COPD

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a common, treatable, and largely preventable lung condition^1.

In Scope

Diagnosis and Management of COPD

Not in scope

Acute exacerbations of COPD – please see IECOPD | acute-gp

Red Flags

Haemoptysis or suspicious features on chest x-ray. Consider Fast Track Suspected Cancer Pathway referral as appropriate

Diagnosis

Diagnosis of COPD is based on the presence of typical clinical features and an obstructive picture on spirometry.

Typical clinical features: suspected in those aged over 35 years, who have a risk factor (such as smoking history, occupational exposure, environmental exposure, genetics, asthma⁵) and symptoms including, but not limited to, exertional breathlessness, wheeze, chronic cough or regular sputum production¹ (this list is not exhaustive)
Obstructive spirometry picture: A post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) of less than 0.7 on spirometry¹.

If a symptomatic smoker has normal spirometry, check eosinophils and refer to Asthma Guidelines. If no suspicion of Asthma consider early COPD and ensure patient has healthy lifestyle advice, E.G. smoking cessation

Assessing severity of COPD

MRC dyspnoea scale¹

COPD Assessment Test

https://www.catestonline.org/patient-site-test-page-english.html

User Guide link here.

Although not required for diagnosis, CXR and FBC are needed if considering referral – see referral instructions below.

Management Optimisation

Consider the need for hospital admission in any patient presenting with an acute exacerbation of COPD - IECOPD | acute-gp

Adopt a shared decision-making approach with the patient and/or their caregivers where appropriate. Local COPD inhaler prescribing guidelines

Summary of initial treatment

2 or more exacerbations or 1 exacerbation leading to hospitalisation, suggested treatment below:
- LABA + LAMA
- Check blood eosinophils and if >0.3 x10*9/L consider adding ICS. (Use of ICS with LABA alone is not recommended¹)

0 or 1 moderate exacerbation not leading to hospitalisation, and MRC 1-2, CAT <10*
- SABA or LABA

LABA preferred choice except in patients with very occasional breathlessness)

0 or 1 moderate exacerbation not leading to hospitalisation, and MRC 3 or more, CAT >10*
- LABA + LAMA

*MRC: Medical Research Council dyspnoea questionnaire; CAT: COPD Assessment Test. Note: GOLD 2024 use modified MRC (mMRC), scored 0-4, whereas NICE and local guidelines use MRC which uses almost identical questions (scored 1-5).

Ongoing treatment:

Following treatment initiation consider the predominant treatable trait to target: dyspnoea or exacerbations. For more information click here.

Consider choice of inhaler in the context of climate change where possible. Please see Cornwall formulary inhaler choices document for more information.

Also consider the following:

Provide patient with information on the condition and risk factors for progression
Smoking cessation treatment and support (where applicable)
Review inhaler technique and adherence regularly with patient and before any adjustment in treatment
Up to date with appropriate vaccines³
Treatment for associated comorbidities (e.g. anxiety, depression- see link for useful resources, cardiovascular disease, osteoporosis)

*this list is not exhaustive

Provide patient with a self-management plan.

Advice and Guidance

Advice and Guidance requests can be submitted to respiratory through the e-referrals system

Respiratory referral criteria

Emergency and red flags

Lung Cancer suspected – refer on Fast Track Suspected Cancer pathway
Acute COPD exacerbation requiring hospital admission discuss with Acute GP as appropriate.

Routine Respiratory Referral

Diagnostic uncertainty. e.g. Difficulty distinguishing COPD from asthma or other conditions such as bronchiectasis or fibrosis
High frequency of exacerbations (5 or more in one year, or 2 requiring hospital admission in one year) Please also refer to Respiratory Specialist Nurses.
If Cor-pulmonale is suspected. Request echo concurrently.
Patient <40 years and/or there is a family history of alpha-1-antitrypsin deficiency
A lung volume reduction procedure may be appropriate in patients with COPD, FEV1 20-50% predicted, who have hyperinflation on CXR or emphysema on HRCT, and are prepared to participate in pulmonary rehab and have stopped smoking (for a minimum 3 months). They can be referred to RCHT but the procedures are only available out of county.

Referrals to further services

Referral criteria to Respiratory Specialist Nurses
- Uncontrolled symptoms despite treatment optimisation
- High frequency of exacerbations (5 or more in one year, or 2 requiring hospital admission in one year) - refer to Respiratory and the Specialist Nurses simultaneously
- Palliative symptoms support
- Long term oxygen therapy assessment if below criteria met
  - Patients must have a respiratory diagnosis
  - Have had other treatment options optimised
  - 8 weeks clear of an exacerbation
  - Sp02 persistently below 92%
  - FEV1 <30%
  - Exclusions:
    - Current Smokers
    - Risky behaviour with drugs and alcohol
Referral to Pulmonary Rehabilitation as appropriate

Referral Instructions

Please check patient compliance and inhaler technique prior to assessing need for referral.

Please include MRC dyspnoea scale.

Investigations required prior to referral

All Patients

Spirometry with reversibility (within the last 12 months) if possible
CXR (within the last 12 months)
FBC to identify anaemia or polycythaemia²and blood eosinophil count
Consider BNP and ECG if indicated
Sputum MC&S

Onset < 40 years (in addition to above)

Alpha 1 antitrypsin

Useful Information

Patient

Professional

References

Page Review Information

Review date: 08 April 2025

Next review date 08 April 2027

Speciality Lead GP Dr Kate Northridge

Contributors Dr Sarah Deacon, Consultant in Respiratory Medicine, RCHT