluticasone >500mcg daily, Beclomethasone >800mcg daily) because of their higher risk of side effects. Medications mentioned for the first time in this table are reviewed later on in this POEM.

Suggested schema for review of people with COPD on ICS
Is there documented evidence of improved:
  • FEV1 or PEFR
  • Dyspnoea on the MRC scale
  • Frequency and severity of cough and sputum
  • Exercise capacity such as distance able to walk
  • Number of exacerbations
  • Is patient using a spacer with good technique?
  • Is a comorbidity contributing to the problem?
  • Check patients ideas and expectations of the ICS
Check that other therapy is optimum
  • Is patient undergoing pulmonary rehabilitation?
  • Would the patient benefit from surgery or oxygen?
  • If you are satisfied with above try reducing ICS at a rate of one puff per month with careful monitoring of patient well-being.

Inhaler technique using spacer

All patients with COPD who are using metered dose inhalers should be using them through a spacer.

A dry powder inhaler may be a good alternative but turbuhalers should be avoided in those few patients who cannot produce inspiratory flow greater than 30L per minute as they may not achieve adequate drug delivery. This does not apply to tiotropium which is delivered through a handihaler.

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