these guidelines have been withdrawn · 4 contents page executive summary of recommendations 1 1...

These guidelines have been withdrawn MOH clinical practice guidelines are considered withdrawn five years after publication unless otherwise specified in individual guidelines. Users should keep in mind that evidence-based guidelines are only as current as the evidence that supports them and new evidence can supersede recommendations made in the guidelines.

Chronic Obstructive PulmonaryDisease Association (Singapore)

College of Family PhysiciansSingapore

Academy of MedicineSingapore

Chapter of Respiratory PhysiciansCollege of Physicians, Singapore

Association of Aged CarePhysicians Singapore

MINISTRY OF HEALTHSINGAPORE

Singapore MedicalAssociation

SINGAPORE THORACIC SOCIETY

Oct 2006

MOH Clinical Practice Guidelines 4/2006ISBN 981-05-6800-2

CLINICAL PRACTICE GUIDELINESCLINICAL PRACTICE GUIDELINES

Chronic ObstructivePulmonary DiseaseChronic ObstructivePulmonary Disease

1

Levels of evidence and grades of recommendation

Levels of evidence Level Type of Evidence 1+ + High quality meta-analyses, systematic reviews of randomised

controlled trials (RCTs), or RCTs with a very low risk of bias.

1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.

1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2+ + High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Grades of recommendation

Grade Recommendation A At least one meta-analysis, systematic review of RCTs, or RCT

rated as 1+ + and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1+ + or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2+ +

D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

GPP (good practice

points)

Recommended best practice based on the clinical experience of the guideline development group.

3

Published by Ministry of Health, Singapore 16 College Road, College of Medicine Building Singapore 169854

Printed by Oxford Graphic Printers Pte Ltd

Copyright 2006 by Ministry of Health, Singapore

ISBN 981-05-6800-2

Available on the MOH website: http://www.moh.gov.sg/cpg

Statement of Intent

These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve.

The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case. These guidelines should neither be construed as including all proper methods of care, nor exclude other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient, in the light of the clinical data presented by the patient and the diagnostic and treatment options available.

5

Chronic obstructive pulmonary disease is a major cause of mortality and morbidity worldwide: it is the fourth leading cause of death worldwide. In terms of morbidity (as measured in disability-adjusted life years lost), chronic obstructive pulmonary disease ranks thirteenth. According to the WHO Global Burden of Disease Study, by 2020 it will be the fifth leading cause of disability-adjusted life years lost.

Chronic obstructive pulmonary disease is the seventh leading cause of death in Singapore today and morbidity due to this disease is rising. It is timely that we develop the first national guidelines on chronic obstructive pulmonary disease in order to deal with the disease. A multidisciplinary expert committee has reviewed the latest evidence from the scientific literature and used their expertise to localize the guidelines.

I hope these guidelines will assist all doctors, especially primary care physicians, in managing their patients with chronic obstructive pulmonary disease.

PROFESSOR K SATKU DIRECTOR OF MEDICAL SERVICES

4

Contents

Page

Executive summary of recommendations 1

1 Introduction 15

71 srotcaf ksiR dna ygoloimedipE 2

3 Definition, Differential Diagnosis and Classification of Severity

18

4 Evaluation 22

5 Pharmacotherapy for Stable COPD 25

6 Non-pharmacological Management of Stable COPD

36

7 Monitoring of patients with Stable COPD 48

8 Management of Acute Exacerbations 49

9 Air Travel 55

75 stneitaP DPOC ni yregruS 01

11 End of Life Care 59

16 tnemevorpmI ytilauQ lacinilC 21

References 62

87 )sQCM( tnemssessa-fleS

38 srebmem puorgkroW

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Executive summary of recommendations Details of recommendations can be found in the main text at the pages indicated.

Definition, Differential Diagnosis and Classification of Severity

D Where diagnostic doubt remains, or both COPD and asthma are present, the following findings will help identify asthma (pg 18):

• A large response (FEV1 greater than 400 ml) to bronchodilators. • A large response (FEV1 greater than 400 ml) to 30 mg oral

prednisolone daily for 2 weeks. • Serial peak flow measurements showing 20% or greater diurnal or

day-to-day variability. Grade D, Level 4

D Where chronic asthma cannot be distinguished from COPD with the current imaging or lung function testing, it is assumed that the two diseases co-exist and their management should be similar to that of asthma (pg 19).

Grade D, Level 4

D COPD should be differentiated from congestive heart failure, bronchiectasis, and obliterative bronchiolitis (pg 19).

Grade D, Level 4

D A classification of disease severity into 5 stages based on spirometry cut points is recommended (pg 20).

Grade D, Level 4

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Table 3 Classification of severity*

Stage Characteristics0: At Risk normal spirometry

chronic symptoms (cough, sputum production)I: Mild COPD FEV1/FVC < 70%

FEV1 ≥ 80% predicted with or without chronic symptoms (cough,

sputum production) II: Moderate COPD FEV1/FVC < 70%

50% ≤ FEV1 < 80% predicted with or without chronic symptoms (cough,

sputum production) III: Severe COPD FEV1/FVC < 70%


sputum production) IV: Very Severe COPD

FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50%

predicted plus chronic respiratory failure *Classification based on postbronchodilator FEV1

FEV1: forced expiratory volume in one second; FVC: forced vital capacity; respiratory failure: arterial partial pressure of oxygen (PaO2) less than 8.0 kPa (60 mm Hg) with or without arterial partial pressure of CO2 (PaCO2) greater than 6.7 kPa (50 mm Hg) while breathing air at sea level.

(Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2005)

Evaluation

D A diagnosis of COPD should be considered in any patient more than 35 years old, who has chronic cough, sputum production, or dyspnoea, and/or a history of exposure to risk factors for the disease(see Table 4) (pg 22).

Grade D, Level 4

D Spirometry is useful for the definitive diagnosis of COPD and for the staging of disease severity and should be performed in individuals with symptoms suggestive of COPD (pg 23).

Grade D, Level 4

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D It is also recommended that bronchodilator reversibility testing be performed to help identify some subjects with asthma or a large asthma component to COPD and to establish a patientʼs best attainable lung function (pg 24).

Grade D, Level 4

D Arterial blood gases should be performed in patients with FEV1<40% predicted or with clinical signs suggestive of respiratory failure or right heart failure (pg 24).

Grade D, Level 4

D A chest X-ray is seldom diagnostic in COPD but it is valuable in excluding alternative diagnoses and should be performed to look for abnormalities that may suggest other conditions. Computed tomography of the chest is not routinely recommended (pg 24).

Grade D, Level 4

Pharmacotherapy for stable COPD

A Inhaled short-acting bronchodilators are recommended as first-line therapy in all stages of COPD to relieve symptoms and improve exercise capacity (pg 26).

Grade A, Level 1+

A Regular treatment with one or both classes of the inhaled long-acting bronchodilators should be considered for patients with moderate to very severe COPD with frequent exacerbations (pg 28). Grade A, Level 1+

D Inhaled long-acting bronchodilators may be added to the treatment regimen when symptoms are not controlled with short-acting inhaled bronchodilators alone (pg 28).

Grade D, Level 4

D Theophylline may be a useful addition where symptom control is still not achieved with existing inhaled bronchodilator therapy. Theophylline may be of value for patients who are non-adherent to or unable to use inhaled therapy (pg 30).

Grade D, Level 4

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A Inhaled corticosteroids as long-term maintenance therapy are recommended for patients with FEV1 <50% predicted who experience frequent exacerbations (pg 32).

Grade A, Level 1+

A Long-term oral corticosteroids are not recommended in stable COPD (pg 32).

Grade A, Level 1+

D Combination inhaled corticosteroids and long-acting ?2-agonists should be considered for patients in whom both its components are indicated (pg 33).

Grade D, Level 4

C Annual influenza vaccination should be offered to the elderly (65 years and above) in all stages of COPD (pg 33).

Grade C, Level 2++

D Pneumococcal vaccination may be considered in COPD patients (pg 34).

Grade D, Level 4

D If considering pneumococcal vaccination for a COPD patient, usually only one dose of the vaccine is needed. A second dose is recommended for persons aged 65 or older who received their first dose when they were under 65, if 5 or more years have passed since that dose (page 34).

Grade D, Level 4

2

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Table 7 Recommended pharmacotherapy in stable COPD

Symptoms Exacerbations Spirometry Recommended pharmacotherapy

Intermittent AND

Few exacerbations

Regardless of FEV1

SABA or Combination SABA/SAAC inhaler

as needed for symptom relief

Persistent* AND/OR

Frequent exacerbations†

AND

FEV1 > 50% predicted

SABA as needed for symptom relief

With one of the following:1) SAAC 4 to 6 hourly or 2) Combination SABA/SAAC

inhaler 4 to 6 hourly or 3) Long-acting anticholinergic

(LAAC) once daily‡

to which may be added:

Long-acting 2-agonist (LABA) 12 hourly‡

AND/OR

Sustained-release theophylline 12 hourly or once daily‡

Intermittent or

Persistent

AND

Frequent exacerbations

AND

FEV1 < 50% predicted

As above

AND

Inhaled corticosteroids

SABA = short-acting 2-agonist SAAC = short-acting anti-cholinergic

* Persistent symptoms: exertional dyspnoea, diminished exercise capacity, persistent cough, wheeze despite SABA/combination SABA/SAAC inhaler as needed.

† Frequent exacerbations: two or more acute exacerbations a year requiring systemic steroids.

‡ GPP The choice between LAAC, LABA or theophylline is dependent on the individual patientʼs response in terms of symptom relief and side-effects, and affordability of the medication. This should be re-evaluated if there is lack of therapeutic response.

GPP

2

2

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Non-pharmacological Management for Stable COPD

Patient education

D Patient education is a vital part of COPD management and should begin at the time of first assessment for COPD and continue with each follow-up visit (pg 36).

Grade D, Level 4

D The intensity and content of patient educational messages should vary depending on the severity of the patientʼs disease (see Table 8) (pg 36).

Table 8 Recommended topics for patient education according to severity of disease

Severity of Disease Patient Education Topic Stage 0: At Risk Information and advice about reducing

risk factors.

Stage I: Mild COPD through Stage III: Severe COPD

Above topic, plus: Information about the nature of COPD. Instruction on how to use inhalers and nebulizer. Information on influenza vaccination and medication. Recognition and treatment of exacerbation. Strategies for minimizing dyspnea Information on pulmonary rehabilitation.

Stage IV: Very Severe COPD

Above topic, plus: Information about complications. Information about oxygen treatment. Advance directive and end-of-life decisions.

[Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD),2005]

Grade D, Level 4

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D Patient education should be (pg 37): • Tailored to meet the needs of the individual patient • Interactive • Directed to improving quality of life • Simple to follow • Practical • Appropriate to the intellectual and social skill of the patient and

the caregivers.Grade D, Level 4

Smoking cessation

A Smoking cessation should be emphasized as an essential first step in management of COPD patients (pg 37).

Grade A, Level 1++

GPP Clinicians should play a prominent role in promoting attempts to stop smoking in their patients (pg 37).

GPP

A All smokers, including those who may be at risk for COPD as well as those who already have the disease, should be offered at least a brief tobacco dependence counseling at every health care provider visit (pg 37).

Grade A, Level 1++

D Pharmacotherapy for smoking cessation is recommended when counseling is not sufficient to help patients quit smoking (pg 38).

Grade D, Level 4

A Treatment of nicotine dependence is effective and should be offered to smokers in addition to counselling (pg 38).

Grade A, Level 1++

A These pharmacotherapies reliably increase long-term smoking abstinence rates and at least one of these medications should be added to counseling if necessary and in the absence of contraindications (pg 38).

Grade A, Level 1++

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Nutrition in COPD

D All patients with COPD should undergo simple nutrition screening (pg 39).

Grade D, Level 4

GPP Nutritional intervention should be considered in all COPD patients with BMI < 18.5 kg/m2 or significant involuntary weight loss (>10% during the last 6 months or > 5% in the past month) (pg 39).

GPP

Pulmonary rehabilitation

D Pulmonary rehabilitation may be considered for patients with the following (pg 41): • persistent symptoms especially dyspnoea, • reduced exercise tolerance or experience a restriction in activities, • recurrent admissions to hospitals over the last 6 months.

Grade D, Level 4

B The physical components of pulmonary rehabilitation should include both lower extremity training (e.g., bicycle, ergometry, treadmill) and upper extremity training (strength and endurance) (pg 41).

Grade B, Level 2+

D Psychosocial and behavioral interventions (health education, smoking cessation clinic, and support groups addressing psychosocial issues) as well as nutritional intervention should also be included as non-physical components of the comprehensive pulmonary rehabilitation programs (pg 41).

Grade D, Level 4 Oxygen therapy in chronic obstructive pulmonary disease

A Patients with very severe COPD and chronic respiratory failure should be assessed for the need for long-term oxygen therapy (pg 42).

Grade A, Level 1+

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A Indications for long-term oxygen therapy (at least 15 hours/day) in patients with COPD should be based on the following indices obtained in stable state (pg 42):

• Without pulmonary hypertension (Cor Pulmonale), congestive heart failure, polycythaemia (Hct >55%):

1. PaO2 < 55 mmHg on Room Air OR

2. SaO2 < 89% on Room Air

• With pulmonary hypertension (Cor Pulmonale), congestive heart failure, polycythaemia (Hct >55%):

1. PaO2 between 55 mmHg - 60 mmHg on Room Air OR

2. SaO2 < 89% on Room Air Grade A, Level 1+

D Oxygen concentrator is the preferred mode of delivery of oxygen. It is the most convenient and economical method of providing long-term oxygen therapy (pg 43).

Grade D, Level 3

D Very severe COPD patients with hypercapnic respiratory failure requiring long-term oxygen therapy should have the oxygen flow rate titrated cautiously to maintain a SaO2 > 90% (pg 43).

Grade D, Level 4

Monitoring of patients with stable COPD

D & GPP Patients should be seen and assessed regularly (e.g. three-monthly in the stable state) (pg 48).

At each follow-up visit:

• Patients should be asked regarding onset of any new symptoms and/or worsening of exercise capacity.

• Current smokers should be given repeated advice to quit.

• Adherence to medications should be assessed, and the patientʼs inhaler technique checked and re-taught if necessary.

Grade D, Level 4/GPP

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D & GPP Indications for specialist referral (pg 48)

• Severe COPD (FEV1 < 50% predicted).

• Frequent exacerbations (e.g. two or more a year) despite compliance to treatment.

• Rapidly progressive course of the disease.

• Development of new symptoms e.g. haemoptysis, or new physical signs e.g. cyanosis, peripheral oedema.


Management of Acute Exacerbations

C Chest radiography is recommended in an acute exacerbation, when other diagnoses like pneumonia or heart failure need to be excluded (pg 50).

Grade C, Level 2+

D Sputum culture is not recommended for routine investigation of patients with exacerbation (pg 50).

Grade D, Level 3

D Pulse oximetry, if available, can assist doctors in identifying patients with hypoxaemia when oxygen saturation (SaO2) is less than 90% (pg 50).

Grade D, Level 3

Pharmacological management

A Inhaled anticholinergic bronchodilators or inhaled short-acting -agonists are beneficial and should be used in the treatment of patients presenting with acute exacerbation of COPD (pg 52).

Grade A, Level 1+

D Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD, as they are equally effective in achieving bronchodilation in COPD exacerbations (pg 52).

Grade D, Level 4

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A In the absence of significant contraindications, oral corticosteroids should be used, in conjunction with other therapies, in all patients admitted to hospital with an exacerbation of COPD (pg 52).

Grade A, Level 1+

A In the absence of significant contraindications, oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in the breathlessness which interferes with daily activities (pg 52).

Grade A, Level 1+

A Prednisolone 30 mg orally should be prescribed for 7 to 14 days to patients with an exacerbation. It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy (pg 53).

Grade A, Level 1+

A Antibiotics should be used to treat exacerbations of COPD when (pg 53):

(1) there is history of purulent sputum (2) there are clinical signs of pneumonia (3) there is consolidation on a chest radiograph

Grade A, Level 1+

Non-pharmacological therapy

GPP Oxygen therapy should be considered if patient is known, or suspected, to have hypoxaemia. This can be administered via nasal prongs, or venturi mask. One should exercise caution in the oxygen dose for patients, such that the lowest possible oxygen concentration to maintain oxygen saturation above 90% is provided. If pulse oximetry is not available, the concentration of the oxygen mask should not exceed 28%, or the nasal prong oxygen flow rate should be kept at 2L/min (pg 53).

GPP

A Non-invasive ventilation should be used as the treatment of choice in the hospital, for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy (pg 53).

Grade A, Level 1+

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Algorithm for the management of an acute exacerbation

*30 mg of prednisolone daily for up to 14 days (Adapted from European Respiratory Society Consensus Statement, 1995)

Mild exacerbations • Initiate, increase dose or frequency, or combine β2-agonist and/or • Anticholinergic • Encourage sputum clearance by coughing • Consider chest physiotherapy • Encourage fluid intake • Avoid sedatives and hypnotics • Consider antibiotics • Consider oral corticosteriods* Instruct patients on symptoms and signs of worsening and actions to take: Contact primary care physician or go to emergency department.

Reassess within 48 hours by physician

Improved Worsened

Refer to hospital

Acute exacerbation

Signs of severe exacerbation (any of the following)

• marked dyspnoea and tachypnoea (>30 respirations/minute)

• use of accessory muscles (sternomastoid and abdominal) at rest

• cyanosis

• confusion

• SaO2 <90%

Consider adding corticosteroids* or a course of antibiotics if not given earlier. Instruct patient on symptoms, signs of worsening and action to take.Stable COPD

management

Continue same management or reduce intensity (step down)

No

Yes

Assessment by physician

Worsened

Not improving

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When to refer to the Emergency Department (ED)

GPP Any one of the following signs may indicate severe exacerbations requiring urgent referral to the Emergency Department (pg 54):

1. marked dyspnoea and tachypnoea (> 30 respirations/minute) 2. use of accessory muscles (sternomastoid and abdominal) at

rest 3. cyanosis 4. confusion 5. SaO2 <90%

GPP

Air Travel

D Patients with severe COPD, history of air travel intolerance with respiratory symptoms (dyspnoea, chest pain, confusion, syncope), co-morbidity with other conditions worsened by hypoxaemia (cerebrovascular disease, coronary artery disease, heart failure), and recent pneumothorax should undergo assessment before flying.

The following assessment is recommended141:

• history and examination with particular reference to cardio-respiratory disease, dyspnoea and previous flying experience

• spirometry (in non-tuberculous patients only)

• measurement of SpO2 by pulse oximetry. Readings should be taken from a warm ear or finger after sufficient delay for the oximeter to display a stable reading. Blood gases are preferred if hypercapnia is known or suspected

(pg 55) Grade D, Level 4

D Patients who have resting sea level oximetry between 92% and 95% and who have additional risk factors (Table 9) should be referred for further assessment (pg 55).

Grade D, Level 4

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Surgery in COPD patients

GPP Preoperative assessment of a COPD patient should include (pg 57):

1. Detailed history and physical examination 2. Assessment of functional capacity (American Society of

Anesthesiology Physical Status Scale). See Table 10. 3. Preoperative Spirometry 4. Arterial Blood Gas especially in moderate to severe COPD 5. Chest Radiograph

GPP

A COPD patients being considered for surgery should be assessed for risk of developing venous thromboembolism and also for thromboprophylaxis during the perioperative assessment (pg 58).

Grade A, Level 1+

A Combination of bronchodilators, chest physiotherapy, antibiotics, smoking cessation for at least 4-8 weeks and a short course of oral corticosteroids should be given for patients with acute exacerbation so as to reduce the risk of postoperative pulmonary complications (pg 58).

Grade A Level 1+

End of Life Care in COPD

D Patients should be educated about their disease, prognosis and possible circumstances of death (pg 59).

Grade D, Level 3

D Physicians should discuss end of life issues and advance care planning with patients (and their relatives) who have severe to very severe COPD (pg 59).

Grade D, Level 3

B Physicians who look after severe to very severe COPD patients (as with all physicians caring for the terminally ill) will need to be prepared to discuss end of life issues with patients (pg 60).

Grade B, Level 1+

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1 Introduction

1.1 Aim and scope of guidelines

The aim of these guidelines is to give physicians a practical approach and guide to the care of chronic obstructive pulmonary disease (COPD) patients. It is hoped that with the aid of the guidelines, the clinician will be able to deliver an even higher standard of care for our patients.

Emphasis is placed on the definition, diagnosis and evaluation of the disease as it has been shown to be frequently under-recognised and under-diagnosed.1

The appropriate management of the patient in the stable state as well as in acute exacerbations with both pharmacological and non-pharmacological measures is explored in detail. A table on the use of pharmacotherapy is created to help clinicians deal with the myriad of drug classes and combinations available for treatment.

Finally, sections on unique aspects of care in COPD patients are also included to ensure comprehensive coverage of the subject.

1.2 Target group

These guidelines are meant for all doctors having to care for COPD patients; in particular, primary care doctors and doctors who are not respiratory physicians.

1.3 Guideline development

It is timely that the nation develops her first national guidelines on COPD with the current recognition of the importance of appropriate management of chronic diseases. The need for these guidelines was first mooted by the College of Family Physicians, Singapore; the chairperson and committee were subsequently appointed by the Ministry of Health.

This committee was carefully selected to represent a multi-disciplinary group of clinicians working in different settings. Both private and public primary care, intermediate care at community

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hospitals as well as acute care physicians in the private and public tertiary hospitals were involved in the development of the guidelines. We also had representatives from the National University of Singapore.

The workgroup reviewed literature from many of the COPD guidelines that had already been developed by renowned bodies in the world [e.g. Global Initiative for Chronic Obstructive Lung Disease (GOLD), National Institute for Health and Clinical Excellence (NICE), American Thoracic Society/European Respiratory Society (ATS/ERS)].2,3,4 Best available current evidence and expert opinions were also sought in areas that were not covered in other published guidelines.

1.5 Review of guidelines

Evidence-based clinical practice guidelines are only as current as the evidence that support them. Users must keep in mind that new evidence could supersede recommendations in these guidelines.

The workgroup advises that these guidelines be scheduled for review three years after publication, or if new evidence appears that requires substantive changes to the recommendations.

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2 Epidemiology and Risk Factors

2.1 Epidemiology

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and disability worldwide.5 Whereas morbidity and mortality of other major chronic diseases have been steadily declining, the trends for COPD are continually increasing, especially among the elderly.6 According to the WHO Global Burden of Disease Study, by 2020, COPD will be the fifth leading cause of disability-adjusted life years (DALY) lost worldwide.7

COPD costs the US economy an estimated $23.9 billion a year, most of it in direct costs of medical care.8 Hospitalization for acutely exacerbated COPD accounts for a large part of the high healthcare expenditure for COPD.8 Expenditure for inpatient hospitalizations of COPD per patient is more than twice that for other inpatients.9

More than half of COPD patients who are hospitalized for acute exacerbations are readmitted at least once within 6 months after hospital discharge.10 Exacerbated COPD results in relatively longer length of stay than most other diseases, and in poor quality of life.11,12

The prevalence of COPD in older adults after 40 years of age varies from 8% to 20% in different countries.1,13

In Singapore, COPD is currently the seventh leading cause of death.14

About 2,000 hospitalizations for COPD per year are recorded and the numbers are steadily increasing.15

COPD is under-recognized and under-diagnosed. Less than 50% of individuals with COPD based on airflow limitation have a doctorʼs diagnosis of COPD.1

2.1.1 Risk factors

The risk of COPD is highest after age 50, and is generally higher in men than women, although this appears to be changing. Smoking is by far the most important risk factor. Other major environmental factors are occupational dusts and chemicals (vapors, irritants, fumes), and indoor/outdoor air pollution.16,17 Severe hereditary deficiency of alpha-1 antitrypsin is a well-documented host factor,18 although rare locally.

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3 Definition, Differential Diagnosis and Classification of Severity

3.1 Definition

COPD is a heterogenous disorder characterised by airflow obstruction that is not fully reversible. The airflow limitation is usually both progressive and associated with exposure to noxious particles or gases.2

3.2 Differential diagnosis

A major differential diagnosis of COPD is bronchial asthma. These two conditions are frequently distinguishable on the basis of history and examination in untreated patients presenting for the first time.2,3

Table 1 shows the features that help to differentiate between COPD and Asthma.

Table 1 Clinical features of COPD and bronchial asthma2,3

COPD Asthma Smoking history Nearly all Possibly Symptoms < 35 years Rare Often Chronic productive cough

Common Uncommon

Breathlessness Persistent/progressive Variable Nocturnal symptoms Uncommon Common Diurnal variation of symptoms

Uncommon Common

D Where diagnostic doubt remains, or both COPD and asthma are present, the following findings will help identify asthma3: • A large response (FEV1 greater than 400 ml) to bronchodilators. • A large response (FEV1 greater than 400 ml) to 30 mg oral

prednisolone daily for 2 weeks. • Serial peak flow measurements showing 20% or greater diurnal or

day-to-day variability. Grade D, Level 4

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The definition of COPD requires confirmation of persistent airflow obstruction after administration of a bronchodilator.4

Bronchoreversibility, however, cannot serve as an absolute criterion for separating asthma from COPD.19 On the other hand, documentation of complete reversibility is useful in excluding COPD, and a documentation of bronchoreversibility of a rise of FEV1 >400 ml has been suggested3 to indicate such a reversibility. Similarly, a variation of 20% or greater diurnal or day-to-day variability is the level for documenting complete bronchoreversibility.19

D Where chronic asthma cannot be distinguished from COPD with the current imaging or lung function testing, it is assumed that the two diseases co-exist and their management should be similar to that of asthma.3

Grade D, Level 4

D COPD should be differentiated from congestive heart failure, bronchiectasis, and obliterative bronchiolitis.3

Grade D, Level 4

Congestive heart failure, bronchiectasis, and obliterative bronchiolitis may present with similar symptoms and signs as COPD. These conditions may mimic COPD or may co-exist in a patient with COPD. See Table 2.

Table 2 Features useful in differentiating other conditions from COPD3

Congestive heart failure – fine basilar crepitations, chest X-ray shows dilated heart, pulmonary oedema, and pulmonary function tests indicate volume restriction and not airflow limitation.

Bronchiectasis – large volumes of purulent sputum, commonly associated with bacterial infection, coarse crepitations on auscultation, clubbing, chest X-ray shows bronchial dilatation and bronchial wall thickening.

Obliterative bronchiolitis – Onset in younger age, non-smoker, may have history of rheumatoid arthritis or fume exposure, computed tomography on expiration shows hypodense areas.

[Source: National Collaborating Centre for Chronic Conditions, National Institute for Health and Clinical Excellence (NICCCC/NICE), 2004]

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3.3 Classification of severity

Spirometry

D A classification of disease severity into 5 stages based on spirometry cut points is recommended.2

Grade D, Level 4

The FEV1 and FEV1/FVC cut-points used by the Global Initiative for Obstructive Lung Disease (GOLD) for classifying the severity of COPD into 5 stages is shown in Table 3. These cut points are used for the purposes of educational simplicity: they have not been clinically validated.














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Other classification systems

Other ways of classifying disease severity have been described. Until their usefulness is validated, the classification of disease severity based on airway obstruction will be used.

Two of the ways of classifying disease severity are:

(1) the use of the Medical Research Council Dyspnoea Scale described by Nishimura et al20, and

(2) the BODE index which is a multidimensional index consisting of body mass index (B), the degree of airway obstruction (O), dyspnoea (D), and exercise capacity (E), measured by the six-minute-walk test.21

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4 Evaluation

4.1 Clinical assessment

D A diagnosis of COPD should be considered in any patient more than 35 years old, who has chronic cough, sputum production, or dyspnoea, and/or a history of exposure to risk factors for the disease22

(see Table 4). Grade D, Level 4

Table 4 Key indicators for considering a diagnosis of COPD

Chronic cough

Present intermittently or everyday. Often present throughout the day; seldom only nocturnal.

Chronic sputum production

Any pattern of chronic sputum production may indicate COPD.

Dyspnoea Progressive (worsens over time). Persistent (present every day). Described by the patient as: “increased effort to breathe,” “heaviness,” “air hunger,” or “gasping.” Worse on exercise. Worse during respiratory infections.

History of exposure to risk factors

Tobacco smoke. Occupational dusts and chemicals. Smoke from home cooking especially and heating fuels.

4.1.1 Physical examination

Physical examination is rarely diagnostic in COPD. Physical signs of airflow obstruction, e.g. hyperinflation, are rarely present until significant lung function impairment has occurred.23,24 Hence their detection has a low sensitivity and specificity.22

Physical signs of airflow obstruction that that may be present are3: • Hyperinflated chest • Purse lip breathing

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• Use of accessory muscle • Paradoxical movements of lower ribs • Reduced crico-sternal distance • Reduced cardiac dullness • Wheeze or quiet breath sounds

Loss of muscle mass and peripheral muscle weakness are present in advanced disease.

4.1.2 Assessment of severity

Assessment of severity is based on the patientʼs level of symptoms, the severity of the spirometric abnormality, and the presence of complications such as cor pulomonale, respiratory failure and right heart failure.22

Physical signs of cor pulmonale to look for are3: • Central cyanosis • Raised jugular venous pressure • Left parasternal heave • Loud P2 and a loud ejection click • Pansystolic murmur or tricuspid regurgitation • Hepatomegaly • Peripheral oedema

Progressive impairment of consciousness, the presence of a bounding pulse, flapping tremor and papilloedema indicate carbon dioxide retention and impending respiratory failure.

4.2 Lung function tests

4.2.1 Spirometry

D Spirometry is useful for the definitive diagnosis of COPD and for the staging of disease severity, and should be performed in individuals with symptoms suggestive of COPD.22

Grade D, Level 4

Spirometry should measure the maximal volume of air forcibly exhaled from the point of maximal inhalation (forced vital capacity, FVC) and the volume of air exhaled during the first second of this

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maneuvre (forced expiratory volume in one second, FEV1), and the ratio of these two measurements (FEV1/FVC) should be calculated.22

The primary benefit of spirometry is to identify COPD patients who may benefit from pharmacologic treatment in order to improve symptoms and exacerbations.25

Spirometry for case finding among all adults with a history of exposure to pulmonary risk factors, whether they have persistent respiratory symptoms or not, is unlikely to be beneficial unless future studies establish that spirometry improves smoking cessation rate, or that treatments other than smoking cessation benefit individuals with airflow obstruction who do not report respiratory symptoms.25 Spirometry for monitoring individuals or adjusting treatment is unlikely to be beneficial unless future studies establish that relative effectiveness between therapies varies according to an individualʼs baseline or follow-up spirometry.25

4.2.2 Bronchodilator reversibility testing

D It is recommended that bronchodilator reversibility testing be performed to help to identify some subjects with asthma or a large asthma component to COPD23 and to establish a patientʼs best attainable lung function.22

Grade D, Level 4

4.3 Arterial blood gases

D Arterial blood gases should be performed in patients with FEV1<40% predicted or with clinical signs suggestive of respiratory failure or right heart failure.22

Grade D, Level 4

4.4 Chest X-ray

D A chest X-ray is seldom diagnostic in COPD but it is valuable in excluding alternative diagnoses1 and should be performed to look for abnormalities that may suggest other conditions. Computed tomography of the chest is not routinely recommended.22

Grade D, Level 4

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5.1 Goals of pharmacotherapy in COPD

• Relieve, reduce and abolish symptoms • Increase exercise capacity • Reduce frequency and severity of acute exacerbations • Improve health related quality of life

These goals should be achieved with minimum side-effects from the medications.

There is currently no evidence that any pharmacotherapy influences lung function decline or mortality in COPD. Evidence from large-scale studies regarding the effect of pharmacotherapy on these outcome measures is anticipated in the near future.

5.2 Principles of therapy

• Treatment needs to be maintained long-term.

• Treatment is according to stage of severity, with step-wise increase usually required, as COPD is a progressive disease.

• Inhaled therapy via metered dose or dry powder inhalers is preferred. The use of a large-volume spacer is advised for patients who have difficulty mastering the metered-dose inhaler technique.

5.3 Drugs used in the pharmacotherapy of stable COPD

I. Bronchodilators : A) Inhaled short-acting 2-agonists B) Inhaled short-acting anti-cholinergic C) Combination short-acting 2-agonists + short-acting

anticholinergic inhalers D) Inhaled long-acting ?2-agonists E) Inhaled long-acting anti-cholinergic F) Oral theophylline

II. Inhaled corticosteroids III. Combination inhaled corticosteroids + long-acting ?2-agonists

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IV. Vaccines – influenza, pneumococcal V. Others

I. Bronchodilators

Bronchodilator drugs are the mainstay of pharmacological therapy in COPD. They relax bronchial smooth muscles, relieve bronchospasm and improve symptoms. All categories of bronchodilators have been shown to increase exercise capacity in COPD, without necessarily producing significant changes in FEV1. Bronchodilators have however not been shown to have any effect on the rate of lung function decline or survival in COPD.

Bronchodilators used in the pharmacotherapy of COPD comprise short- and long-acting anti-cholinergics (available only as inhaled medications), and short- and long-acting ? 2-agonists (available in the oral and inhaled form) and oral theophylline.

Inhaled therapy via metered-dose or dry powder inhaler is preferred as these have a more rapid onset of action, with less systemic side effects than the oral formulations. Wet nebulizers are generally not recommended for regular use in stable COPD – the delivery of higher drug doses via this method may increase side effects, and these devices are more costly and require appropriate maintenance.26

The choice of bronchodilator(s) would depend on the individual patientʼs response in terms of symptom relief, side-effects and affordability.

Short-acting inhaled bronchodilators

A Inhaled short-acting bronchodilators are recommended as first-line therapy in all stages of COPD to relieve symptoms and improve exercise capacity.

Grade A, Level 1+

A. Short-acting 2-agonists (SABA)

Examples of inhaled short-acting 2-agonists: • salbutamol (Ventolin®, Respolin®, Salamol®, Buventol®) • terbutaline (Bricanyl®) • fenoterol (Berotec®)

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2-agonists produce bronchodilation by smooth muscle relaxation through the activation of the adenylate cyclase pathway which increases intracellular concentrations of cyclic adenosine monophosphate. Regular administration of inhaled short-acting 2-agonists is an effective and inexpensive treatment for the management of patients with stable COPD.27 SABAs produce bronchodilation more rapidly than anti-cholinergic agents, acting within 15 minutes of administration with effects lasting 4 to 5 hours. They may be used up to a maximum of 4 to 6 times a day. They may be used as on-demand medications for relief of acute dyspnoea and for prophylaxis prior to exertion. The main side-effects are tremor and palpitations.

B. Short-acting anti-cholinergic (SAAC)

Example: ipratropium bromide (Atrovent®)

Anti-cholinergic agents induce bronchodilation by attenuating vagal tone in the airways via the blockage of acetylcholineʼs effect on M3 receptors. Ipratropium bromide is either equivalent to or more potent than 2-agonist as a bronchodilator in COPD.28 It should be taken regularly (4 to 6 hourly) rather than on an as-needed basis because of its relatively slow onset of action. As quaternary anti-cholinergic agents are poorly absorbed into the circulation, they are virtually free of systemic side effects. The main side-effect is dryness of the mouth. Tachyphylaxis does not develop despite prolonged usage of anticholinergics.

Combination inhaler containing SAAC and SABA

Examples of combination products are: • fenoterol combined with ipratropium bromide (Berodual®,

Duovent® nebuliser solution) • salbutamol combined with ipratropium bromide (Combivent®)

As 2-agonists and anticholinergics produce bronchodilation through different pathways, combination products were introduced in the hope of achieving greater bronchodilation than with monotherapy. The combination product was shown to produce greater and more sustained improvements in FEV1 than either drug alone.29

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Long-acting inhaled bronchodilators

A Regular treatment with one or both classes of the inhaled long-acting bronchodilators should be considered for patients with moderate to very severe COPD with frequent exacerbations.

Grade A, Level 1+

D Inhaled long-acting bronchodilators may be added to the treatment regimen when symptoms are not controlled with short-acting inhaled bronchodilators alone.2,3

Grade D, Level 4

C. Long-acting 2-agonists (LABA)

Examples of long-acting inhaled 2-agonists • salmeterol (Serevent®) • formoterol (Foradil®/ Oxis®)

Salmeterol and formoterol are potent 2-agonists with 12-hour or greater duration of action when inhaled by patients with partially reversible COPD.30 Formoterol has a faster onset of action (one to three minutes compared with 10 to 20 minutes for salmeterol). Peak effects are achieved at 1 to 2 hours for both compounds.

Regular use of LABAs has been shown to improve health status and to reduce acute exacerbation rates compared to placebo31 but evidence for effects of LABAs on symptoms and health-related quality of life is inconsistent.32 Despite their dosing convenience, LABAs are more expensive and evidence for advantage over ipratropium in terms of efficacy is inconsistent in patients with poorly reversible stable COPD.33 LABAs should be reserved for COPD patients who report definite improvement (in terms of better exercise capacity or reduced symptoms) whilst on this therapy.

D. Long-acting anticholinergic

Tiotropium (Spiriva®) is the only long-acting cholinergic currently available. It has a duration of action greater than 24 hours. Like ipratropium, tiotropium is poorly absorbed from the gastrointestinal tract and the lung, thus reducing systemic bioavailability and accounting for a favorable systemic safety profile.

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Tiotropium has been shown to be effective in reducing acute exacerbations, reducing symptoms and improving health-related quality of life compared to placebo and to ipratropium bromide.31,34

One-year clinical trials suggest that it may slow FEV1 decline.35

Additional long-term studies are required to evaluate its effect on mortality and change in FEV1, to clarify its role in comparison to, or in combination with, long-acting ?2-agonists and to assess its effectiveness in mild and very severe COPD.

The effect of co-administration of other anticholinergic-containing drugs with tiotropium has not been studied and is best avoided.

Combined use of a short or long-anticholinergic and LABA

Combining bronchodilators with different mechanisms and durations of actions may increase the degree of bronchodilation for equivalent or fewer side-effects. Previous studies in patients with moderate-to-severe stable COPD demonstrated that combination of ipratropium with either formoterol or salmeterol is more effective than a combination of the anti-cholinergic with SABAs, and shows additiveeffects in improving lung function.36 Randomized controlled studies have pointed favorably in the direction of combination of tiotropium with a LABA.37 Findings suggest that since tiotropium ensures prolonged bronchodilation, whereas formoterol adds fast onset and a greater peak effect, the two drugs appear complementary.38

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Table 5 Inhaled bronchodilators

ffup / egasoD gurD(µg)

Inhaler delivery device

Duration of action

Short-acting 2-agonists (SABA)

Salbutamol (Ventolin®) 100 MDI 4 - 6 h

Terbutaline (Bricanyl®) 500 DPI (turbuhaler) 4 - 6 h

Fenoterol (Berotec®) 200 MDI 4 - 6 h

Short-acting Anti-Cholinergic (SAAC)

Ipratropium bromide

(Atrovent®)

20 MDI 4 - 6 h

Combination SABA + SAAC

Fenoterol / Ipratropium (Berodual®)

50 / 20 MDI 4 - 6 h

Salbutamol / Ipratropium (Combivent®)

120 / 20 MDI 4 - 6 h

Long-acting 2-agonists (LABA)

Formoterol (Oxis®) 4.5, 9 DPI (turbuhaler) 12+ h

Salmeterol (Serevent®) 25 MDI 12+ h

Long-acting Anti-Cholinergic

Tiotropium (Spiriva®) 18 DPI (handihaler) 24+ h

MDI = metered-dose inhaler DPI = dry powder inhaler

E. Theophylline

D Theophylline may be a useful addition where symptom control is still not achieved with existing inhaled bronchodilator therapy. Theophylline may be of value for patients who are non-adherent to or unable to use inhaled therapy.26

Grade D, Level 4

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Oral theophylline, a non-specific phosphodiesterase inhibitor, has been used for many years for the treatment of obstructive airway diseases. In addition to its bronchodilator function, theophylline also has effects on the respiratory muscles, mucociliary clearance, ventilatory drive, and has immunomodulatory properties.

Careful monitoring for side-effects and drug interactions is needed in view of its narrow therapeutic index. A target therapeutic range of 8 to 13 mg/dl is recommended. It is important to be aware of factors which decrease its clearance, including potential drug interactions, and which may precipitate drug toxicity (Table 6). Signs of toxicity include arrhythmias and convulsions.

Table 6 Drugs and physiological variables that affect theophylline metabolism in COPD2

Increased clearance Decreased clearance

• Cigarette smoking

• Anticonvulsant drugs

• Rifampicin

• Alcohol

• Old age

• Hypoxemia

• Respiratory acidosis

• Congestive cardiac failure

• Liver cirrhosis

• Erythromycin, clarithromycin

• Quinolones

• Cimetidine (not ranitidine)

• Viral infections

• Some herbal remedies [Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2005]

A systematic review and meta-analysis of 20 randomised controlled trials showed that theophylline improves lung function, ventilatory capacity and arterial blood gas tensions compared to placebo, and that patients preferred theophylline compared to placebo, although the risk of nausea was increased.39

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There are on-going trials to assess the efficacy and safety of the new, specific (Type IV) phosphodiesterase inhibitors (oral or inhaled) in COPD.

II. Inhaled corticosteroids

A Inhaled corticosteroids as long-term maintenance therapy are recommended for patients with FEV1 < 50% predicted who experience frequent exacerbations.

Grade A, Level 1+

Examples of inhaled corticosteroids (ICSs) are beclomethasone dipropionate (Becloforte®), budesonide (Pulmicort®) and fluticasone propionate (Flixotide®).

Unlike asthma where ICSs play a key anti-inflammatory role and are recommended first-line therapy, current evidence supports limiting the use of ICSs in COPD to patients with moderate to severe disease and who have frequent exacerbations. Six placebo-controlled trials with at least 6 months follow-up period of inhaled corticosteroids at moderate to high doses showed that ICS led to a 24% reduction in exacerbations.40-45 This beneficial effect was uniformly seen in studies with patients who had mean FEV1 < 2.0 L (or < 70% predicted), regardless of the duration of the study or specific formulation used.31

ICSs have only a modest effect on lung function in COPD. Individual long-term studies have shown that they do not affect the rate of FEV1

decline in COPD of all severity grades.45-47

ICSs are associated with increased risk of oral candidiasis, dysphonia and easy bruising, and may have a modest deleterious effect on bone mineral density, although there was no clinically increased risk of fractures reported in the trials.47,48

Oral corticosteroids

A Long-term oral corticosteroids are not recommended in stable COPD.49

Grade A, Level 1+

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Although a short course of high dose oral corticosteroid (prednisolone 30 mg/day) can improve lung function in some COPD patients, long term use of lower doses (prednisolone at < 10 to 15 mg/day) does not prevent worsening of the condition and is associated with increased risk of adverse effects such as diabetes and osteoporosis.49

III. Combination ICS + LABA

D Combination inhaled corticosteroids and long-acting 2-agonists should be considered for patients in whom both its components are indicated.26

Grade D, Level 4

The combination products available are Seretide® (fluticasone propionate + salmeterol xinfonate) and Symbicort® (budesonide + formoterol).

Three trials showed that combination therapy was associated with lower exacerbation rates compared to monotherapy with LABA or placebo.50-52 The effect was additive and not synergistic. Combination therapy was also effective in improving trough FEV1 compared to placebo, LABA and inhaled corticosteroids.

The combination formulation will be more convenient and will aid compliance in patients for whom both an ICS and LABA are indicated.

IV. Vaccines

Influenza vaccination

C Annual influenza vaccination should be offered to the elderly (65 years old and above) in all stages of COPD.

Grade C, Level 2++

Influenza vaccination was associated with fewer hospitalizations for pneumonia and influenza and with lower risk for death during the influenza seasons in the elderly with chronic lung disease.53

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Pneumococcal vaccination

D Pneumococcal vaccination may be considered in COPD patients.3

Grade D, Level 4

Although there is currently no firm evidence for its protective effect against pneumococcal pneumonia and its usefulness in COPD patients per se, the 23-valent polysaccharide pneumococcal vaccine is advocated by some experts and national authorities for the elderly and those with certain medical conditions including chronic heart and lung disease. Vaccination has been shown to reduce bacteremic pneumococcal disease in adults, and to be associated with reduced death, complications and length of stay among hospitalized adults with community-acquired pneumonia.54,55

D If considering pneumococcal vaccination for a COPD patient, usually only one dose of the vaccine is needed. A second dose is recommended for persons aged 65 or older who received their first dose when they were under 65, if 5 or more years have passed since that dose.55a

Grade D, Level 4

V. Others

There is no evidence to date to support the benefit of the routine use of maintenance antibiotic therapy, mucolytics/anti-oxidants respiratory stimulants, vasodilators, nedocromil sodium or leukotriene modifiers in stable COPD.

5.4 Cost-effectiveness of pharmacotherapy in COPD

A recent methodological critique of seven pharmacoeconomic studies on maintenance therapy for COPD showed tiotropium to be considered cost-effective relative to ipratropium, and inhaled corticosteroids to be cost-effective for patient with moderate to severe COPD relative to standard care.56 No conclusive information could be reached for the cost-effectiveness of long-acting ? 2-agonists.

Variations in drug costs and primary and tertiary healthcare costs make it difficult to extrapolate the findings of cost-effectiveness analyses in other healthcare settings to the local situation.

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Intermittent AND

Few exacerbations

Regardless of FEV1

SABA or Combination SABA/SAAC inhaler

as needed for symptom relief

Persistent* AND/OR


AND



With one of the following:1) SAAC 4 to 6 hourly or 2) Combination SABA/ SAAC





AND/OR


Intermittent or

Persistent

AND


AND


As above

AND



* Persistent symptoms: exertional dyspnoea, diminished exercise capacity, persistent cough, wheeze despite SABA/combination SABA/SAAC inhaler as needed

† Frequent exacerbations: two or more acute exacerbations a year requiring systemic steroids


GPP

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6 Non-pharmacological Management for Stable COPD

6.1 Patient education

Patient education plays a role in improving patient responses to exacerbations, ability to cope with illness, improving health status and smoking cessation.57-63

D Patient education is a vital part of COPD management and should begin at the time of first assessment for COPD and continue with each follow-up visit.64,65

Grade D, Level 4

The patient should be informed about the nature of his/her condition and its treatment.

D The intensity and content of patient educational messages should vary depending on the severity of the patient’s disease (see Table 8).


Severity of Disease Patient Education Topic Stage 0: At Risk Information and advice about reducing risk

factors. Stage I: Mild COPD through Stage III: Severe COPD

Above topic, plus: Information about the nature of COPD. Instruction on how to use inhalers and nebulizer. Information on influenza vaccination and medication Recognition and treatment of exacerbation. Strategies for minimizing dyspnea Information on pulmonary rehabilitation.


Above topic, plus: Information about complications Information about oxygen treatment Advance directive and end-of-life decisions

[Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD),2005]

Grade D, Level 4

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D Patient education should be:64 • Tailored to meet the needs of the individual patient • Interactive • Directed to improving quality of life • Simple to follow • Practical • Appropriate to the intellectual and social skill of the patient and

the caregivers.Grade D, Level 4

Providing information and tools to enhance self-management in an interactive session is more effective than didactic teaching.61,62

6.2 Smoking cessation

Smoking cessation is the single most effective and cost-effective way in reducing the risk of developing COPD and stopping its progression.66

A Smoking cessation should be emphasized as an essential first step in management of COPD patients.66-71

Grade A, Level 1++

GPP Clinicians should play a prominent role in promoting attempts to stop smoking in their patients.

GPP

A All smokers, including those who may be at risk for COPD as well as those who already have the disease, should be offered at least a brief tobacco dependence counseling at every health care provider visit.68,72,73

Grade A, Level 1++

Brief strategies to help smokers to quit are summarized in the 5 As approach68,74,75:

Ask: Systematically identify all tobacco users at every visit. Implement an office-wide system that ensure that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented.

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Advise: Strongly urge all tobacco users to quit. In a clear, strong and personalized manner, urge every tobacco user to quit.

Assess: Determine willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g. within the next 30 days)

Assist: Aid the patient in quitting. Help the patient with a quit plan; provide practical counseling; provide social support; recommend use of approved pharmacotherapy; provide supplementary materials

Arrange: Schedule follow-up contact. Schedule follow-up contact, either in person or via telephone

Pharmacotherapy

D Pharmacotherapy for smoking cessation is recommended when counseling is not sufficient to help patients quit smoking.68

Grade D, Level 4

A Treatment of nicotine dependence is effective and should be offered to smokers in addition to counseling.73,76-81

Grade A, Level 1++

In Singapore, there are four types of pharmacotherapies for tobacco dependence available currently i.e. bupropion SR, nicotine gum, nicotine inhaler, and nicotine patch.

A These pharmacotherapies reliably increase long-term smoking abstinence rates72,73,75,76-89 and at least one of these medications should be added to counseling if necessary and in the absence of contraindications.68,75

Grade A, Level 1++

The choice of medication is a matter of the patient’s personal preference, medication availability, past experience, medical history and the presence of contraindications.76,90

These guidelines have been withdrawn MOH clinical practice guidelines are considered withdrawn five years after publication unless otherwise specified in individual guidelines. Users should keep in mind that evidence-based guidelines are only as current as the evidence that supports them and new evidence can supercede recommendations made in the guidelines.

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Cost-effectiveness of smoking interventions

Studies done in the United States on the cost effectiveness of the clinical practice recommendation in the AHCPR guideline for smoking cessation showed: the average cost per quitter was US$3,779; the average cost per life-year saved, US$2,587; and the average cost per QALY (quality-adjusted life-year) saved, US$1,915.91

6.3 Nutrition in COPD

Prospective studies have shown that both weight loss and muscle wasting are associated with an increased risk of mortality, morbidity, and disability in COPD patients.92 At the same time, significant loss in FFM (fat-free mass) has also been shown to be related to impaired skeletal muscle strength, exercise capacity as well as decreased health status.93 Prevalence studies have shown that malnutrition is found in 25% of patients with moderate to severe COPD patients and up to 35% of cases with very severe disease.94

The goal of nutritional intervention is to maintain reasonable body weight (BMI 18.5 to 23).95 Nutritional intervention can be extended to prevention and early treatment of weight loss in COPD patients. It can also be combined with exercise and other components of a comprehensive pulmonary rehabilitation programme.

D All patients with COPD should undergo simple nutrition screening.

Grade D, Level 4

This can be done by the following ways96:• Measurement of body-mass index • Evaluation of food, nutrient and fluid intake• Other anthropometric measurements e.g. skin fold thickness • Evaluation of biochemical markers e.g. serum albumin

GPP Nutritional intervention should be considered in all COPD patients with BMI < 18.5 kg/m2 or significant involuntary weight loss (>10% during the last 6 months or > 5% in the past month).

GPP

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This can be done by the following ways97:• Modification of patients’ dietary habits and administration of

energy dense nutritional supplement • Maintenance of adequate dietary intake of vitamins and minerals • Adoption of healthy lifestyle e.g., stop smoking, encourage

moderate physical activity • Patients who become breathless while eating should be advised to

take small, frequent meals (to avoid post-prandial dyspnoea and satiety and to improve compliance)

• Referral to dietician for further nutritional optimization

There is limited evidence that COPD patients benefit from nutritional intervention per se. However, nutritional assessment in combination with pulmonary rehabilitation and nutritional intervention has been shown to improve the functional status of COPD patients.98,99

6.4 Pulmonary rehabilitation

Pulmonary rehabilitation is a structured multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.100 Team members include respiratory physicians, family physicians, nurses, physiotherapists, occupational therapists, dieticians, and medical social workers.100 Pulmonary rehabilitation can be conducted as inpatient, outpatient or home programs. Consideration of cost, availability and accessibility will determine the patient’s choice.101-103

Studies have shown that COPD patients undergoing pulmonary rehabilitation have experienced the following benefits: • Improvement in exercise capacity and functional walking

distance.104-106 • Relief of dyspnoea and fatigue as well as enhancement of mastery

(sense of control over condition).104,106,107

• Improvement in health related quality of life.104-107

• Reduction in the number of hospitalizations and days in hospital.101,105,108,109

• Reduction in anxiety and depression.101

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D Pulmonary rehabilitation may be considered for patients with the following:100,105,106

• persistent symptoms especially dyspnoea, • reduced exercise tolerance or experience a restriction in activities, • recurrent admissions to hospital over the last 6 months.

Grade D, Level 4

The following conditions may adversely affect the outcome of pulmonary rehabilitation:100

1. Conditions that may interfere with the patient undergoing the rehabilitation programme e.g. advanced arthritis, inability to learn or disruptive behavior.

2. Conditions that may place the patient at undue risk during exercise training e.g. severe pulmonary hypertension, unstable angina or recent myocardial infarction.

3. Poorly motivated patients who are unable to complete the entire rehabilitation programme.

B The physical components of pulmonary rehabilitation should include both lower extremity training (e.g. bicycle, ergometry, treadmill) and upper extremity training (strength and endurance).110

Grade B, Level 2+

D Psychosocial and behavioural interventions (health education, smoking cessation clinic, and support groups addressing psychosocial issues) as well as nutritional intervention should also be included as non-physical components of the comprehensive pulmonary rehabilitation programmes.100

Grade D, Level 4

6.5 Oxygen therapy in chronic obstructive pulmonarydisease

Long-term oxygen therapy (LTOT) has been shown to improve survival in COPD patients with severe chronic respiratory failure.111,112 The precise mechanism of this improvement in survival is unknown.

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Long-term oxygen therapy may also have a beneficial impact on sleep, cognitive function and exercise tolerance in COPD patients with chronic hypoxaemia.111,113

Domiciliary oxygen therapy has not been shown to improve survival in COPD patients with mild to moderate hypoxaemia (i.e. PaO2 > 55 mmHg) or with only nocturnal arterial desaturation.114,115

The goal of long-term oxygen therapy is to maintain a baseline PaO2 >60 mmHg and SaO2 > 90%. This is to ensure adequate oxygen delivery to vital organs.

Inappropriate prescription for long-term oxygen therapy in patients with COPD can result in respiratory depression.

A Patients with very severe COPD and chronic respiratory failure should be assessed for the need for long-term oxygen therapy.

Grade A, Level 1+

A Indications for long-term oxygen therapy (at least 15 hours/day) in patients with COPD should be based on the following indices obtained in stable state111,112:

• Without pulmonary hypertension (Cor Pulmonale), congestive heart failure, polycythaemia (Hct >55%)






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D Oxygen concentrator is the preferred mode of delivery of oxygen. It is the most convenient and economical method of providing long-term oxygen therapy.116

Grade D, Level 3

Prescription for oxygen therapy usually includes the following117:

1. Source of supplemental oxygen (liquid oxygen, gas cylinders or oxygen concentrators)

2. Method of delivery (e.g. intranasal prongs, demand nasal prongs, reservoir cannula, etc.)

3. Duration of use.

4. Oxygen flow rate at rest, during exercise or sleep.

Ambulatory COPD patients who need supplemental oxygen outside the home are usually prescribed oxygen sources e.g. portable gas cylinders or liquid oxygen.117

As there is a risk of fire and explosion, very severe COPD patients requiring long-term oxygen therapy should be advised against smoking cigarettes.117

D Very severe COPD patients with hypercapnoiec respiratory failure requiring long-term oxygen therapy should have the oxygen flow rate titrated cautiously to maintain a SaO2 > 90%.117

Grade D, Level 4

6.6 Surgical options for COPD patients

There are a variety of surgical options available for patients with COPD. These options are primarily focused at improving symptoms and restoring function in a select group of COPD patients.118

The surgical options available are:

1. Bullectomy 2. Lung Volume Reduction Surgery 3. Lung Transplantation

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6.6.1 Bullectomy

Surgical removal of large bullae in COPD patients may improve symptoms, exercise tolerance and pulmonary function.119,120

Bullectomy can be performed via standard lateral thoracotomy, midline sternotomy or via Video-Assisted Thoracoscopy with stapling of the bullae.118 Removal of the giant bulla is thought to improve the function of the adjacent compressed lung tissue and improve symptoms of dyspnoea and exercise tolerance.

Surgical mortality for bullectomy rages from 0-22.5%.121

D Selection of patients with giant bullae who will benefit from bullectomy should be based on clinical, radiological and pulmonary physiological parameters as indicated below.122

Indications Contraindications 1. Severe functional limitation

despite maximal medical therapy

2. Ex-smoker

3. Bulla occupying > 1/3 of the hermithorax noted on CT thorax with crowding of pulmonary vascular and parenchyma around the bulla

4. FEV1 > 40% FVC is normal Elevated RV Normal DLCo Normal PaO2 & PaCO2

5. Ventilation / Perfusion scan showing localized matched defect with normal uptake/washout from surrounding normal lung

1. Substantial emphysema elsewhere in the lung

2. Pulmonary hypertension

3. Co-morbid illness e.g. heart failure

4. Old age FEV1 < 35% Reduced DLCo

5. Absence of target zones, poor washout in remaining lung regions

CT = Computed Tomography FEV1 = Forced Expiratory Volume in the 1st second FVC = Forced Vital Capacity DLCo = Diffusing Capacity for Carbon Monoxide RV = Residual Volume

Grade D, Level 3

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6.6.2 Lung Volume Reduction Surgery (LVRS)

LVRS in COPD patients involves the resection of approximately 20-30% of poorly functioning lung tissue in each lung thereby reducing the intra-thoracic volume and also the mechanical disadvantage faced by the diaphragm and other respiratory muscles.123

Overall LVRS has been shown to improve FEV1, exercise tolerance, quality of life and may be long-term survival.124,125 The effect of LVRS seems to be maximal at 6 months post surgery.124

A Selection of patients that will benefit from LVRS is based on the following indications and contraindications:122,126

Indications Contraindications 1. Severe functional limitation

2. Post-bronchodilator: 20% > FEV1 < 45% predicted RV > 150% predicted TLC > 100% predicted DLCo > 20% predicted

3. PaO2 > 45 mmHg PaO2 < 60 mmHg

4. Upper lobe predominance of heterogeneous pulmonary emphysema noted on HRCT thorax

5. Pulmonary Artery Systolic Pressure < 45 mmHg or mean Pulmonary Artery Pressure < 35 mmHg

6. Post-pulmonary rehabilitation cycle ergometry exercise capacity: Female: < 25 Watts Male: < 40 Watts

1. Co-morbid illness e.g. heart failure, cancer

2. Post-bronchodilator: FEV1 < 20% predicted DLCo < 20% predicted

3. High dose steroids (Prednisolone >20 mg/day)

4. Homogenous distribution of emphysema on HRCT thorax

5. Pulmonary arterial hypertension

6. Obesity

Note: LVRS has an unacceptably high mortality in patients with the following pre-operative pulmonary physiological and radiological parameters:126

FEV1 < 20% predicted Non-upper lobe predominant emphysema on HRCT thorax DLCo < 20% predicted

Grade A, Level 1+

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Investigations for patients being considered for LVRS include the following:

1. High resolution computed tomography thorax 2. Pulmonary Function Test including Diffusion Capacity 3. Arterial Blood gas 4. Cycle ergometry to determine exercise capacity post-pulmonary

rehabilitation 5. 2D-echocardiogram or right heart catheter study to determine

pulmonary arterial pressure.

GPP LVRS and lung transplantation are surgical options, which are usually considered in selected patients with advanced COPD unresponsive to medical therapy. These patients should be referred to specialty centres where these procedures are done for further evaluation.

GPP

The National Emphysema Treatment Trial showed significant benefit of LVRS on mortality, exercise capacity and quality of life in COPD patients with upper lobe emphysema and low exercise capacity.124

In patients with non-upper lobe emphysema and high exercise capacity, LVRS led to increased mortality and a reduction in exercise tolerance.124 Overall 90-day surgical mortality in the non-high risk group was 5.2% compared to 1.5% in the medically treated arm.124

6.6.3 Lung transplantation

COPD is the most common indication for lung transplantation.

The choice of bilateral lung transplantation (BLT) or single lung transplantation (SLT) for COPD remains controversial.127,128 Bilateral lung transplantation results in greater improvement in FEV1, but improvements in exercise capacity are not always significantly greater than SLT.129

Overall (both BLT and SLT) 5-year survival is approximately 59%. However, COPD patients who have undergone BLT have a better 5-year survival rate of 67% compared to 45% for SLT.130

��

Lung transplantation leads to improvement in FEV1, exercise capacity and quality of life.129

D Lung transplantation should be considered in selected patients with end-stage COPD.129 Selection criteria are as follows130,131:

Indications Contraindications1. Age of patient: BLT <55 years SLT <60 years2. FEV1 <25% predicted 3. PaCO2 >55 mmHg on Room

Air 4. PaO2 >55 mmHg on Room

Air requiring long-term oxygen therapy

5. Pulmonary Hypertension 6. Rapid decline in FEV1 +/- life

threatening exacerbations

1. Age >60 years 2. Symptomatic Osteoporosis 3. Prednisolone >20 mg/day 4. Unresolved psychosocial

and substance abuse (cig. Smoking)

5. Infections (HIV, Hep. B, C, etc.)

6. Active malignancy 7. Renal, Heart or Liver

Dysfunction 8. Poor rehabilitative potential

Severe Musculskeletal Disorder

(Adapted from Cassivi SD et al, 2002; American Thoracic Society, 1998.)

Grade D, Level 3 & 4

Compared to patients with other cardiopulmonary disease, patients with COPD exhibit the best overall survival after lung transplantation.132

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7 Monitoring of Patients with Stable COPD

D & GPP Patients should be seen and assessed regularly (e.g. three-monthly in the stable state).3




• Adherence to medications should be assessed, and the patient’s inhaler technique checked and re-taught if necessary.


D & GPP Indications for specialist referral3






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8 Management of Acute Exacerbations

8.1 Principles of management

Ideally, the frequency of exacerbation should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations.

The impact of exacerbations should be minimised by:

– giving self-management advice on responding promptly to the symptoms of an exacerbation

– starting appropriate treatment with oral steroids and/or antibiotics

– using non-invasive ventilation when indicated.

8.2 Definition of an acute exacerbation

There is no widely accepted definition of acute exacerbation of COPD. Most published definitions describe an exacerbation as an acute event with worsening of the patient’s symptoms from their usual stable state, which is beyond normal day-to-day variations. Commonly reported symptoms are worsening breathlessness, cough, increased sputum volume and sputum purulence.

An acute exacerbation of COPD is a clinical diagnosis.

8.3 Differential diagnoses of acute exacerbations:

• pneumonia • pneumothorax • left ventricular failure/pulmonary oedema • pulmonary embolism • lung cancer • upper airway obstruction • pleural effusion • recurrent aspiration.

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8.4 Causes of acute exacerbation of COPD

The most common causes of an exacerbation are infection of the tracheo-bronchial tree (often viral), and air pollution.

Other contributing factors may be co-existing diseases like:

• Pneumonia • Right or left heart failure or arrhythmias • Pulmonary embolism • Spontaneous pneumothorax • Inappropriate oxygen administration • Drugs (hypnotics, tranquillisers, diuretics, etc.) • Metabolic diseases (diabetes, electrolyte disturbances, etc.) • Poor nutritional state • Other diseases (gastrointestinal bleeding, etc.) • End-stage respiratory disease (fatigue of respiratory muscles,

etc.)

8.5 Investigations for patients with exacerbation

C Chest radiography is recommended in an acute exacerbation, when other diagnoses like pneumonia or heart failure need to be excluded.133

Grade C, Level 2+

D Sputum culture is not recommended for routine investigation of patients with exacerbation.3

Grade D, Level 3

D Pulse oximetry, if available, can assist doctors in identifying patients with hypoxaemia when oxygen saturation (SaO2) is less than 90%.3

Grade D, Level 3

��


*30 mg of prednisolone daily for up to 14 days (Adapted from European Respiratory Society Consensus Statement, 1995)

Mild exacerbations • Initiate, increase dose or frequency, or combine β2-agonist and/or • Anticholinergic • Encourage sputum clearance by coughing • Consider chest physiotherapy • Encourage fluid intake • Avoid sedatives and hypnotics • Consider antibiotics • Consider oral corticosteriods* Instruct patients on symptoms and signs of worsening and actions to take: Contact primary care physician or go to emergency department.


Improved Worsened

Refer to hospital

Acute exacerbation




• cyanosis

• confusion

• SaO2 <90%

Consider adding corticosteroids* or a course of antibiotics if not given earlier. Instruct patient on symptoms, signs of worsening and action to take. Stable COPD

management


No

Yes


Worsened

Not improving

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8.6 Pharmacological management

8.6.1 Bronchodilators

A Inhaled anticholinergic bronchodilators or inhaled short-acting 2-agonists are beneficial and should be used in the treatment of patients presenting with acute exacerbation of COPD.135

Grade A, Level 1+

Since the inhaled anticholinergic bronchodilators have fewer and more benign side effects, consider these agents first. Only after the initial bronchodilator is at maximum dose is the addition of a second inhaled bronchodilator beneficial.135

Delivery systems for inhaled therapy during exacerbations

D Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD, as they are equally effective in achieving bronchodilation in COPD exacerbations.136

Grade D, Level 4

The choice of delivery system should depend on the dose of drug required, the ability of the patient to use the device and the resources available to supervise the administration of the therapy.

8.6.2 Systemic corticosteroids

A In the absence of significant contraindications, oral corticosteroids should be used, in conjunction with other therapies, in all patients admitted to hospital with an exacerbation of COPD.137

Grade A, Level 1+

A In the absence of significant contraindications, oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in the breathlessness which interferes with daily activities.137

Grade A, Level 1+

2

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A Prednisolone 30 mg orally should be prescribed for 7 to 14 days to patients with an exacerbation. It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy.137

Grade A, Level 1+

8.6.3 Antibiotics

A Antibiotics should be used to treat exacerbations of COPD when138:(1) there is history of purulent sputum (2) there are clinical signs of pneumonia (3) there is consolidation on a chest radiograph

Grade A, Level 1+

Initial empirical treatment can be a beta lactam-beta lactamase inhibitor combination, a 2nd generation macrolide, a 2nd generation cephalosporin139, or a quinolone. When initiating empirical antibiotic treatment, prescribers should always take account of any guidance issued by their local microbiologists.

8.7 Non-pharmacological therapy

8.7.1 Oxygen therapy

GPP Oxygen therapy should be considered if patient is known, or suspected, to have hypoxaemia. This can be administered via nasal prongs, or venturi mask. One should exercise caution in the oxygen dose for patients, such that the lowest possible oxygen concentration to maintain oxygen saturation above 90% is provided. If pulse oximetry is not available, the concentration of the oxygen mask should not exceed 28%, or the nasal prong oxygen flow rate should be kept at 2L/min.

GPP

8.7.2 Non-invasive ventilation (NIV)

A Non-invasive ventilation should be used as the treatment of choice in the hospital, for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy.140

Grade A, Level 1+

��

8.8 When to refer to the Emergency Department (ED)

Severe exacerbation

GPP Any one of the following signs may indicate severe exacerbations requiring urgent referral to the Emergency Department:

1. marked dyspnoea and tachypnoea (> 30 respirations/minute) 2. use of accessory muscles (sternomastoid and abdominal) at

rest 3. cyanosis 4. confusion 5. SaO2 < 90%

GPP

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9 Air Travel

In spite of commercial aircraft cabin being pressurized to cabin altitudes up to 2438 m, altitude exposure may exacerbate hypoxaemia in patients with COPD. At 2438 m, the partial pressure of oxygen falls to the equivalent of breathing 15% oxygen at sea level. Therefore, particular caution should be paid to those who are hypoxaemic at sea level.

COPD patients with large bullae are also at risk of pneumothorax as a result of volume expansion at reduced cabin pressures. The volume of gas in a non-communicating bulla will increase by nearly 38% on ascent from sea level to 2438 m. However, there are no data to state with any confidence what the maximum volume of a bulla should be before it entails an unacceptable level of risk of rupture leading to tension pneumothorax, pneumomediastinum or air embolism.

D Patients with severe COPD, history of air travel intolerance with respiratory symptoms (dyspnoea, chest pain, confusion, syncope), co-morbidity with other conditions worsened by hypoxaemia (cerebrovascular disease, coronary artery disease, heart failure), and recent pneumothorax should undergo assessment before flying.141




• measurement of SpO2 by pulse oximetry. Readings should be taken from a warm ear or finger after sufficient delay for the oximeter to display a stable reading. Blood gases are preferred if hypercapnia is known or suspected

Grade D, Level 4

D Patients who have resting sea level oximetry between 92% and 95% and who have additional risk factors (Table 9) should be referred for further assessment.

Grade D, Level 4

��

Table 9 Results of initial assessment141

Screening result Recommendation

• Sea level SpO2 > 95% Oxygen not required

• Sea level SpO2 92-95% and no risk*

Oxygen not required

• Sea level SpO2 92-95% and additional risk factor*

Refer for hypoxic challenge test with arterial or capillary measurements

• Sea level SpO2 < 92% In-flight oxygen

• Receiving supplemental oxygen at sea level

Increase the flow while at cruising altitude

(Adapted from British Thoracic Society Standards of Care Committee, 2002)

SpO2 = Spot oxygen saturation

* Additional risk factors: hypercapnia, FEV1 < 50% predicted, lung cancer, restrictive lung disease involving the parenchyma (fibrosis,) chest wall (kyphoscoliosis) or respiratory muscles, ventilator support, cerebrovascular or cardiac disease, within six weeks of discharge for exacerbation of chronic lung or cardiac disease.

��

10 Surgery in COPD Patients

Perioperative pulmonary complications are increased in COPD patients by approximately 2.7 to 4.7 fold depending on the anatomical site of the surgery and severity of lung disease.142

Patients with COPD undergoing upper abdominal or abdominal vascular, cardiac, orthopaedic and head/neck surgery are at increased risk of postoperative pulmonary complications e.g. atelectasis, pneumonia, exacerbation of COPD, prolonged mechanical ventilation and venous thromboembolism.142-144

GPP Preoperative assessment of a COPD patient should include:

1. Detailed history and physical examination 2. Assessment of functional capacity (American Society of


GPP

Table 10 American Society of Anesthesiology (ASA)

Physical Status Scale

Class Physical Status

I Normal, Healthy <80 years old

II Mild systemic disease or healthy individual > 80 years

III Severe but not incapacitating systemic disease

IV Incapacitating systemic disease that is a constant threat to life

V Moribund patient not expected to survive 24 hours despite surgery

Note: ASA class >II is associated with a 1.7-fold increased risk of postoperative pulmonary complication.145

��

A COPD patients being considered for surgery should be assessed for risk of developing venous thromboembolism and also for thromboprophylaxis during the perioperative assessment.146

Grade A, Level 1+

A Combination of bronchodilators, chest physiotherapy, antibiotics, smoking cessation for at least 4-8 weeks and a short course of oral corticosteroids should be given to patients with acute exacerbation so as to reduce the risk of postoperative pulmonary complications.135,137,138

Grade A, Level 1+

COPD patients who have symptoms and signs of airflow obstruction should be treated aggressively. Elective surgery in these patients should be deferred especially if the patient has an acute exacerbation.

��

11 End of Life Care

It has been shown that the quality of end of life care in COPD patients is likely to be worse than that for patients with other diseases.147,148

COPD patients have poorer symptom control, spend progressively more time in hospital towards the end of life and are more likely to die in hospitals.148,149

A major area of end of life care of COPD patients relates to the patientsʼ and their relativesʼ preparedness concerning the dying process, as well as their choice of interventions during the terminal phase.

• D Patients should be educated about their disease, prognosis and possible circumstances of death.

Grade D, Level 3

Patients with COPD desire more information on diagnosis, disease process, treatment, prognosis and what dying might be like. It has been shown that patients feel unprepared to cope with their poor state of health due to a lack of information about their condition.147,150

• D Physicians should discuss end of life issues and advance care

planning with patients (and their relatives) who have severe to very severe COPD.

Grade D, Level 3

Studies suggest that physicians caring for patients with severe COPD frequently do not initiate discussions about end of life care and patients usually do not ask about them. Patients generally expect their physicians to raise these issues with them.151-153 In addition, many patients would like to contribute to the decision making process regarding their end of life care.151,154

Patients with severe to very severe COPD disease are most likely to benefit from end of life discussions because of their risk of respiratory failure and the potential need for mechanical ventilation. Discussions about end of life should ideally take place when the patient is stable.150,152,154

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• B Physicians who look after severe to very severe COPD patients (as with all physicians caring for the terminally ill) will need to be prepared to discuss end of life issues with patients.

Grade B, Level 1+

Physicians can improve their communication with patients on end of life issues with appropriate training.153,155

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12 Clinical Quality Improvement

The workgroup proposes some possible clinical quality indicators, based on recommendations in these guidelines, that healthcare providers may use in monitoring their practice and to better gauge their quality of care.

Quality indicators

Recommended minimum frequency*

Examples of suggested measurable indicators

Smoking Annual

Percentage of COPD patients whose smoking habits and desire to quit were assessed on ≥ 1 occasions in the past one year (except for those who have never smoked where smoking habits should be recorded once)

Inhaler technique

Annual Percentage of COPD patients who have a record of inhaler technique assessment in the past one year

Weight or BMI

Annual Percentage of COPD patients who have a record of weight or BMI assessment in the past one year

Influenza vaccination

Annual Percentage of COPD patients who have a record of influenza vaccination being offered in the past one year

*Users may consider allowing an added margin of time (e.g. +3 months) when assessing adherence to recommended annual frequencies.

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104. Lacasse Y, Brosseau L, Milbe S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews 2005, Issue 4.

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114. Gorecka D, Gorzelak K, Sliwinski P, et al. Effect of long-term oxygen therapy on survival in patients with chronic obstructive

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122. Martinez FJ. Surgical therapy for chronic obstructive pulmonary disease: conventional bullectomy and lung volume reduction surgery in the absence of giant bullae. Semin. Respir. Crit. Care Med. 1999; 20:351-364.

123. Cooper JD, Trulock EP, Triantafillon AN, et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J. Thorac. Cardiovasc. Surg. 1995; 109(1): 106-116.

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124. National Emphysema Treatment Trial Research Group. A randomised trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. NEJM 2003;348:2059-2073.

125. Geddes D, Davies M, Koyawa H, et al. Effect of lung-volume-reduction surgery in patients with severe emphysema. NEJM 2000; 343:239-245.

126. National Emphysema Treatment trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. NEJM 2001; 345:1075-1083.

127. Mal H, Sleiman C, Jebrak G, et al. Functional results of single-lung transplantation for chronic obstructive lung disease. Am. J. Respir. Crit. Care Med. 149;1476-1481.

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129. Trulock EP. Lung Transplantation for COPD. Chest 1998; 113(4):269S-276S.

130. Cassivi SD, Meyers BF, Battafarano RJ, et al. Thirteen-year experience in lung transplantation for emphysema. Ann Thorac Surg 2002;74(5):1663-1669.

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134. Siafakas NM et al. Optimal assessment and management of COPD: ERS Consensus Statement. Eur Rep J 1995 (8): 1398-1420.

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135. Shrestha M, OʼBrien T, Haddox R, Gourlay HS, Reed G. Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to beta-agonist therapy. Ann Emerg Med. 1991;20:1206-9.

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137. Niewoehner DE, Erbland ML et al. Effect of Systemic Glucocorticoids on Exacerbations of Chronic Obstructive Pulmonary Disease. NEJM 1999; 340(25): 1941-1947.

138. Saint et al. Antibiotics in Chronic Obstructive Pulmonary Disease Exacerbations: A Meta-analysis. JAMA 1995; 273(12):957-960.

139. Staton GW. Chronic Obstructive Diseases of the Lung. ACP Medicine 2004.

140. Lightowler JV et al. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 2003; 326(7382):185-189.

141. British Thoracic Society Standards of Care Committee Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002;57:289-304.

142. Smetana GW. Perioperative Pulmonary Evaluation. NEJM 1999;340:937-944.

143. Epstein RS, Sherwood LM. From outcomes research to disease management: a guide for the perplexed. Ann Intern Med 1996; 124:832-837.

144. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised control trial. Lancet 2000;355:362-368.

145. Geerts HW, Pineo GF, Heit JA, et al. Prevention of Venous Thromboembolism. Chest 2004;126:338S-400S.

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146. Haas SK. Venous Thromboembolic risk and its prevention in hospitalised medical patients. Semin. Thromb. Hemost. 2002;28 (6):577-84.

147. Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000;55:1000-1006.

148. Edmonds P, Karlsen S, .Khan S et al. A comparison of the palliative care needs of patients dying from chronic respiratory disease and lung cancer. Palliat Med 2001;15:287-295.

149. End of life care in COPD - CTS recommendations for management of COPD. Can Resp J. Vol 11 Supp B July/Aug 2004.

150. Curtis JR, Wenrich MD, Carlibe JD, et al. Patientʼ perspectives on physician skill in end of life care. Differences in patients with COPD, cancer and AIDs. Chest 2002;122:356-362.

151. Curtis JR, Engelberg RA, Nielsen EL, Au DH, Patrick DL. Patient-physician communication about end of life care for patients with severe COPD. Eur Resp J 2004:24:200-214.

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153. Markson LJ, Frank K. Steel, D. Kern. Implementing advance directives in the primary care setting. Archives of Int Med. Vol. 154:20.

154. Heffner JE, Fahy B, Hilling L. Attitudes regarding advanced directives among patients in pulmonary rehabilitation. Am J Respir Crit Care Med 1996;154:1735-40.

155. Fallowfield L, Jenkins V, Farewell V, et al. Efficacy of a Cancer research UK communication skills training model for oncologists: a randomized controlled trial. Lancet 2002; 359: 650-656.

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Self-assessment (MCQs)

After reading the Clinical Practice Guidelines, you can claim one CME point under Category III (Self-Study) of the SMC Online CME System. Before you login to claim the CME point, we encourage you to evaluate whether you have mastered the key points in the Guidelines by completing this set of MCQs. This is an extension of the learning process and is not intended to “judge” your knowledge and is not compulsory. The answers can be found at the end of the questionnaire.

Instruction: Choose the best answer

1. In the assessment of a 40 year old smoker with chronic cough, breathlessness and sputum production, which of the following is most correct concerning COPD?

A) Physical examination is crucial to the diagnosis B) Chest x-ray is diagnostic C) Hemoptysis is a typical presentation D) Brochiectasis and congestive heart failure are possible differential

diagnoses E) Alpha-1 anti-trypsin deficiency is a common cause

2. The severity of COPD is determined by:

A) Duration of the disease B) The presence of cough C) The amount of sputum production D) Number of hospital admissions E) Post bronchodilator FEV1 reading

3. Evidence of airway obstruction using spirometry is best based on which of the following:

A) FEV1 < 80 percent predicted B) FVC > 80 percent predicted C) FEV1/FVC < 70% D) Post-bronchodilator FEV1 > 80 percent predicted

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4. Which of the following is not a key indicator for considering a diagnosis of COPD?

A) Chronic cough B) Dyspnoea C) History of exposure to risk factors D) Chest discomfort E) Sputum production

5. Spirometry is least useful for which of the following:

A) To establish the diagnosis of COPD B) To determine the severity of COPD C) To help differentiate between COPD and bronchial asthma by

bronchodilator reversibility testing D) To determine the severity of an exacerbation of COPD E) To evaluate changes in lung function over time or with therapy

6. Which of the following statements is TRUE:

A) Inhaled short-acting bronchodilators have been shown to slow the rate of FEV1 in COPD

B) Bronchodilators improve exercise tolerance in COPD despite having little or modest effect on increasing FEV1

C) Tiotropium has a duration of action of 12 hours D) Salmeterol and Formoterol have similar time to peak effect E) Ipratropium bromide is best used on an as-needed basis for quick

symptom relief

7. Which of the following statements is FALSE:

A) Inhaled corticosteroids (ICS) have been shown to reduce acute exacerbations in COPD patients with moderate to severe COPD

B) ICS have been shown to slow the rate of FEV1 decline in COPD C) Theophylline clearance is decreased by quinolones D) Combination ICS and long-acting 2-agonists (LABA) have been

shown to reduce acute exacerbations compared to monotherapy with LABA

E) Inhaled corticosteroids are not indicated for patients with Stage I COPD

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8. Patient education is vital to COPD management and should be provided at

A) Stage 0 B) Stage 1 and 2 C) Stage 3 and 4 D) All stages

9. The 5 As of smoking cessation are

A) Ask, assess, assist, advise, arrange follow-up B) Assess, advocate, ask, advise, arrange follow-up C) Advocate, ask, assess, advise, arrange follow-up D) Ask, advise, assess, assist, arrange follow-up E) Ask, admonish, advocate, assess, arrange follow-up

10. Pulmonary rehabilitation has been shown to have the following benefits except: A) Improvement of exercise capacity B) Improvement of lung function C) Reducing number of hospitalizations D) Improvement in health-related quality of life

11. Components of pulmonary rehabilitation include the following except: A) Physical training B) Nutritional intervention C) Psychosocial and behavioral intervention D) Optimizing pharmacotherapy (inhaler)

12. Which of the following statements about long-term oxygen therapy (LTOT) is false:

A) Long-term oxygen therapy has been shown to improve survival in COPD patients with mild to moderate hypoxaemia.

B) Goal of long-term oxygen therapy is to maintain baseline PaO2 > 60 mmHg.

C) Long-term oxygen therapy has a beneficial impact on sleep, exercise tolerance and cognitive function.

D) Long-term oxygen therapy should be cautiously titrated to maintain SaO2 > 90% in COPD patients with chronic hypercapnic respiratory failure.

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13. The most common cause of an acute exacerbation of COPD is

A) Pneumonia B) Poor nutritional state C) Infection of tracheobronchial tree D) Heart failure E) Arrhythmia

14. Which of the following is beneficial in the relief of an acute exacerbation of COPD?

A) Inhaled short-acting 2-agonist B) Inhaled steroids C) Oral theophylline D) Oral antibiotics

15. Which of the following statements is correct?

A) Patients often do not want to know too much about their prognosis

B) Patients with mild disease benefit most from advanced care planning

C) Physicians are generally adequate in their end of life discussions with patients.

D) Physicians can improve their communication on end of life issues with training

E) All of the above

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Answer

1. D (pg 19)

2. E (pg 20)

3. C (pg 20)

4. D (pg 22)

5. D (pg 24)

6. B (pg 26, 28)

7. B (pg 31-33)

8. D (pg 36)

9. D (pg 37)

10. B (pg 40)

11. D (pgs 40-41)

12. A (pgs 41-43)

13. C (pg 50)

14. A (pg 52)

15. D (pgs 59-60)

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Workgroup members

The members of the workgroup, who were appointed in their personal professional capacity, are:

Chairperson Dr Tan Boon Yeow Consultant Family Physician Head, Medical Services St Lukeʼs Hospital

Vice Chairperson Dr Ong Kian Chung Consultant Respiratory Physician

KC Ong Chest & Medical Clinic Mt Elizabeth Medical Centre

srebmeM

Prof Ong Yong Yau Emeritus Consultant Dept of Internal Medicine Singapore General Hospital

A/Prof Goh Lee Gan Dept of COFM Yong Loo Lin School of Medicine National University of Singapore

A/Prof Ng Tze Pin Dept of Psychological Medicine Yong Loo Lin School of Medicine National University Hospital

Dr Cynthia Chee Bin Eng Senior Consultant Dept of Respiratory Medicine Tan Tock Seng Hospital

Dr Jagadesan Raghuram Senior Consultant Dept of Respiratory Medicine & Critical Care Singapore General Hospital

Dr Lew Yii Jen Senior Family Physician Deputy Director Dept of Clinical Services NHG Polyclinics

Dr Chia Tee Hien Family physician Registrar St Lukeʼs Hospital

Dr Ng Chung Wai Family Physician Associate Consultant Singhealth Polyclinics-Outram

Dr Seow Hoong Wei Gabriel Consultant Family Physician Private Practice

Ms Lathy D/O Prabhakaran Senior Nurse Clinician Dept of Nursing Services Tan Tock Seng Hospital

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Acknowledgement to:

A/Prof Pang Weng Sun, Senior Consultant Geriatrician, Alexandra Hospital for his comments on the end of life care section.

Subsidiary editors

Dr Pwee Keng Ho Assistant Director (Clinical Guidelines & Technology Assessment) Clinical Quality Division Ministry of Health

Dr Rajni Gupta Clinical Guidelines & Technology Assessment Executive Clinical Quality Division Ministry of Health









Oct 2006

MOH Clinical Practice Guidelines 4/2006ISBN 981-05-6800-2

CLINICAL PRACTICE GUIDELINESCLINICAL PRACTICE GUIDELINES

Chronic ObstructivePulmonary DiseaseChronic ObstructivePulmonary Disease

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MOH CLINICAL PRACTICE GUIDELINES 4/2006

Chronic Obstructive Pulmonary Disease

Executive summary of recommendations









�

�

Executive summary of recommendations Details of recommendations can be found in the main text at the pages indicated.

Definition, Differential Diagnosis and Classification of Severity

D Where diagnostic doubt remains, or both COPD and asthma are present, the following findings will help identify asthma (pg 18):

• A large response (FEV1 greater than 400 ml) to bronchodilators. • A large response (FEV1 greater than 400 ml) to 30 mg oral prednisolone

daily for 2 weeks. • Serial peak flow measurements showing 20% or greater diurnal or day-

to-day variability.

Grade D, Level 4

D Where chronic asthma cannot be distinguished from COPD with the current imaging or lung function testing, it is assumed that the two diseases co-exist and their management should be similar to that of asthma (pg 19).

Grade D, Level 4 D COPD should be differentiated from congestive heart failure, bronchiectasis, and obliterative bronchiolitis (pg 19).

Grade D, Level 4

D A classification of disease severity into 5 stages based on spirometry cut points is recommended (pg 20).

Grade D, Level 4

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Evaluation

D A diagnosis of COPD should be considered in any patient more than 35 years old, who has chronic cough, sputum production, or dyspnoea, and/or a history of exposure to risk factors for the disease (see Table 4) (pg 22).

Grade D, Level 4

D Spirometry is useful for the definitive diagnosis of COPD and for the staging of disease severity, and should be performed in individuals with symptoms suggestive of COPD (pg 23).

Grade D, Level 4

�

D It is also recommended that bronchodilator reversibility testing be performed to help identify some subjects with asthma or a large asthma component to COPD and to establish a patientʼs best attainable lung function (pg 24).

Grade D, Level 4

D Arterial blood gases should be performed in patients with FEV1 <40% predicted or with clinical signs suggestive of respiratory failure or right heart failure (pg 24).

Grade D, Level 4

D A chest X-ray is seldom diagnostic in COPD but it is valuable in excluding alternative diagnoses and should be performed to look for abnormalities that may suggest other conditions. Computed tomography of the chest is not routinely recommended (pg 24).

Grade D, Level 4

Pharmacotherapy for stable COPD

A Inhaled short-acting bronchodilators are recommended as first-line therapy in all stages of COPD to relieve symptoms and improve exercise capacity (pg 26).

Grade A, Level 1+

A Regular treatment with one or both classes of the inhaled long-acting bronchodilators should be considered for patients with moderate to very severe COPD with frequent exacerbations (pg 28).

Grade A, Level 1

D Inhaled long-acting bronchodilators may be added to the treatment regimen when symptoms are not controlled with short-acting inhaled bronchodilators alone (pg 28). Grade D, Level 4

D Theophylline may be a useful addition where symptom control is still not achieved with existing inhaled bronchodilator therapy. Theophylline may be of value for patients who are non-adherent to or unable to use inhaled therapy (pg 30).

Grade D, Level 4

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A Inhaled corticosteroids as long-term maintenance therapy are recommended for patients with FEV1 <50% predicted who experience frequent exacerbations (pg 32).

Grade A, Level 1+

A Long-term oral corticosteroids are not recommended in stable COPD (pg 32).

Grade A, Level 1+

D Combination inhaled corticosteroids and long-acting 2-agonists should be considered for patients in whom both its components are indicated (pg 33).

Grade D, Level 4

C Annual influenza vaccination should be offered to the elderly (65 years old and above) in all stages of COPD (pg 33).

Grade C, Level 2++

D Pneumococcal vaccination may be considered in COPD patients (pg 34).

Grade D, Level 4

D If considering pneumococcal vaccination for a COPD patient, usually only one dose of the vaccine is needed. A second dose is recommended for persons aged 65 or older who received their first dose when they were under 65, if 5 or more years have passed since that dose (page 34).

Grade D, Level 4

2

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Intermittent AND

Few exacerbations

Regardless of FEV1

SABA or Combination SABA/SAAC

inhaler as needed for symptom relief

Persistent* AND/OR


AND



With one of the following:1) SAAC 4 to 6 hourly or 2) Combination SABA/SAAC





AND/OR


Intermittent or

Persistent

AND


AND


As above

AND



* Persistent symptoms: exertional dyspnoea, diminished exercise capacity, persistent cough, wheeze despite SABA/combination SABA/SAAC inhaler as needed.† Frequent exacerbations: two or more acute exacerbations a year requiring systemic steroids.


GPP

2

2

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Non-pharmacological Management for Stable COPD

Patient education

D Patient education is a vital part of COPD management and should begin at the time of first assessment for COPD and continue with each follow-up visit (pg 36).

Grade D, Level 4

D The intensity and content of patient educational messages should vary depending on the severity of the patientʼs disease (see Table 8) (pg 36).


Severity of Disease Patient Education Topic Stage 0: At Risk Information and advice about reducing

risk factors.

Stage I: Mild COPD through Stage III: Severe COPD

Above topic, plus: Information about the nature of COPD. Instruction on how to use inhalers and nebulizer. Information on influenza vaccination and medication. Recognition and treatment of exacerbation. Strategies for minimizing dyspnea Information on pulmonary rehabilitation.


Above topic, plus: Information about complications. Information about oxygen treatment. Advance directive and end-of-life decisions.

[Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2005]

Grade D, Level 4

�

D Patient education should be (pg 37): • Tailored to meet the needs of the individual patient • Interactive • Directed to improving quality of life • Simple to follow • Practical • Appropriate to the intellectual and social skill of the patient and the

caregivers.Grade D, Level 4

Smoking cessation

A Smoking cessation should be emphasized as an essential first step in management of COPD patients (pg 37).

Grade A, Level 1++

GPP Clinicians should play a prominent role in promoting attempts to stop smoking in their patients (pg 37).

GPP

A All smokers, including those who may be at risk for COPD as well as those who already have the disease, should be offered at least a brief tobacco dependence counseling at every health care provider visit (pg 37).

Grade A, Level 1++

D Pharmacotherapy for smoking cessation is recommended when counseling is not sufficient to help patients quit smoking (pg 38).

Grade D, Level 4

A Treatment of nicotine dependence is effective and should be offered to smokers in addition to counselling (pg 38).

Grade A, Level 1++

A These pharmacotherapies reliably increase long-term smoking abstinence rates and at least one of these medications should be added to counseling if necessary and in the absence of contraindications (pg 38).

Grade A, Level 1++

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Nutrition in COPD

D All patients with COPD should undergo simple nutrition screening (pg 39).

Grade D, Level 4

GPP Nutritional intervention should be considered in all COPD patients with BMI < 18.5 kg/m2 or significant involuntary weight loss (>10% during the last 6 months or > 5% in the past month) (pg 39).

GPP

Pulmonary rehabilitation

D Pulmonary rehabilitation may be considered for patients with the following (pg 41): • persistent symptoms especially dyspnoea, • reduced exercise tolerance or experience a restriction in activities, • recurrent admissions to hospitals over the last 6 months.

Grade D, Level 4

B The physical components of pulmonary rehabilitation should include both lower extremity training (e.g. bicycle, ergometry, treadmill) and upper extremity training (strength and endurance) (pg 41).

Grade B, Level 2+

D Psychosocial and behavioral interventions (health education, smoking cessation clinic, and support groups addressing psychosocial issues) as well as nutritional intervention should also be included as non-physical components of the comprehensive pulmonary rehabilitation programs (pg 41).

Grade D, Level 4

Oxygen therapy in chronic obstructive pulmonary disease

A Patients with very severe COPD and chronic respiratory failure should be assessed for the need for long-term oxygen therapy (pg 42).

Grade A, Level 1+

A Indications for long-term oxygen therapy (at least 15 hours/day) in patients with COPD should be based on the following indices obtained in stable state (pg 42):

• Without pulmonary hypertension (Cor Pulmonale), congestive heart failure, polycythaemia (Hct >55%):

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D Oxygen concentrator is the preferred mode of delivery of oxygen. It is the most convenient and economical method of providing long-term oxygen therapy (pg 43).

Grade D, Level 3

D Very severe COPD patients with hypercapnoiec respiratory failure requiring long-term oxygen therapy should have the oxygen flow rate titrated cautiously to maintain a SaO2 > 90% (pg 43).

Grade D, Level 4

Monitoring of patients with stable COPD

D & GPP Patients should be seen and assessed regularly (e.g. three-monthly in the stable state) (pg 48).




• Adherence to medications should be assessed, and the patientʼs inhaler technique checked and re-taught if necessary.


D & GPP Indications for specialist referral (pg 48)




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Management of Acute Exacerbations

C Chest radiography is recommended in an acute exacerbation, when other diagnoses like pneumonia or heart failure need to be excluded (pg 50).

Grade C, Level 2+

D Sputum culture is not recommended for routine investigation of patients with exacerbation (pg 50).

Grade D, Level 3

D Pulse oximetry, if available, can assist doctors in identifying patients with hypoxaemia when oxygen saturation (SaO2) is less th an 90% (pg 50).

Grade D, Level 3

Pharmacological management

A Inhaled anticholinergic bronchodilators or inhaled short-acting β2-agonists are beneficial and should be used in the treatment of patients presenting with acute exacerbation of COPD (pg 52).

Grade A, Level 1+

D Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD, as they are equally effective in achieving bronchodilation in COPD exacerbations (pg 52).

Grade D, Level 4

A In the absence of significant contraindications, oral corticosteroids should be used, in conjunction with other therapies, in all patients admitted to hospital with an exacerbation of COPD (pg 52).

Grade A, Level 1+

A In the absence of significant contraindications, oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in the breathlessness which interferes with daily activities (pg 52).

Grade A, Level 1+

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A Prednisolone 30 mg orally should be prescribed for 7 to 14 days to patients with an exacerbation. It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy (pg 53).

Grade A, Level 1+

A Antibiotics should be used to treat exacerbations of COPD when (pg 53): (1) there is history of purulent sputum (2) there are clinical signs of pneumonia (3) there is consolidation on a chest radiograph

Grade A, Level 1+

Non-pharmacological therapy GPP Oxygen therapy should be considered if patient is known, or suspected, to have hypoxaemia. This can be administered via nasal prongs, or venturi mask. One should exercise caution in the oxygen dose for patients, such that the lowest possible oxygen concentration to maintain oxygen saturation above 90% is provided. If pulse oxymeter is not available, the concentration of the oxygen mask should not exceed 28%, or the nasal prong oxygen flow rate should be kept at 2L/min (pg 53).

GPP A Non-invasive ventilation should be used as the treatment of choice in the hospital, for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy (pg 53).

Grade A, Level 1+

��


*30 mg of prednisolone daily for up to 14 days (Adapted from European Respiratory Society Consensus Statement,1995)

Mild exacerbations • Initiate, increase dose or frequency, or combine β2-agonist and/or • Anticholinergic • Encourage sputum clearance by coughing • Consider chest physiotherapy • Encourage fluid intake • Avoid sedatives and hypnotics • Consider antibiotics • Consider oral corticosteriods Instruct patients on symptoms and signs of worsening and actions to take: Contact primary care physician or go to emergency department.


Improved Worsened

Refer to hospital




• cyanosis

• confusion

• SaO2 <90%

Consider adding corticosteroids* or a course of antibiotics if not given earlier. Instruct patient on symptoms, signs of worseningand action to take.Stable COPD

management


No

Yes


Worsened

Not improving

Acute exacerbation

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When to refer to the Emergency Department (ED)

GPP Any one of the following signs may indicate severe exacerbations requiring urgent referral to the Emergency Department (pg 54):

1. marked dyspnoea and tachypnoea (> 30 respirations/minute) 2. use of accessory muscles (sternomastoid and abdominal) at rest 3. cyanosis 4. confusion 5. SaO2 <90%

GPP

Air Travel

D Patients with severe COPD, history of air travel intolerance with respiratory symptoms (dyspnoea, chest pain, confusion, syncope), co-morbidity with other conditions worsened by hypoxaemia (cerebrovascular disease, coronary artery disease, heart failure), and recent pneumothorax should undergo assessment before flying.




• measurement of SpO2 by pulse oximetry. Readings should be taken from a warm ear or finger after sufficient delay for the oximeter to display a stable reading. Blood gases are preferred if hypercapnia is known or suspected (pg 55) Grade D, Level 4

D Patients who have resting sea level oximetry between 92% and 95% and who have additional risk factors (Table 9) should be referred for further assessment (pg 55).

Grade D, Level 4

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Surgery in COPD patients

GPP Preoperative assessment of a COPD patient should include (pg 57): 1. Detailed history and physical examination 2. Assessment of functional capacity (American Society of


GPP

A COPD patients being considered for surgery should be assessed for risk of developing venous thromboembolism and also for thromboprophylaxis during the perioperative assessment (pg 58).

Grade A, Level 1+

A Combination of bronchodilators, chest physiotherapy, antibiotics, smoking cessation for at least 4-8 weeks and a short course of oral corticosteroids should be given to patients with acute exacerbation so as to reduce the risk of postoperative pulmonary complications (pg 58).

Grade A Level 1+

End of Life Care in COPD

D Patients should be educated about their disease, prognosis and possible circumstances of death (pg 59).

Grade D, Level 3

D Physicians should discuss end of life issues and advance care planning with patients (and their relatives) who have severe to very severe COPD (pg 59).

Grade D, Level 3

B Physicians who look after severe to very severe COPD patients (as with all physicians caring for the terminally ill) will need to be prepared to discuss end of life issues with patients (pg 60).

Grade B, Level 1+

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Levels of evidence and grades of recommendation

Levels of evidence Level Type of Evidence

1+ + High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias.

1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.

1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2+ + High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Grades of recommendation

Grade Recommendation A At least one meta-analysis, systematic review of RCTs, or RCT

rated as 1+ + and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1+ + or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2+ +

D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

GPP (good practice

points)

Recommended best practice based on the clinical experience of the guideline development group.

these guidelines have been withdrawn · 4 contents page executive summary of recommendations 1 1...

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