The COPD-X Plan:
Australia and New Zealand guidelines for the management of
COPD
Presentation Authors: COPD National Program Executive Committee
A/Professor Ian Yang, Professor Peter Frith, Professor Christine McDonald,
Dr Kerry Hancock, Dr Julia Walters, Mrs Liz Harper
Presenter: Dr Bajee Krishna Sriram
Affiliations
Overview
• Present Australian COPD clinical guidelines
• Stepwise diagnosis and management of patients with COPD
• Available resources for primary care
Action points:
 Register on www.copdx.org.au to receive the updated COPD-X
guidelines and the new handbook to be released soon
 Use Stepwise Management of Stable COPD
 Use COPD Action Plan
 Use COPD Assessment Tool (CAT)
 Use Lung Health Checklist
 Use Lung Foundation Australia resources for COPD
www.copdx.org.au
New GP Handbook coming soon:
COPD-X Concise Guide for Primary Care
Register now on www.copdx.org.au to receive an
email update as soon as it is available
Australian COPD-X guidelines
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Case ID & Confirm
Optimise
Prevent
Develop
eXacerbations
diagnosis
function
deterioration
support network & self
management plan
management
• COPD-X Concise Guide for Primary Care
(due October 2013)
Chronic Obstructive Pulmonary Disease
• A common preventable and treatable
disease
Spirometry
• Characterised by persistent airflow limitation
that is usually progressive and associated with an
enhanced chronic inflammatory response in the
airways and the lung to noxious particles or gases.
• Exacerbations and comorbidities contribute to the overall
severity in individual patients
Case Identification
Case Finding – General Practice and
Pharmacy
Lung Health
Checklist
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Piko6 or
COPD6
Cough
Sputum
Chest infections
Dyspnoea
Confirm Diagnosis
www.copdx.org.au
Diagnosis of COPD
• Gold Standard Test –
Spirometry
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Cough
Sputum
Chest infections
Dyspnoea
Spirometry (example of volume-time curve)
Expired volume
(litres)
Forced vital capacity
FVC 4.3 L
FEV1 3.5 L
Forced expiratory
volume in 1 sec
Examples of spirograms and flow-volume loops
From:
Johns and Pierce 2008:
Spirometry
(National Asthma Council)
Severity of disease (Australian guidelines)
Diagnosis: Post-bronchodilator airflow obstruction
that is not fully reversible
Investigations
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Spirometry
Gas transfer
Chest X-ray
6 min walk
• Sputum
• Arterial Blood
Gases (ABGs)
• CT chest
Pre- and post-bronchodilator
Detect emphysema physiologically
Exclude other causes of dyspnoea
Measure exercise capacity &
desaturation
Microscopy, culture, sensitivity
Measure gas exchange & acid- base
status
Exclude other causes of dyspnoea
(not needed in all patients)
Optimise Function
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
PLEASE TICK IN THE BOX THAT APPLIES TO YOU
(ONE BOX ONLY)
mMRC Grade 0. I only get breathless with strenuous exercise.
mMRC Grade 1. I get short of breath when hurrying on the level
or walking up a slight hill.
mMRC Grade 2. I walk slower than people of the same age on the
level because of breathlessness, or I have to stop for breath when
walking on my own pace on the level.
mMRC Grade 3. I stop for breath after walking about 100 meters or
after a few minutes on the level.
mMRC Grade 4. I am too breathless to leave the house or I am
breathless when dressing or undressing.
Cough
Sputum
Chest tightness
www.catestonline.org
Walking up hill
Scores
ADLs
11-20 medium impact
Leaving the house
> 20 high impact
Sleep
Energy levels
Non-pharmacological interventions
• Consider referral to Pulmonary Rehabilitation for
patients who display exertional dyspnoea and after
an exacerbation
- Level 1 evidence for reducing dysnoea, fatigue,
anxiety and depression and improving exercise
capacity, emotional function and health related
quality of life outcomes
- Level II evidence for reducing hospital admissions
Relievers -Short-acting β2-agonists
(SABAs)
•Acute onset (1-3 min)
•Short duration of action (4hr)
•Relaxation of airway smooth muscle by stimulating
β2-adrenoceptors
•Use as needed
•Salbutamol (100 mcg, 2-4 inhalations PRN)
•Terbutaline (500 mcg, 1-3 inhalations PRN)
LABAs
Long-acting β2-agonists (LABAs)- bd
• Slow onset – salmeterol (15-20 min)
MDI 25 mcg AH 50 mcg
• Fast onset – eformoterol (1-3 mins)
• Long duration of action (12 h)
• Relaxation of airway smooth muscle by binding
and occupying β2-adrenoceptors
6, 12 mcg TH
12 mcg Aerolizer, 12 mcg bd
Once a day LABA
Once a day - Long-acting β2-agonists
(LABAs)
- indacaterol
DPI 150 mcg, 300 mcg
150 to 300 mcg once daily
• Long duration of action (24hr)
• Relaxation of airway smooth muscle by binding and
occupying β2-adrenoceptors
LAMA
Long-acting muscarinic antagonist
(LAMA)
(long-acting anticholinergic)
- Tiotropium (18mcg daily)
• Slow onset (30min)
• Long duration of action (24hr)
• Relaxation of airway smooth muscle by
binding and occupying muscarinic M3
receptors
Combination inhalers (ICS/LABA)
salmeterol/fluticasone
MDI 250/25
2 inhalations bd
AH 500/50
1 inhalation bd
Preventer
eformoterol/budesonide
Controller
TH 400/12 mcg
1 inhalation bd
+
Prevent Deterioration
www.copdx.org.au
Smoking Cessation
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Brief intervention
Counselling – behavioural intervention
Nicotine replacement therapy
Pharmacological agents
– Varenicline
– Bupropion
RACGP smoking cessation guidelines
www.racgp.org.au/your-practice/guidelines/smokingcessation
Immunisations
• Annual influenza immunisations
• Pneumococcal immunisation every five years
or as per the Australian Immunisation Handbook
Long-term Oxygen Therapy for COPD
Position on continuous oxygen therapy
Continuous oxygen therapy is indicated to improve survival
and quality of life for:
• PaO2 ≤ 55 mmHg at rest, or
• PaO2 56-59 mmHg with right heart failure, pulmonary
hypertension or polycythaemia
Flow rate to maintain oxygen saturation >90% at rest
Increase by 1L/min during:
- Sleep
- Exertion
- Air travel
TSANZ guidelines: McDonald et al, MJA 2005: 182: 621-626
Develop a plan of care
www.copdx.org.au
Lung Foundation Resources
• Primary Care Respiratory Toolkit
– Spirometry Calculator
– Lung age estimator
• Stepwise Management of Stable COPD
• COPD online, an interactive training
program for primary care nurses
• Website listings
– Pulmonary Rehabilitation program locations
– Patient support groups
– Lungs in Action exercise maintenance classes
• Patient Resources (fact sheets, brochures,
Better Living Guide, Getting Started on
O2)
• Lung Health Checklist
• Pulmonary Rehab Toolkit
• NEW (soon) – COPD-X: Concise Guide for
Primary Care
Respiratory Education Team
(Multi-disciplinary Management of COPD)
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COPD knowledge and symptom awareness
Symptom control
Inhaler technique, delivery devices
Written COPD action plan
Self-management education
COPD first aid
Palliative and Supportive Care
End of Life Discussions/ Advanced Care Planning
www.lungfoundation.com.au
When to start
antibiotics and
prednisolone
Or Call 1800 654 301 to have
the editable pdf emailed
directly to you
Indigenous version also
available
Support Teams
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Patient Support Groups & Family, friends
GP , Practice Nurse
Respiratory nurse specialist
Respiratory educator
Allied Health: Physiotherapist , Occupational therapist, Social
worker, Psychologist, Dietitian, Speech therapist
Respiratory Specialist
Pharmacist – Home Medicine Reviews, Quality Use of
Medicines Checks, Inhaler Technique
Home Carers, Oxygen suppliers
Pulmonary Rehabilitation
Lungs in Action classes (post rehab)
Manage eXacerbations
www.copdx.org.au
Primary care management of exacerbations
Tests:
• Oximetry
• Spirometry (if required)
• Chest x-ray (if clinically indicated)
• Sputum MCS
Treatment:
•Bronchodilators
e.g salbutamol 100mcg, 2-4 (up to 10) inhalations via spacer
•Oral steroids
e.g. prednisolone 30-50mg, 7-14 days
•Antibiotics
e.g. amoxycillin 500mg tds, 5 days
or doxycycline, 100 mg bd, 5 days
(or consider other antibiotics)
• When do you refer to hospital?
• What is NIV?
• Who is likely to require ICU admission?
• What about referral to pulmonary rehabilitation after
an exacerbation?
New GP Handbook coming in October:
COPD-X Concise Guidelines for Primary
Care
• Visit www.copdx.org.au and register to receive
COPD-X pdf. This will register you for updates.
• COPD-X Concise Guide for Primary Care is available in
pdf in October. It contains key recommendations
and grades the strength of recommendations and
quality of evidence.
• Stepwise diagnosis and management of patients with
COPD – also available to download as pdf from
www.lungfoundation.com.au (single page summary)
Summary Actions
• COPD-x guidelines
• Lung Foundation Australia resources
– COPD Action plan
– Lung health checklist
– Primary Care Respiratory Toolkit
– COPD Online training for practice nurses
– Database of Pulmonary Rehab programs
– Database of Patient Support Groups
– Database of Lungs in Action classes
– Patient Education materials
– 1800 654 301
– www.lungfoundation.com.au