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NICE guideline sets COPD management standards

Geoff Hall
Freelance journalist commissioned by NICE

Preventing worsening of the condition by encouraging sufferers to stop smoking is just one recommendation to come from a new NICE guideline covering the management of patients with stable illness and those suffering exacerbations. Chronic obstructive pulmonary disease (COPD) provides detailed, evidence-based advice and standards for the management of COPD in adults in primary and secondary care. Professor Peter Littlejohns, Clinical Director at NICE and Executive lead for the guideline, launched the guideline saying: "For people with COPD, their carers and the health professionals responsible for their care this guideline offers clear advice on what the NHS should provide. The guideline compiles evidence-based recommendations on best practice in the management of COPD that have been developed following a collaborative and consultative approach. In implementing this guideline, healthcare professionals across England and Wales can feel confident that they are providing people with COPD with the best possible treatment, based upon the best available evidence."
This chronic disabling condition is almost exclusively caused by smoking, and nearly all sufferers are over 35 years of age. An estimated 900,000 people in the UK have diagnosed COPD, and there may be as many again who remain undiagnosed. COPD is the fifth commonest cause of death in England and Wales, accounting for approximately 30,000 deaths each year. 
COPD, of course, cannot be cured. However, various treatments are effective in improving quality of life for patients. NICE claims the new guidelines will improve care for diagnosed sufferers of COPD and improve the accuracy of diagnosis. 
The guideline identifies seven key priorities for implementation. These cover: diagnosis, stopping smoking, effective inhaled therapy, pulmonary rehabilitation, the use of noninvasive ventilation, management of exacerbations and multidisciplinary working. As patients with COPD are likely to have a wide range of care needs during the progress of the disease, the guideline stresses the need for patients to have access to a multidisciplinary team across primary, secondary and tertiary care.

Diagnosis
The guideline states that a diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (almost always smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter "bronchitis" or wheeze.
Spirometry should be used to confirm the presence of airflow obstruction, and to this end, the guideline insists that all health professionals who are managing patients with COPD should have access to spirometry and be competent in the interpretation of the results. There is guidance on detailed aspects of diagnosis. In addition to respiratory symptomatology, the guideline suggests questions that may point to alternative diagnoses and clear guidance on further investigations, reversibility testing and assessment of severity.

Managing stable COPD
The section dealing with management of stable COPD emphasises the importance of smoking cessation. An up-to-date smoking history, including pack-years smoked, should be documented for all COPD patients. And the guideline has no time for the "well, the damage is done now" school of thought: "All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity," it insists.
To this end, the guideline recommends the use of bupropion or nicotine replacement therapy combined with appropriate support for all COPD patients who still smoke, unless contraindicated.
The guideline lays down standards for drug therapy. Short-acting bronchodilators should be used as the initial empirical treatment for the relief of breathlessness and limitation of daily active life. It also advocates a variety of measures to determine the effectiveness. These include improvement in symptoms, activities of daily living, exercise capacity and rapid symptom relief, rather than assessment of lung function in isolation. In patients who remain symptomatic, the guideline recommends using a combination of short-acting bronchodilators - a beta(2)-agonist and an anticholinergic or the addition of a long-acting bronchodilator.
Other therapeutic options reviewed are long-acting theophylline and oral and inhaled corticosteroids. There are detailed tips on the use of inhaled corticosteroids, including the recommendation that: "Inhaled corticosteroids should be prescribed for patients with an FEV(1) less than or equal to 50% predicted, who are having two or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12-month period." The guideline acknowledges that this recommendation is made despite the current status of these drugs - none of which is licensed for use alone in the treatment of COPD. There are also evidence-based suggestions on combination therapy and detailed guidance on the use of devices such as nebulisers and spacers.
The guideline devotes several pages to the use of oxygen, as long-term oxygen therapy, ambulatory oxygen therapy short-burst oxygen and noninvasive ventilation. It gives precise guidance matching usage with equipment.
The guidance on long-term oxygen therapy sounds a warning that, used inappropriately in COPD patients, it may cause respiratory depression. Long-term oxygen is indicated in patients with a PaO(2) less than 7.3kPa when stable or a PaO(2) greater than 7.3 and less than 8PaO(2) if accompanied by one of these conditions: secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary hypertension.
Patients on long-term oxygen therapy should be reviewed at least once a year by practitioners familiar with this therapy. The review should include pulse oximetry. Other factors in the long-term management of COPD that the guideline addresses include management of cor pulmonale, the importance of offering vaccination against pneumococcal infection and influenza to all patients with COPD. Looking at the role of pulmonary rehabilitation, the guideline defines this as: "a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise the individual's physical and social performance and autonomy". In practice, the guideline says that this should be offered to all patients who see themselves as functionally disabled by their condition.
However, the approach is not suitable for those unable to walk, suffer from unstable angina or who have had a recent myocardial infarction. As well as involving multicomponent, multidisciplinary interventions, rehabilitation must be designed, timed and planned to suit the patients who, in turn, make the commitment to gaining the benefits of the programme. The follow-up of patients with COPD is highlighted and based on distinguishing between mild/moderate and severe illness.

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Managing exacerbations of COPD
In a patient with COPD, a sustained worsening of symptoms from their usual stable state - and which is beyond normal day-to-day variations - is an exacerbation. These changes will often mean a change in medication, but for health professionals in primary care, the first decision that has to be made is whether the patient requires hospital treatment.
The guideline provides clear guidance for general practitioners on factors to consider when deciding where the patient should be treated.

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In patients with an exacerbation managed in primary care the guideline does not recommend that GPs routinely send sputum samples for culture. Pulse oximetry is of value in these patients in primary care if there are clinical features of a severe exacerbation. The relatively new option of "hospital-at-home" and assisted discharge schemes are, according to the guideline, safe and effective and should be used as an alternative way of managing patients with exacerbations of COPD. However, as there are currently insufficient data on which to base firm recommendations about which patients with an exacerbation are most suitable for hospital-at-home, the guideline suggests that patient selection should depend on the resources available and the absence of factors associated with a poor prognosis such as acidosis.
The guidance on pharmacological management of exacerbations is detailed and clarifies a number of issues, such as choice of delivery systems for inhaled therapy, the use of systemic corticosteroids, antibiotics, xanthines and respiratory stimulants.
Dame Helena Shovelton, Chief Executive of the British Lung Foundation, commented: "These guidelines are extremely important because for the first time clear recommendations for the type of service and treatment patients with COPD can expect to receive from their hospital and PCT have been set out. It must be acknowledged, however, that they are only guidelines and it is up to each individual hospital or PCT to implement them. We would, therefore, urge local health communities to implement the guideline as quickly as possible so that people with COPD can benefit from these recommendations for improvements in the diagnosis and treatment of their condition without delay."
Dr David Halpin, Chair of the Guideline Development Group, added: "Many patients with COPD live with distressing breathlessness every day - they struggle to perform simple tasks most people take for granted and often end up in hospital. Many feel neglected and despondent. These guidelines recommend management strategies that will make a significant difference to their quality of life."