This site is intended for health professionals only

The NICE Guidelines on COPD: their impact on primary care

JE Scullion
RGN BA(Hons) MSc
Consultant Respiratory Nurse
University Hospitals Leicester
Part-time Clinical Fellow
University of Aberdeen

COPD is a disease characterised by a mixture of small airways disease (obstructive bronchiolitis) and parenchymal destruction of the lung (emphysema), with individual variability in the degree to which patients have these elements.(1) It is a progressive and chronic condition that in the UK is the third most common cause of death, and by the year 2020 this is expected to be the same worldwide.(2-4) However, although death rates are important, the impact of COPD on morbidity presents the greatest challenge.
Around 90% of care of patients with COPD happens in primary care.(5) A general practice with 10,000 patients is estimated to have 200 patients with COPD.(6) However, traditionally these patients may have not had the best treatment, due perhaps to a misunderstanding of the impact of the disease on patients, to misdiagnosis or to a nihilistic attitude towards the disease from patients and healthcare professionals. With a growing awareness of the disease this is gradually changing and general practice is taking on the challenge of COPD care.
In 1997 the British Thoracic Society (BTS) produced the first guidelines on the management of COPD.(7) Further guidelines by the National Heart, Lung and Blood Institute (NHLBI), referred to as the GOLD guidelines, supplemented these.(1) Although the GOLD guidelines are living guidelines being updated as new evidence becomes available, the National Institute for Clinical Excellence (NICE) in conjunction with the BTS decided to generate new guidelines through the National Collaborating Centre for Chronic Conditions.(8)
The new guidelines give nearly 200 ­recommendations and identify seven key priority areas: diagnosis; smoking cessation; effective inhaled therapy; pulmonary rehabilitation for those who ­consider themselves disabled by their disease; noninvasive ventilation; management of exacerbations; and multidisciplinary working.

Diagnosis
Early identification of individuals with COPD is the key to effective management, treatment and care. One of the problems in treating COPD is the often late presentation of the patient for diagnosis when much of the damage has already been done. Research from the BTS COPD Consortium has recently found that one in five smokers aged between 15 and 54 have a persistent smoker's cough, yet almost half do not realise that it could be an early warning sign of a potentially serious lung disease. Of those adults suffering from one or more symptoms, 42% had not visited their GP to have them checked out.
The guidelines recommend that a diagnosis of COPD should be considered in all patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms: exertional breathlessness; chronic cough; regular sputum production; frequent winter "bronchitis"; and wheeze.(8)
The guidelines go on to recommend that patients in whom a diagnosis of COPD is considered should be asked about weight loss, effort intolerance, waking at night, ankle swelling and fatigue, as these may help with the ­clinical picture and may exclude alternative diagnoses.
The guidelines reinforce the fact that there is not a single definitive diagnostic test for COPD; diagnosis depends upon good clinical judgement and a combination of age, history, physical examination and airflow obstruction on spirometric testing. Spirometry remains the GOLD standard diagnostic test.(8) The guidelines recommend that every practice should have a spirometer and staff trained in its use. Spirometry is seen as useful on initial diagnosis and then recommended annually unless there is a good response to treatment that could indicate asthma, or alternatively a very rapid progression of ­symptoms out of proportion to what may be expected.
Spirometry measures two important parameters - the forced expiratory volume in one second (FEV(1)), which in the normal lung is usually 80% of the total volume that can be expelled, and the forced vital capacity (FVC), which shows how much air can be expelled from the lungs. If the ratio of FEV(1)/FVC is below 70% it indicates an airflow obstruction, while an FEV(1) below 80% indicates the severity of the obstruction (see Table 1).

[[NIP22_table1_19]]

The FEV(1) % predicted in the guidelines differs slightly from previous guidelines, in that they don't recommend routine reversibility testing. This is because reversibility is a snapshot measurement subject to day-to-day variation in patients, and a lack of reversibility has not meant that patients would not benefit from treatment.(8) However, reversibility is one of the outcome indicators for COPD in the GMS contract and may still be part of the COPD patient's assessment in primary care.

Smoking cessation
Smoking cessation is increasingly recognised as the only intervention that impacts on the disease progression of COPD.(9) Smoking reduces the rate of decline in lung function seen in COPD.(8) The guidelines reiterate that all patients should be encouraged to stop and be offered help to do so at every opportunity by using appropriate therapies that have a proven benefit.(8)

Effective inhaled therapy
Inhaled therapy is aimed at treating the patient's symptoms and remains the basis of treatment. However, the guidelines recognise the importance of checking a patient's inhaler technique. All patients who are symptomatic despite using short-acting bronchodilators should be commenced on long-acting bronchodilators (either b(2)-agonists or anticholinergics) to control symptoms and improve exercise tolerance. Inhaled corticosteroids should be used in conjunction with long-acting b(2)-agonists in patients with an FEV(1)

Pulmonary rehabilitation
Pulmonary rehabilitation is an evidence-based therapy for patients with COPD, increasing exercise tolerance and improving health-related quality of life.(10) The guidelines recommend that pulmonary rehabilitation should be offered to all patients who consider themselves ­disabled by their COPD, while recognising that it is not currently available in all areas of the country.(8)
 
Noninvasive ventilation
Noninvasive ventilation is a method of ventilatory support not requiring intubation but delivered by a mask covering the nose and mouth or by nasal prongs. The use of noninvasive ventilation is recommended as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations where there is limited response to optimal medical therapy.(8) The guidelines recommend that staff are trained in its application, experienced in its use and aware of its limitations. This has implications for the acute sector and service provision as noninvasive ventilation is not yet routinely available.

Management of exacerbations
In COPD, exacerbations are recognised as a major cause of worsening symptoms and have a major impact on a patient's quality of life.(11) The guidelines remind us that exacerbation frequency can be reduced by use of bronchodilators, inhaled steroids and influenza vaccinations. Although there is less evidence on its effectiveness, the guidelines encourage self-management aimed at giving patients stores of antibiotics and steroids to be used to treat exacerbations promptly. Currently many patients wait to consult a healthcare professional for treatment of an exacerbation, or fail to consult at all.

Multidisciplinary working
The guidelines advocate multidisciplinary working. Many practice nurses have taken on the challenge of COPD care and require support from their GP ­colleagues. Other members of the team that could be involved are dietitians, physiotherapists, pharmacists, occupational therapists and social workers. The key to effective multidisciplinary working is a respect for each individual's contribution and a willingness to work together for the common good of the patient.

Conclusion
In general practice, while the NICE/BTS guidelines are leading to improvements in patient care, perhaps the drive has been increased by the GMS contract, which recognises COPD as one of its performance indicators. The increasing number of practice nurses taking registered respiratory courses through national centres has assisted this, together with a growth in nurse-led clinics. Whatever the impetus the care, management and treatment of COPD in primary care is moving forward.

[[nip22_box1_19]]

References

  1. NHLBI. Global strategy for the diagnosis, management and prevention of chronic obstructive disease. Bethesda (MD): NIH; 2001.
  2. Barnes PJ. Managing COPD. London: Science Press; 1999.
  3. Crockett A.  Managing COPD in primary care. Oxford: Blackwell Sciences; 2002.
  4. Pauwels RA, et al. Am J Respir Crit Care Med 2001;163;1256-76.
  5. Morgan M.G Med 2000;30(12):15-7.
  6. Halpin DMG. COPD. London: Mosby; 2001.
  7. British Thoracic Society COPD Guidelines Group of the Standards of Care Committee. Thorax 1997;52 Suppl 5:S1-28.
  8. National Collaborating Centre for Chronic Conditions.  Thorax 2004;59 Suppl 1:1-232.
  9. Anthonisen NR, et al. JAMA 1994; 272:1497-505.
  10. Reis AL, et al. Chest 1997; 112:1363-96.
  11. Price D, et al. Asthma and COPD. Edinburgh: Churchill Livingstone; 2004.

Resources
Action on Smoking and Health (ASH)
T:020 7739 5902
W:www.ash.org.uk
British Lung Foundation
T:020 7831 5831
W:www.lunguk.org
National Asthma and Respiratory Training Centre
T:01926 493313
W:www.nartc.org.uk
Respiratory Education Resource Centre
T:0151 529 3943
W:www.respiratoryerc.com