Consensus Statement on Management
of Chronic Pulmonary Disease March 2001
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
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
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
HOW SHOULD WE ASSESS PATIENTS WITH COPD ?
Adults with persistent symptoms of cough, sputum or shortness of
breath should be assessed for COPD
Assessment should comprise clinical history, including smoking and
occupation, symptoms, impact on daily living, recording of co-morbidity
and objective tests.
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
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.
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
Lung inflammation in COPD is most marked in the large airways in
those with sputum. The relevance of this remains uncertain.
Inhaled steroids do not affect rate of decline in FEV1. There is
no evidence to support their use in mild COPD.
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.
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
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 ?
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.
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.
Uncontrolled oxygen treatment during ambulance transfer is dangerous.
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
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.
Management decisions are best made with knowledge of the patient's
wishes, any advance directive and their previous clinical and home
Following discharge, patients should be reviewed to optimise current
treatment and for consideration of long-term oxygen therapy and/or
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
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.
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.
Patients who are disabled (e.g. MRC scale 3-5) by COPD in spite of
optimal treatment should be considered for rehabilitation.
Rehabilitation should be made up of a comprehensive programme of
education, psychological and nutritional advice, social support and
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.
The ideal length of the initial programme and of follow up and maintenance
needs to be established.
To alleviate handicap steps should be taken to provide social support,
increased physical access and occupational rehabilitation.
Self help groups for patients and carers providing mutual support,
information and education should be encouraged.
COPD is common, often under recognised, preventable and treatable.
A co-ordinated national approach has to be a high priority.
Effective methods of smoking cessation are available and need to
be easily accessed from primary and secondary care.
Spirometry, carried out by trained operators, is essential for diagnosis
and should be readily available in primary and secondary care.
Body mass index and MRC dyspnoea scale should be part of routine
Pulmonary rehabilitation should be widely available in every health
board or district.
Early supported discharge schemes improve efficiency. Non-invasive
ventilation saves lives. Both should be widely available.
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