Mount Carmel Health Partners Clinical Guidelines Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease Clinical Guideline Definition: Chronic Obstructive Pulmonary Disease (COPD) is a common and treatable disease that is characterized by airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. Causes: Chronic bronchitis, emphysema, and bronchospasm infection are common causes. It is made worse by tobacco smoking, air pollution, and recurrent infections. Quick Guide to Chronic Obstructive Pulmonary Disease Care COPD exacerbations account for a significant number of ED visits. The goal of this guideline is to provide a consolidation of best practice recommendations in order to decrease the number of exacerbations and therefore improve ER utilizations. A brief synopsis of recommendations follows. • Make the diagnosis and stage the patient with spirometry. This is recommended by most, if not all, pulmonary expert panels. • See patients in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) severe and very severe categories at least twice a year. • Address tobacco cessation early and often. This is by far the most effective and cost-effective intervention. • Treat early with long-acting bronchodilators and/or combination steroid/beta-2 agonist inhaled products based on GOLD guidelines staging. • Avoid regular use of antitussives. • Use antibiotics for infectious exacerbations. • Vaccinate for influenza annually and administer pneumococcal vaccine at diagnosis and again at least once after age 65 (per current recommendation). • Treat with chronic oxygen if, and when, SaO₂ drops below 88% resting. • Enroll patients who are symptomatic and/or have decreased daily life activities due to COPD into a pulmonary rehabilitation program. • For acute exacerbations, add short-acting bronchodilators, a short (5 day burst) tapering course of prednisone, and antibiotics for patients with signs of infectious exacerbation. • 30% of hospital admissions for exacerbation have no identifiable cause. • See patients following an ED visit or within 2 weeks of hospitalization. COPD symptoms present or exposure to risk factors in 40+ year old individuals Confirm diagnosis and stage using spirometry Measure FEV1, FEV1/FVC, post bronchodilator study to determine airflow limitation and reversibility Diagnosis is not COPD; pursue alternative diagnosis No Is postbronchodilator FEV1/FVC less than 70%? Yes Assess symptoms and/or risk of exacerbations using either mMRC or CAT Evaluation Treatment Group A – Low Risk (less symptoms) 0 to 1 exacerbation per year and no hospitalization for exacerbation; and mMRC 0-1 or CAT <10 Group B – Low Risk (more symptoms) 0 to 1 exacerbation per year and no hospitalization for exacerbation; and mMRC grade ≥ 2 or CAT ≥10 Short-acting bronchodilator when needed; anticholinergic alone or with beta-agonist 1 when needed and 2 OR Initial treatment: 3 or 4 Step-up treatment: 3 and 4 (stat if severe breathlessness) Group C – High Risk (less symptoms) ≥ 2 exacerbation per year or ≥ 1 hospitalization for exacerbation: and mMRC 0-1 or CAT <10 1 when needed and 2 OR Initial treatment: 3 Step-up treatment: 3 and 4 Alternative step-up treatment: 4 and 5 Group D High Risk (more symptoms) ≥ 2 exacerbation per year or ≥ 1 hospitalization for exacerbation: mMRC grade ≥ 2 or CAT ≥10 1 when needed and 2 OR Initial treatment:3 and 4 OR 4 and 5 (if asthma and COPD overlap) Step-up treatment: • Triple therapy with 3 , 4, 5 Alternative step-up treatment: • add 6 • add macrolide • stop 5 Treatment Key: 1 Short-acting bronchodilator 2 Pulmonary rehabilitation 3 Long-acting anticholinergic 4 Long-acting beta-agonist 5 Inhaled glucocorticoid 6 Phosphodiesterase-4 inhibitor *Adapted from Global Initiative for Chronic Obstructive Lung Disease 2018 Report. Modified British Research Council Questionnaire (mMRC), COPD Assessment Test (CAT). QI Draft May 2018