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

Cardio-Respiratory Unit Direct Access Spirometry Service (North Warwickshire Patients Only)

The Cardio-Respiratory Unit will provide an auxiliary spirometry service for community based spirometry.

This service will be provided with the aim of addressing the current backlog of patients waiting for community spirometry testing. \The backlog has been generated due to a temporary cessation of community spirometry services during the COVID-19 pandemic. This will be a short term diagnostic service, only, and will not be linked to medical review.

The use of quality assured spirometry will aid diagnosis of a range of respiratory conditions including obstructive lung disease (COPD/ Asthma) and restrictive lung disease.

It is also used to quantify the severity and or progression of disease. A diagnosis of lung disease cannot be made by spirometry alone and should be reviewed alongside patient history and / or further testing such as chest x-ray, blood etc.

Referral (North Warwickshire patients only)

Triage process

Patients identified for spirometry testing are to be considered on a case by case basis and should be reviewed to ensure spirometry is necessary and likely to either:-

Patients awaiting spirometry must be triaged and referred into the Cardio-Respiratory Unit in order of priority. This must be performed by an appropriate referrer.
Patients may be triaged by priority using the following criterion:

• Criteria 1. Aid to diagnose
• Criteria 2. Commenced onto new treatment
• Criteria 3. Routine review

Referrals to be made using the Cardio-Respiratory Unit Spirometry Direct access referral form (see referral link right).

There are two types of investigation that can be requested, spirometry and bronchodilator response (see service provision for details).

Failure to correctly complete a referral form may result a delay in an appointment or cancellation of the referral.

If requesting a bronchodilator response study the form must be signed by a prescribing physician, if not then spirometry alone will be performed as physiologists are, currently not prescribers, and must work under a PGD policy.

Update: April 2023 The GEH spirometry service are receiving an increasing number of referral requests for spirometry with bronchodilator response that are not completed appropriately.

A medical or non-medical prescriber is required to sign the prescription on the request form in order for the physiology team to administer the bronchodilator drug.

Failure to complete this section fully will result in a delay of patient appointment or repeated tests being performed unnecessarily

Referral

Emailing form to: Respiratory.Physiologists@geh.nhs.uk

Service provision

Location:  Cardio- Respiratory Unit where there is fully equipped pulmonary function rooms fit for purpose.

Staffing: The service will be staffed by members of the GEH Cardio-Respiratory team who are fully qualified in the performance and interpretation of spirometry testing.

Testing and results: Patients will be contacted by letter and phone to inform them of their appointment for spirometry testing. Patients will be pre-screened at this time to ensure they have no current symptoms of COVID 19. They will be advised to contact the department, prior to their appointment, should their status change. Symptom questioning is to be repeated on arrival for testing. Patients who have been asked to isolate will be offered an alternative appointment.

Spirometry Testing: Spirometry will be performed to ARTP standards and provide the measurements of slow vital capacity (SVC), forced expiratory volume (FEV1), forced vital capacity (FVC) and peak flow (PEF) along with a graphical display of a flow volume loop.

If a bronchodilator response is required this will be performed to Salbutamol 400mcg via MDI and spacer device. Post bronchodilator spirometry results will include FEV1, FVC and PEF. Results will be provided in a digital format and including table of results, flow volume loop graph and an interpretation of results.

Results: will be returned to the referrer via the DOCMAN platform, paper copies will not be sent unless specifically requested individually via the electronic referral

Pulmonary Rehabilitation and Respiratory Physio (North Warwickshire)