Obstructive Airways

Disease
Asthma and COPD

Definitions:
Asthma: It's a chronic respiratory condition that
causes the airways to constrict become inflamed
and collect mucus. It can be triggered by natural
allergens, cigarette smoke, pets, exercise or
emotional stress.
COPD: is characterized by air flow obstruction.
The airflow obstruction is usually progressive,
not fully reversible and doesn't change markedly
over several months. The disease is
predominantly caused by smoking.

Diagnosis of COPD
It should be considered in patients over the age
of 35 who have a risk factor, generally smoking,
and who present with exertional dyspnoea,
chronic cough, regular sputum production,
frequent winter bronchitis or wheeze. The
presence of airflow obstruction should be
confirmed by performing spirometry.
All health professionals should be competent
in the interpretation of the results

COPD contd.
Airflow obstruction is defined as a reduced FEV1 and reduced
FEV1/FVC ratio, such that post bronchodilator FEV1 is less than
80% predicted and post bronchodilator FEV1/FVC is less than 0.7.
The airflow obstruction is due to a combination of airway and
parenchymal damage.
The damage is the result of chronic inflammation that differs from
that seen in asthma and which is usually the result of tobacco
smoke.
Significant airflow obstruction and lung damage may be present
before the individual is aware of it.
COPD produces symptoms, disability and impaired quality of life
which may respond to pharmacological and other therapies that
have limited or no impact on airflow obstruction.

COPD contd:
Other symptoms
Weight loss
Effort tolerance
Waking at night
Ankle swelling
Fatigue
Occupational hazards
Chest pain
Haemoptysis

MRC dyspnoea scale

Grade 1. Dyspnoea on strenuous exercise.
Grade 2. Short of breath when hurrying or
walking up a slight hill.
Grade 3. Walks slower then contemporaries on
level ground because of breathlessness, or has
to stop for breath when walking at own pace.
Grade 4. Stops for breath after walking about
100meters or after a few minutes on level
ground.
Grade 5. Too breathless to leave the house, or
breathless when dressing or undressing.

Investigations of COPD
Spirometry
CXR
FBC
BMI
Additional investigations: serial PEFR,
alpha-1 antitripsin, CT Scan Thorax,ECG,
Echocardiogram, pulse oximetry, sputum
culture if sputum persistently purulent.

History

COPD

Asthma

Smoker or ex-smoker

Almost
always

Possibly

Symptoms under age 35

Rare

Common

Chronic productive cough Common

Uncommon

Breathlessness

Persistent/ Variable
Progressive

Night time waking with

sob and wheeze

Uncommon Common

Significant diurnal or day

to day variability of
symptoms

Uncommon Common

Assessment of severity of COPD

MILD AIRFLOW
OBSTRUCTION
MODERATE
AIRFLOW
OBSTRUCTION
SEVERE AIRFLOW
OBSTRUCTION

FEV1 50-80%
PREDICTED
FEV1 30-49%
PREDICTED
FEV1 <30%
PREDICTED

Management of COPD
Quit smoking
Short acting bronchodilator- beta 2 agonist or
anticholenergic
Combination of the above inhalers
Long acting beta-2-agonists or long acting anticholinergic
In moderate to severe COPD; if symptoms persist, with at
least two exacerbations requiring oral antibiotics and
steroids, consider a combination of a long-acting beta-2agonist and inhaled corticosteroid; discontinue if no
benefit after 4 weeks
If still symptomatic-consider adding Theophylline
Mucolytics e.g. carbocystiene

Devices to Deliver Medications

Delivery system used to treat patients with
stable COPD: Several devices are available
best may be MDI with a spacer.
Make sure the technique is good with regular
checks.
Nebuliser therapy should not continue to be
prescribed without proper assessment.
LTOT: PO2 <7.3KPa or PO2 between 7.3 to
8KPa with secondary polycythaemia, nocturnal
hypoxia i.e. less then 90% SaO2 for more than
30% of time, peripheral oedema or pulmonary
hypertension.

Corpulmonale
COPD associated with peripheral
oedema,
A raised venous pressure, a systolic
parasternal heave and loud second heart
sound.
These patients need to be considered for
LTOT, diuretics, ACE inhibitors, calcium
channel blockers, alpha blockers and
Digoxin

Pulmonary rehabilitation

This should incorporate a programme of

physical training, disease education,
nutritional, psychological and behavioural
intervention.

Other therapies
Vaccination
Lung surgery
Physiotherapy
Management of anxiety and depression
Nutritional factors
Exercise
Palliative care
Assessment for occupational therapy
Social services
Self-management Rescue packs etc
Follow up of patients with COPDAT LEAST TWICE A YEAR IN GP PRACTICE
Need spirometry once a year etc.
Multi-disciplinary team- Unique care

Reasons for Referral to Secondary care

Reason

Purpose

There is diagnostic
uncertainty

confirm diagnosis and optimise therapy

Suspected severe COPD

Confirm diagnosis and optimise

therapy

The patient requests a

second opinion.

Confirm diagnosis and optimise

therapy

Onset of cor pulmonale

Confirm diagnosis and optimise

therapy

Assessment for oxygen

therapy

Optimise therapy and measure blood

gases

Assessment for long-term

nebuliser therapy

Optimise therapy and exclude

inappropriate prescriptions

Assessment for oral

coticosteroid therapy

Justify need for long-term treatment or

supervise withdrawal

Bullous lung disease

Identify candidates for surgery

Reasons for Referral to Secondary care contd.

Reason

Purpose

A rapid decline in FEV1

Encourage early intervention

Assessment for pulmonary

rehabilitation

Identify candidate for rehab

Assessment for lung

transplantation

To identify candidates for surgery

Age under 40 or a family

history or alpha-1 antitripsin
deficiency

Consider therapy and screen family

Uncertain diagnosis

Make a diagnosis

Frequent infections

Exclude bronchiectasis

Haemoptysis

To exclude carcinoma

Guide to Therapy
Use short acting bronchodilator prn
(either beta-2-agonist or anticolinergic)
If still symptomatic, try combined therapy with a short-acting
beta-2-agonist and short-acting anticolinergic
If still symptomatic, use a long-acting bronchodilator
(beta-2-agonist or anticolinergic)
In moderate or severe COPD: If still symptomatic,
consider a combination of a long-acting beta-2-agonist and inhale
corticosteroid (discontinue if no benefit after 4 weeks)
If still symptomatic- consider adding theophylline
Consider mucolytic agents if patient complains
of thick, tenacious sputum which is hard to cough up

No
symptoms
Stop smoking
Influenza/ Pneumococcal
Exercise and dietary advice

Bronchodilation
Intermittent short-acting bronchodilators
Regular bronchodilation with:
Long-acting anticholinergics
Long- acting b2- agonists (LABA)
Mucolytics for cough
Pulmonary Rehabilitation

Combination LABA/ ICS

Self-Management Plans
(Look for depression/ anxiety)

Consider:
Referral for:
Long-term domiciliary oxygen therapy (LTOT)
Surgical interventions
Palliative care

Symptoms

Disability

Exacerbations

Failing Lung
Hypoxia/ Cor
Pulmonale

Indicator

Points

Payment
Stages

Records
COPD1. The practice can produce a register of
patients with COPD

Initial diagnosis
COPD 12. The percentage of all patients with COPD
diagnosed after 1st April 2008 in whom the diagnosis
has been confirmed by post-bronchodilator spirometry

40-80%

Ongoing management
COPD 10. The percentage of patients with COPD with
a record of FEV1 in the previous 15 months

40-70%

COPD 13. The percentage of patients with COPD who

have had a review, undertaken by a healthcare
professional, including an assessment of
breathlessness using the MRC dyspnoea score in the
preceding 15months

40-90%

COPD 8. The percentage of patients with COPD who

have had influenza immunisation in the preceding 1st
September to 31st March

40-85%

Quality and Outcomes Framework: Asthma

Indicator

Points

Payment stages

The practice can produce a register

of patients with asthma (excluding
those who havent been prescribed
asthma drugs for the past 12 months)

Percentage of people aged 8 years

and older diagnosed as having
asthma from 1 April 2006 with
measures of variability or reversibility

15

40-80%

Percentage of people between the

age of 14 and 19 years with asthma
in whom there is a record of smoking
status within the past 15 months

40-80%

Percentage of people with asthma

who have had an asthma review in
the previous 15 months. Note that
this cannot be done by telephone

20

40-70%

Clinical management tips

Advise your patient to stop smoking because this will reduce the progression of COPD
Consider referring your patient for pulmonary rehabilitation if they are becoming disabled by their COPD and they
have a Medical Research Council dyspnoea score of 3 or more
Prescribe bronchodilators if your patient had symptoms, rather than basing your decision on an improvement in
lung function. You should therefore be judging whether treatment has been successful according to symptom
relief
Start high dose combination inhaled corticosteroid/ long acting beta2 agonist inhalers in patients with an
FEV1 50% predicted and two or more exacerbations a year
For example, you can give either budesonide/ formeterol 400/12 one puff twice daily or fluticasone/ salmeterol
500/50 one puff twice daily. The benefit is about a 25% reduction in exacerbations
Be aware that aresponse to a course of oral steroids does not help you to predict which patients will benefit
Refer patients with an oxygen saturation of <92% for assessment to see whether they would benefit from long
term oxygen therapy
You should consider this in patients who have an FEV1 <30% of predicted, polycythaemia, peripheral oedema, or
signs of right heart failure
Long term oxygen therapy must be given over a minimum of 15 hours each day to correct chronic hypoxia
Be aware of the impact on carers of patients with severe COPD
Consider the palliative care needs of patients with severe COPD, especially those who have been admitted to
hospital with respiratory failure
Be aware that your patient can stop taking oral steroids abruptly, provided they have not taken them for more than
three weeks in total
Consider carrying out bone densitometry on patients with FEV1<50%. Irrespective of inhaled corticosteroid use
there is a high risk of osteoporosis in this group

Assess symptoms/ problems of a patient with COPD and manage as described below:

How can I put this into practice?

Ideas for audit towards appraisal/ revalidation are:
Number of patients with COPD who have an exacerbation in the last
year who have a personalised action plan
Number of patients with FEV1 of 50% and 2 or more exacerbations
who are on ICS/IABA combination therapy
Number of patients with MRC dyspnoea score of 3 (excluding
housebound) who have ever been referred for pulmonary
rehabilitation
Number of patients with FEV1<50% who have had a record of pulse
oximetry being carried out in the last year

Possible ways of identifying patients with

COPD for inclusion on a practice palliative care
register
Hospital admission for a severe exacerbation of COPD
Being housebound due to COPD
Having an FEV1 of 30% or less
Being on long term oxygen therapy
Having depression or a poor quality of life
Other parameters such as a low body mass index (<20) and
comorbidities (especially heart failure)
GPs and nurses asking themselves the question: Would I be
surprised if my patient were to die in the next twelve months? This
could be considered during routine consultations or on reviewing the
register. If the answer is No, I would not be surprised the palliative
or anticipatory care approach may be indicated

Tasks
1. How would you achieve maximum QOF
points in patients with COPD in your practice?
2. How would you achieve maximum points in
patients with asthma in your practice?
3. How would set up an asthma clinic in your
practice? Include various equipment required
and staff involved in achieving this task
4. How would you audit asthma control in your
patients in your practice? Focus on one or two
criteria. Complete audit cycle

QOF Indicators and points for Asthma

Indicator
ASTHMA 1. The practice can produce a register of patients with asthma excluding
patients with asthma who have been prescribed no asthma related drugs in the last
twelve months

Pts

Max.
Threshold

ASTHMA 2. The percentage of patients age eight and over diagnosed as having
asthma from 1st April 2003 where the diagnosis has been confirmed by spirometry or
peak flow measurement

15

70%

ASTHMA 3. The percentage of patients with asthma between the ages of 14 and 19
in whom there is a record of smoking status in the previous 15 months

70%

ASTHMA 4. The percentage of patients age 20 and over with asthma whose notes
record smoking status in the past 15 months except those who have never smoked
where smoking status should be recorded at least once

70%

ASTHMA 5. The percentage of patients with asthma who smoke, and whose notes
contain a record that smoking cessation advice has been offered within last 15
months.

70%

ASTHMA 6. The percentage of patients with asthma who have had an asthma review
in the last 15 months

20

70%

ASTHMA 7. The percentage of patients age 16 years and over with asthma who have
had influenza immunisation in the preceding 1st September to 31st March

12

50%

QOF indicators and points for COPD

No.
Indicator
COPD 1

The practice can produce a register of

patients with COPD

Points Payment
Stages

COPD 12 The percentage of all patients with COPD

40-80%

COPD 10 The percentage of patients with COPD with

40-70%

COPD 11 The percentage of patients with COPD

40-90%

40-85%

diagnosed after 1 April 2008 in whom the

diagnosis has been confirmed by postbronchodilator spirometry
st

a record of FEV1 in the previous 15 months

received inhaled treatments in whom there
is a record that inhaler technique has been
checked in the previous 15 months

COPD 8

The percentage of patients with COPD who

have had influenza immunisation in the
preceding 1st September to 31st March