{"id":3792,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/chronicobstructivepulmonarydisease\/"},"modified":"2024-07-30T09:15:08","modified_gmt":"2024-07-30T08:15:08","slug":"chronicobstructivepulmonarydisease","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/respiratory\/chronicobstructivepulmonarydisease\/","title":{"rendered":"Chronic Obstructive Pulmonary Disease"},"content":{"rendered":"\n<h3 class=\"wp-block-heading\">Diagnosis of New Cases of COPD<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>spirometry &#8211; an assessment of severity based on % predicted FEV1<\/li>\n\n\n\n<li>chest x-ray\n<ul class=\"wp-block-list\">\n<li>possibility of a new alternate diagnosis<\/li>\n\n\n\n<li>patient responds to treatment<\/li>\n\n\n\n<li>patient condition is worsening<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>body mass index<\/li>\n\n\n\n<li>MRC dyspnoea scale (see below)<\/li>\n\n\n\n<li>exacerbation frequency<\/li>\n\n\n\n<li>alpha 1 antitrypsin deficiency \u2013 should be suspected and referred to respiratory physician if the patient is:\n<ul class=\"wp-block-list\">\n<li>under 45 years old<\/li>\n\n\n\n<li>of Caucasian descent<\/li>\n\n\n\n<li>if family has a history of COPD<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>record comorbidity.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table border=\"1\"><tbody><tr><td colspan=\"6\"><strong>Medical Research Council (MRC) Breathlessness Scale<\/strong>&nbsp;\u200b \u200b \u200b \u200b \u200b<\/td><\/tr><tr><td><strong>Grade<\/strong><\/td><td>1<\/td><td>2<\/td><td>3<\/td><td>4<\/td><td>5<\/td><\/tr><tr><td><strong>Degree of breathless-ness related to activities<\/strong><\/td><td>Not troubled by breathlessness except on strenuous exercise.<\/td><td>Short of breath when hurrying or walking up a slight hill.<\/td><td>Walks slower than contemporaries on level ground because of breathlessness<br>or has to stop for breath when walking at own pace.<\/td><td>Stops for breath after walking about 100m or after a few minutes on level ground.<\/td><td>Too breathless to leave the house, or breathless when dressing or undressing.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\">Differential diagnosis of COPD<\/h3>\n\n\n\n<p><strong>Asthma<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Onset early in life (often childhood)<\/li>\n\n\n\n<li>Symptoms vary from day to day<\/li>\n\n\n\n<li>Symptoms at night\/early morning<\/li>\n\n\n\n<li>Allergy, rhinitis, and\/or eczema<\/li>\n\n\n\n<li>Family history of asthma<\/li>\n\n\n\n<li>Largely reversible airflow limitation<\/li>\n<\/ul>\n\n\n\n<p><strong>Bronchiectasis<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Large volumes of purulent sputum<\/li>\n\n\n\n<li>Commonly associated with bacterial infection<\/li>\n\n\n\n<li>Coarse crackles on auscultation<\/li>\n\n\n\n<li>CXR\/CT shows bronchial wall thickening<\/li>\n<\/ul>\n\n\n\n<p><strong>Congestive cardiac failure<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Fine basilar crackles on auscultation<\/li>\n\n\n\n<li>CXR shows dilated heart, pulmonary oedema<\/li>\n\n\n\n<li>PFTs show restriction<\/li>\n<\/ul>\n\n\n\n<p><strong>Management is based on<\/strong><a href=\"\/refhelp\/furtherinfo\/Respiratory-Definition-of-COPD-Severity\/\"><\/a><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Respiratory-Definition-of-COPD-Severity.pdf\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>definition of COPD severity<\/strong><\/a><\/li>\n<\/ul>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Indications for hospital assessment or admission for exacerbations of COPD<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Marked increase in intensity of symptoms, such as sudden development of breathlessness at rest<\/li>\n\n\n\n<li>Severe underlying COPD<\/li>\n\n\n\n<li>Onset of new physical signs(e.g. cyanosis, peripheral oedema)<\/li>\n\n\n\n<li>Failure of exacerbation to respond to initial medical management<\/li>\n\n\n\n<li>Significant comorbidities<\/li>\n\n\n\n<li>Frequent exacerbations<\/li>\n\n\n\n<li>Impaired level of consciousness<\/li>\n\n\n\n<li>Confusion<\/li>\n\n\n\n<li>Diagnostic uncertainties<\/li>\n\n\n\n<li>Older age<\/li>\n\n\n\n<li>Insufficient home support<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who to refer:<\/h4>\n\n\n\n<p><strong><\/strong><strong>For confirmation of new cases of COPD, consider referring for Spirometry only (which includes reversibility to salbutamol) using the &#8216;Primary Care Spirometry request&#8217; form in Gateway<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Reason<\/strong><\/td><td><strong>Purpose<\/strong><\/td><\/tr><tr><td>There is diagnostic uncertainty<\/td><td>Confirm diagnosis and optimise therapy<\/td><\/tr><tr><td>Suspected severe COPD<\/td><td>Confirm diagnosis and optimise therapy<\/td><\/tr><tr><td>Onset of cor pulmonale<\/td><td>Confirm diagnosis and optimise therapy<\/td><\/tr><tr><td>Frequent exacerbations (two or more\/year)<\/td><td>Optimise therapy<\/td><\/tr><tr><td>Rapidly progressive course of disease (a rapid decline in FEV1, progressive dyspnoea, decreased exercise tolerance)<\/td><td>Encourage early intervention<\/td><\/tr><tr><td>Assessment for oxygen therapy<\/td><td>Optimise therapy and measure blood gases<\/td><\/tr><tr><td>Assessment for long-term nubuliser therapy<\/td><td>Optimise therapy and exclude inappropriate prescriptions<\/td><\/tr><tr><td>Assessment for oral coticosteroid therapy<\/td><td>Justify need for long-term treatment or supervise withdrawal<\/td><\/tr><tr><td>Bullous lung disease<\/td><td>Identify candidates for surgery<\/td><\/tr><tr><td>Assessment for pulmonary rehabilitation<\/td><td>Identify candidates for pulmonary rehabilitation<\/td><\/tr><tr><td>Assessment for lung volume reduction surgery<\/td><td>Identify candidates for surgery<\/td><\/tr><tr><td>Assessment for lung transplantion<\/td><td>Identify candidates for surgery<\/td><\/tr><tr><td>Dyfunctional breathing<\/td><td>Confirm diagnosis, optimise pharmacotherapy and access other therapies<\/td><\/tr><tr><td>Aged under 40 years or a family history of alpha-1-antitrypsin deficiency<\/td><td>Identify alpha-1 antitrypsin deficiency, consider therapy and screen family<\/td><\/tr><tr><td>Uncertain diagnosis<\/td><td>Make a diagnosis<\/td><\/tr><tr><td>Symptoms disproportionate to lung function deficit<\/td><td>Look for other explanations<\/td><\/tr><tr><td>Frequent infections<\/td><td>Exclude bronchiectasis<\/td><\/tr><tr><td>Haemoptysis<\/td><td>Exclude carcinoma of the bronchus<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>See above<\/li>\n\n\n\n<li>See management advice for patients with stable COPD<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">How to refer:<\/h4>\n\n\n\n<p>Use Sci Gateway for referral to these services.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Royal Infirmary of Edinburgh, Respiratory Medicine Clinics,&nbsp;Spirometry only or respiratory OP clinic&nbsp;<\/li>\n\n\n\n<li>Western General Hospital, Edinburgh, Respiratory Medicine Clinics, Spirometry only or respiratory OP clinic&nbsp;<\/li>\n\n\n\n<li>St. Johns Hospital, Howden, Livingston, Respiratory Medicine Clinics<\/li>\n\n\n\n<li>Leith CTC, Respiratory Medicine Clinics, Spirometry only or respiratory OP clinic&nbsp;<\/li>\n\n\n\n<li>Click here for details about the&nbsp;<a href=\"\/refhelp\/guidelines\/EdinburghCommunityRespiratoryTeam\">Edinburgh&nbsp;<\/a><a href=\"\/refhelp\/guidelines\/EdinburghCommunityRespiratoryTeam\" target=\"_blank\" rel=\"noreferrer noopener\">Community Physiotherapy Respiratory Team<\/a><\/li>\n\n\n\n<li>Click here for details about&nbsp;<a href=\"\/refhelp\/guidelines\/MidlothianCommunityRespiratoryTeam\" target=\"_blank\" rel=\"noreferrer noopener\">Midlothian Community Respiratory&nbsp;Team.aspx<\/a><\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h3 class=\"wp-block-heading\"><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Management-of-COPD-exacerbation-in-Primary-Care.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Management-of-COPD-exacerbation-in-Primary-Care.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Protocol for management of COPD exacerbation in primary care<\/a><\/h3>\n\n\n\n<p>Many patients with an exacerbation of COPD can be managed successfully at home.&nbsp; However, there should be a low threshold for emergency admission to hospital for patients with evidence of a severe exacerbation of COPD and for those who do not respond to initial treatment. Decisions about management of a patient with an exacerbation of COPD will vary depending on the patient&#8217;s individual circumstances including the severity of their underlying disease, the presence of other medical conditions, and their social situation.<\/p>\n\n\n\n<p>The following algorithm provides guidance for the management of COPD exacerbations in primary care (for use in GP practices and out of hours service).<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"\/files\/sites\/2\/Management-of-COPD-exacerbation-in-primarycare.jpg\" alt=\"Management of COPD exacerbation in primarycare.jpg\" \/><figcaption class=\"wp-element-caption\">Flowchart Copyright NHS Lothian<\/figcaption><\/figure>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>\u200b<a href=\"\/refhelp\/guidelines\/IMProvedAnticipatoryCareandTreatmentIMPACT\" target=\"_blank\" rel=\"noreferrer noopener\">IMProved Anticipatory Care and Treatment<\/a>&nbsp;<\/p>\n\n\n\n<p><a rel=\"noreferrer noopener\" href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/fitforhealth-physicalactivity\/\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/fitforhealth-physicalactivity\/\" target=\"_blank\">Fit for Health &#8211; information for patients and clinicians <\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Respiratory-Community-Respiratory-Team-Poster-frm-Intranet-Sep18.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Respiratory &#8211; Community Respiratory Team &#8211; Poster frm Intranet Sep18<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Respiratory-Lothian-COPD-Guidance-April-2018-v0-4-Combined-2-1.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Respiratory-Lothian-COPD-Guidance-April-2018-v0-4-Combined-2-1.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Respiratory -Lothian COPD Guidance April 2018 v0 4 Combined (2)<\/a><\/p>\n\n\n\n<p><a rel=\"noreferrer noopener\" href=\"https:\/\/www.nice.org.uk\/guidance\/NG115\" data-type=\"URL\" data-id=\"https:\/\/www.nice.org.uk\/guidance\/NG115\" target=\"_blank\">NICE guideline NG115 on COPD<\/a> <\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Diagnosis of New Cases of COPD Medical Research Council (MRC) Breathlessness Scale&nbsp;&#8203; &#8203; &#8203; &#8203; &#8203; Grade 1 2 3 4 5 Degree of breathless-ness related to activities Not troubled by breathlessness except on strenuous exercise. Short of breath when hurrying or walking up a slight hill. Walks slower than contemporaries on level ground because<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":4381,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[593],"class_list":["post-3792","page","type-page","status-publish","hentry","category-chronicobstructivepulmonarydisease"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/respiratory\/chronicobstructivepulmonarydisease\/\" rel=\"tag\">Chronic Obstructive Pulmonary Disease<\/a>","rttpg_excerpt":"Diagnosis of New Cases of COPD Medical Research Council (MRC) Breathlessness Scale&nbsp;&#8203; &#8203; &#8203; &#8203; &#8203; Grade 1 2 3 4 5 Degree of breathless-ness related to activities Not troubled by breathlessness except on strenuous exercise. Short of breath when hurrying or walking up a slight hill. Walks slower than contemporaries on level ground because","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3792","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=3792"}],"version-history":[{"count":12,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3792\/revisions"}],"predecessor-version":[{"id":20257,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3792\/revisions\/20257"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4381"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=3792"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=3792"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}