COPD
Overview
- In most patients, the best place for diagnosis and management for COPD is within the primary care setting
- The diagnosis of COPD is made by completing post-bronchodilator spirometry in symptomatic, “at risk” individuals. Demonstration of fixed airflow obstruction is essential to objectively prove the diagnosis and help differentiate from conditions such as asthma
- Clinical exam, history and chest imaging can help exclude other conditions on the differential diagnosis for dyspnea and cough, such as congestive heart failure, bronchiectasis, tuberculosis and other less common airway conditions
- Spirometry is also used along with the level of disability to classify severity of COPD and subsequently guide therapy decisions
- Consideration should be given to referral to a Certified Respiratory Educator to provide COPD education, smoking cessation advice and ensure proper inhaler technique
- Consider providing patient with Shortness of Breath Handout
- Prescription inhaled medications (chosen according to national/international treatment guidelines) help to prevent COPD exacerbations which lead to increased morbidity and mortality
- Prompt treatment of exacerbations with a “COPD Action Plan” can help reduce frequency and severity of COPD exacerbations
- A multi-disciplinary approach to address needs in more severe patients (such as dietitian, palliative care as well as pulmonary specialists) can improve the overall quality of life for COPD patients
- More information on managing a COPD exacerbation can be found at Chronic Obstructive Pulmonary Disease (COPD) Pathway
Review patient management yearly in stable patient. Review more frequently in severe disease, recent medication changes, or recent exacerbation.
Ongoing surveillance includes:
- Patient self-reports feeling better/same/worse; if better or same, ensure patient is maintained on a LAMA/LABA depending on severity
- mMRC
- Weight- patients in end stage COPD will lose weight
- O2 sat
- Exacerbation history
- C-x-ray not routine; consider repeat spirometry if deterioration
Non-urgent considerations:
- Alberta blue cross coverage for triple therapy is met (hyperlink to Alberta blue cross)
- Smoking cessation referral
- Consider pneumococcal immunization, flu shot, COVID vaccine
In severe COPD patients discuss goals of care, dyspnea control and referral to palliative care for advanced symptom management
- Review and update goals of care
- Consider pulmonary consult (reasons for referral may include co-management, diagnostic uncertainty, prognostatician, other therapies, including potential for lung transplant)
- Discuss advanced symptom management
- Consider palliative and end of life care
This AHS/Specialist Link Calgary Zone pathway Chronic Obstructive Pulmonary Disease (COPD) Pathway is a best-practice clinical pathway for management of COPD relevant to the primary care medical home that includes a flow diagram and expanded details. It will be updated to reflect the new evidence.
COPD and other pathways related to Respirology can be found at Alberta's Pathway Hub.
We will update and add content to this page in future.
Overview
- A COPD exacerbation is defined as a flare up of COPD symptoms that get worse for at least 48 hours
- Prompt treatment of exacerbations with a “COPD Action Plan” can help reduce frequency and severity of COPD exacerbations
- Symptoms include: increased coughing/wheezing, shortness of breath, and mucus production. Exacerbations are classified into simple and complicated based on the following patient factors:
- Simple: COPD without risk factors
- Complicated: COPD with one of following risk factors:
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- FEV1 < 50% predicted
- ≥ 4 exacerbations yearly
- Ischemic heart disease
- Home O2
- Chronic steroid use
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- More information on managing a COPD exacerbation can be found at Chronic Obstructive Pulmonary Disease (COPD) Pathway
- Patients should be reviewed one week after being treated for COPD exacerbation - upon discharge from hospital or ER visit for COPD exacerbation
- In severe COPD patients discuss goals of care, dyspnea control and referral to palliative care for advanced symptom management
Exacerbation Pearls
- Ensure that inhaler technique is correct- referring patient to a certified respiratory educator or community pharmacist can support this
- Perform clinical status check within 7 days of intervention for exacerbation (same or improvement expected)
- Remember return to baseline may take up to 6 weeks
- Always encourage smoking cessation at every visit
- Long term daily inhaled combination LABA/LAMA therapy in moderate to severe COPD will help prevent exacerbations
- In patients that have moderate to severe COPD and experience one or more exacerbations, consider moving to triple inhaled therapy, ideally in a single inhaler device (i.e. LAMA/LABA/ICS) to prevent further exacerbations
- Consider providing ‘COPD Action Plan’ to all patients who have history of exacerbations
- Refer to COPD exacerbation pathway within the COPD Pathway as shown below:
