Consensus Statement on Management of Chronic Pulmonary Disease March 2001

INTRODUCTION

COPD is the sixth most common cause of death worldwide and the burden of disease is set to rise as the number of older people increases. Considering the disability it causes the disease is not given the importance it deserves and public awareness about its effects remains poor. COPD is responsible for ten percent emergency admissions in the UK every year and accounts for 30,000 deaths. COPD care costs the NHS an estimated £500 million/year.

It is a chronic slowly progressive disorder characterised by airways obstruction (reduced FEV1 and FEV1/VC ratio <70%) which does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy. The cause is an abnormal inflammatory response of the lungs to noxious gases or particles e.g. cigarette smoke.

Avoidance of smoking is the most important measure in reducing the burden of this disease. Cessation of smoking is the only intervention proven to modify disease progression. Intervention to prevent smoking is obligatory.

Unrecognised early disease is common. The value of attempting to identify these people by screening has not been evaluated.

There is a range of pathological processes in COPD in different parts of the lung e.g. emphysema, small airways disease, chronic bronchitis, bronchiectasis. These are important for classifying patients for clinical studies but seldom affect patient management.

Many treatments do not alter disease progression but do improve patients' well being. The patient's opinion about the value of any treatment is important. Consensus guidelines on treatment exist but need to be more widely implemented.

HOW SHOULD WE ASSESS PATIENTS WITH COPD ?

1. Adults with persistent symptoms of cough, sputum or shortness of breath should be assessed for COPD

2. Assessment should comprise clinical history, including smoking and occupation, symptoms, impact on daily living, recording of co-morbidity and objective tests.

3. Objective tests should include spirometry to establish the diagnosis, body mass index and chest x-ray to exclude other conditions. If obstruction is confirmed, reversibility testing should be performed with high dose inhaled bronchodilators. A substantial response in FEV1 (>400mls) suggests asthma. Patients with a lesser response can still benefit from treatment. Repeated tests are not necessary. For long term monitoring the post-bronchodilator FEV1 is the most stable measure which also predicts survival.

4. The effect of breathlessness on daily living should be assessed and recorded using a standardised scoring system such as the Medical Research Council dyspnoea scale.

5. Specialist referral should be considered if unusual features are present. These include age less than 40, < 10 pack years smoking or variable symptoms. Disabled patients (MRC scale 3-5) should be referred to a respiratory clinic for more detailed clinical assessment and tests. These may include: full lung function testing, arterial blood gases, exercise testing, CT scan and an oral steroid trial.

DOES ANTI-INFLAMMATORY TREATMENT HAVE A ROLE IN THE MANAGEMENT OF COPD ?

1. Lung inflammation in COPD is most marked in the large airways in those with sputum. The relevance of this remains uncertain.

2. Inhaled steroids do not affect rate of decline in FEV1. There is no evidence to support their use in mild COPD.

3. In severe COPD (FEV1 <50% predicted), there is evidence that long-term inhaled steroids and other treatments such as long acting bronchodilators reduce the frequency of exacerbations. Inhaled steroids can slow the rate of decline of health status while long acting bronchodilators can result in an improvement. Their relative role needs to be defined. Until such evidence is available these options either alone or in combination can be justified.

4. The following are not known in relation to inhaled corticosteroid use in COPD: optimum dose, best delivery system, the relative merits of the different drugs, how to identify in advance which patient will benefit and the overall balance of benefit against side effects and cost.

5. The evidence supports the use of N-acetyl cystine and carbocystine to reduce exacerbation frequency in chronic sputum producers and the drug should be available for NHS prescription.

ACUTE EXACERBATION - WHAT SHOULD WE DO ?

1. An exacerbation is a sustained worsening of COPD symptoms requiring a change in usual treatment. The majority are bacterial and/or viral. Other causes include environmental pollution. Many patients do not seek medical advice but the vast majority who do are managed in primary care. Patients admitted to hospital are those with more severe disease and more severe exacerbations. Factors suggesting infection include increased sputum volume and purulence.

2. Treatment in primary care can include increased bronchodilators, antibiotics and a course of oral steroids. For many patients the exacerbation may be the first contact with the GP and should be seen as an opportunity for diagnosis and assessment of COPD and consideration of long term treatment. This will usually require organised follow-up.

3. Uncontrolled oxygen treatment during ambulance transfer is dangerous.

4. The need for hospital assessment is suggested by: marked increase in breathlessness, severe COPD, long term oxygen, failure to improve with treatment, co-morbidity, inability to cope and diagnostic uncertainty. Hospital assessment includes chest x-ray, arterial blood gases and initial treatment followed by a decision on supervised home care or admission.

5. Treatment in hospital includes: high dose bronchodilators, antibiotics, a course of systemic steroids and controlled oxygen therapy. Non-invasive ventilatory support is effective and should be available for those with respiratory acidosis. Sufficient intensive care and high dependency services must be available.

6. Management decisions are best made with knowledge of the patient's wishes, any advance directive and their previous clinical and home circumstances.

7. Following discharge, patients should be reviewed to optimise current treatment and for consideration of long-term oxygen therapy and/or rehabilitation.

8. Evidence supports early discharge programmes. Self management, shared-care programmes and respiratory outreach services need to be further evaluated.

LONG TERM REHABILITATION IN COPD - WHAT, WHEN AND WHERE

1. Pulmonary rehabilitation is a multidisciplinary programme of care that is individually tailored and designed to optimise physical and social performance. There is strong evidence of benefit and it needs to be made universally available.

2. All patients with COPD should be advised to take regular exercise such as walking or cycling. Patients need to be stimulated to co-operate in self management as many are likely to be in a downward spiral of breathlessness, inactivity, social isolation and apathy.

3. Patients who are disabled (e.g. MRC scale 3-5) by COPD in spite of optimal treatment should be considered for rehabilitation.

4. Rehabilitation should be made up of a comprehensive programme of education, psychological and nutritional advice, social support and individualised exercise.

5. A supervised exercise programme should last for at least 6 weeks with supervision of at least 2 sessions/week, supplemented by a home training programme. Lower limb aerobic exercise is mandatory. There is evidence to support strength training but further research is needed to define its role. The location of the programme is less important than its content.

6. The ideal length of the initial programme and of follow up and maintenance needs to be established.

7. To alleviate handicap steps should be taken to provide social support, increased physical access and occupational rehabilitation.

8. Self help groups for patients and carers providing mutual support, information and education should be encouraged.

RECOMMENDATIONS

1. COPD is common, often under recognised, preventable and treatable. A co-ordinated national approach has to be a high priority.

2. Effective methods of smoking cessation are available and need to be easily accessed from primary and secondary care.

3. Spirometry, carried out by trained operators, is essential for diagnosis and should be readily available in primary and secondary care.

4. Body mass index and MRC dyspnoea scale should be part of routine assessment.

5. Pulmonary rehabilitation should be widely available in every health board or district.

6. Early supported discharge schemes improve efficiency. Non-invasive ventilation saves lives. Both should be widely available.

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Graeme McAlister,
Publications Department of the Royal College of Physicians of Edinburgh,
9 Queen Street, Edinburgh EH2 1JQ.
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