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Chronic Obstructive Pulmonary Disease – Spirometry

  

Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, emphysema and chronic obstructive airways disease.


Spirometry Update

Interim Spirometry Service Post Covid

Coventry Community COPD Service is currently providing an interim spirometry service whilst usual primary care spirometry services are interrupted

See below for details

Area Prescribing Committee COPD Guidance

Follow link for local prescribing guidance (Jan 2021)

Management Principles

Diagnosis of COPD

Consider in any patient who has dyspnoea, chronic cough or sputum production, a history of recurrent lower respiratory tract infections and/or a history of exposure to risk factors for the disease.

Requires the presence of irreversible airways obstruction; if unable to perform effective spirometry reconsider diagnosis & refer to secondary care

Airflow obstruction is defined as reduced FEV1/FVC ratio (<0.70). This must persist after administration of bronchodilators. No longer necessary to have an FEV1 <80% predicted for definition of airflow obstruction

If FEV1 is >80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms e.g. breathlessness or cough

If the FEV1 improves markedly over time, with treatment or spontaneously, the diagnosis of COPD must be reconsidered, provided all the FEV1 measurements are reliable and taken in the clinically stable state (ie not during a exacerbation)

Consider alternative diagnosis (a fifth of all people on COPD registers do not have a diagnosis of COPD). Exclude diagnosis of asthma (variable chest tightness, wheeze, cough and breathlessness; night-time waking; significant diurnal variation of symptoms and peak expiratory flow; symptoms related to work; normalisation of spirometry after inhaled beta2 agonist or inhaled/oral corticosteroid course)

Ensure other investigations including Chest X Ray, Full Blood Count (to identify anaemia & polycythaemia) are performed and reviewed

Treatments and plans should be revisited and assessed at every review

Practice Points:

Check for other co-existing conditions, for example, cardiac failure, bronchiectasis (consider HRCT chest), ischaemic heart disease, lung cancer, cor-pulmonale, anxiety and depression then manage appropriately

Offer treatment and support to stop smoking

Consider pharmacological treatment as per GOLD 2021 – Is the patient adherent to their treatments? Ask the patient and check prescription refill records – Can the patient use their inhalers correctly?

Optimise inhaled therapy as per GOLD 2021

Give general self management advice & co-develop a personalised self-management plan

Refer for dietetic advice if Body Mass Index (BMI) <20 or >25 kg/m2 or changing over time

Offer pneumococcal vaccine, annual Influenza vaccine and pulmonary rehabilitation (PR) if indicated

Smoking Cessation

Smoking cessation services are delivered in GP surgeries and also by other providers (Any Qualified Provider).

Pulmonary rehabilitation

Does your patient have a confirmed diagnosis of COPD? Would they benefit from pulmonary rehab? Sessions are held at Atrium Health, Unit 1 Watch Close (off Spon Street), Coventry, CV1 3LN.

Available for patients across Coventry & Rugby (but transport is not available from Rugby)

Helps the patients:

  • Feel less breathless and understand condition better
  • Improve confidence and coping strategies
  • Help recognise and cope with chest infections
  • Learn about drugs and inhalers and ensure they are working
  • Improve walking distance and stamina

The class runs on Monday and Thursday afternoons, 13:30-15:30. Most patients attend twice per week but there is some flexibility.

It is run in small groups and each session is split into 2 parts:

13:30—Informal discussions/talks on a variety of topics to help you learn more about your lungs, breathing, and treatment.

14:30—Exercise in a safe environment with health professionals on hand to help.

Atrium has started a Vascular and a Heart Failure Group offering a more functional, strength and balanced based class for more significantly disabled patients

Referral Forms

The Pulmonary Rehab referral form is available to download – see link right. Referrals cannot be accepted without a confirmed COPD diagnosis; full referral criteria are explained on the form. Completed forms are to be emailed to uhc-tr.covprreferrals@nhs.net

Please ensure practice nurses are aware of this service.

Oxygen

Please visit the GP Gateway Oxygen page for more information.

Management of Exacerbations

Assessment:

If an acute exacerbation is suspected, assess its severity

Features suggestive of an acute exacerbation include:

  • Worsening breathlessness
  • Increased sputum volume and purulence
  • Cough
  • Wheeze
  • Fever without an obvious source
  • Upper respiratory tract infection in the past 5 days
  • Increased respiratory rate or heart rate increase 20% over baseline

A severe exacerbation may be suggested by:

  • Marked breathlessness and tachypnoea
  • Pursed-lip breathing and/or use of accessory muscles at rest
  • New-onset cyanosis or peripheral oedema
  • Acute confusion or drowsiness
  • Marked reduction in activities of daily living.

Consider the need for hospital admission.

Consider other causes of symptoms (such as myocardial infarction, worsening heart failure, pulmonary embolus and pneumonia).

Management:

If admission is not indicated, advise the person to increase the doses or frequency of short-acting bronchodilators (not exceeding the maximum dose).

If there are no contraindications, consider oral corticosteroids for people with a significant increase in breathlessness that interferes with daily activities

Offer 30 mg (NICE) – 40mg (GOLD) oral prednisolone once daily for 5 days – discuss adverse effects of prolonged therapy.

Do not send sputum samples for culture routinely

Follow link right for full document

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Coventry Guidance  

Coventry Community COPD Service

Interim Spirometry Service Post Covid

Coventry Community COPD Service is currently providing an interim spirometry service whilst usual primary care spirometry services are interrupted

This service is for Coventry patients only

Referral criteria for diagnostic spirometry with the Community COPD service

SUSPICIOUS OF COPD

Essential criteria:

  • Age 35 and over
  • History of smoking or current smoker
  • Chronic breathlessness/exertional breathlessness

Additional symptoms:

  • Chronic cough
  • Regular sputum production
  • Frequent ‘winter’ bronchitis

If symptoms of CCF such as peripheral oedema are present, please do a BNP to rule this out before referring to the COPD service.

SUSPICIOUS OF ASTHMA

  • Recurrent episodes of symptoms including; wheeze, cough breathlessness and chest tightness
  • Symptom variability
  • Absence of symptoms of an alternative diagnosis
  • Personal history of atopy
  • Historical record of Eosinophils

PRIORITY PATIENTS

  • Patients whom diagnostic spirometry will impact their treatment pathway (ask the question would spirometry alter diagnosis or treatment?)
  • Patients awaiting referrals or rejected referrals to COPD, Pulmonary rehab or respiratory services due to lack of spirometry
  • Patients with a provisional diagnosis but poor response to treatment

Referrals to COPD Service:

Patients registered with a Coventry GP with a confirmed diagnosis of COPD.

Referrals may be appropriate at ALL stages of the disease when clinically indicated and / or where specialist advice is required.

Referrals are accepted for patients with COPD in both a stable phase and during acute exacerbation (see Acute Exacerbation of COPD Pathway for referral criteria).

We offer both clinic-based and domiciliary assessment as required.

The following information is required when referring a patient:

  • Spirometry (graph desirable)
  • Most recent Chest X-Ray
  • Past medical history
  • Current medication (including oxygen)
  • Full Blood Count

For queries, please contact the Community COPD Service directly.

Contact: 02476 237005

Jodie Storrow, Lead Nurse / Advanced Clinical Practitioner

Dr J. Bhat, Consultant in Respiratory Medicine

This service is available on the NHS eReferral Service. Specialty: Respiratory Medicine Clinic Type: COPD. The service is setup as a Referral Assessment Service, so all referrals will be reviewed before an appointment is allocated.

Acute Exacerbation COPD – Community Pathway

The Community COPD service is available to support primary care in the management of COPD patients during an acute exacerbation.

Rapid access to specialist opinion for patients at home suffering an acute exacerbation of COPD preventing avoidable hospital admissions.

It is expected that referrals to this service will be from the patient’s GP and that patients will have been reviewed by their GP during this exacerbation to confirm the diagnosis

Referrals:

Availability Monday-Friday 9-5pm

Contact: 02476237005  – GP to discuss with the COPD team.

Outcome:

The Community COPD service will assess patients (in clinic or at home) and will provide either;

  • Management plan and transfer patient care back to referring GP
  • Management plan and share care with the patient’s GP until the patient is stable
  • Admit patient to hospital for further assessment if required

Please note: restricted to individuals with an established diagnosis of COPD (i.e. not first presentation) with an acute exacerbation.

Exclusions: Chest pain, Pneumonia, Pulmonary Embolus, Cardiac Failure etc.

Rugby Guidance  
SINGING FOR LUNG HEALTH

Breathe Arts Health Research are commissioned to deliver singing groups for adults with chronic respiratory conditions.

This will consist of 6-week courses led by an experienced singing specialist.

https://breatheahr.org/breathe-sing/

Current Activity: Breathe Arts Health Research have recently delivered a taster session for interested stakeholders.

A steering group has also been set up. Looking Ahead: Planned activity will be the start of the first Singing for Lung Health 10-week programme in June 2021.

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