A. Patient with Established Diagnosis of COPD - Chronic obstructive pulmonary disease (COPD) is defined by the American Thoracic Society (ATS) in Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease (1995). Further detail on lung function testing is found in another ATS publication (1991).

1. Definitions 


a. Chronic obstructive pulmonary disease (COPD) is a disorder characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperreactivity, and may be partially reversible.

b. Chronic bronchitis is defined as the presence of chronic productive cough for 3 months of each of two successive years in a patient in whom other causes of chronic cough have been excluded.

c. Emphysema is defined as abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

d. Asthma is by definition associated with reversible airflow obstruction. Patients with asthma whose airflow obstruction is completely reversible are not considered to have COPD. The obstruction in many patients with COPD may include a significant reversible component. Some patients with asthma may develop irreversible airflow obstruction indistinguishable from COPD.

B. Perform Clinical Assessment, History, Physical Examination, Lab Tests, and Spirometry

1. History 


a. Smoking - Age at initiation, quantity smoked per day, whether or not still smoker and if not, date of cessation

b. Environmental (chronological) - May disclose important risk factors

c. Cough (chronic, productive) - Frequency and duration, whether or not productive (especially on awakening)

d. Wheezing

e. Acute chest illnesses - Frequency, productive cough, wheezing, dyspnea, fever

f. Dyspnea

 

2. Physical Examination of Chest 



a. Airflow obstruction evidenced by:
• Wheezing during auscultation on slow or forced breathing
• Forced expiration time of more than 6 seconds
 

b. Severe emphysema indicated by:

• Overdistention of lungs in stable state, low diaphragmatic position
• Decreased intensity of breath and heart sounds
 

c. Severe disease suggested by (characteristics not diagnostic):

• Pursed-lip breathing
• Use of accessory respiratory muscles
• Indrawing of lower interspaces
 

3. Other - Unusual positions to relieve dyspnea at rest, digital clubbing (suggests possibility of lung cancer or bronchiectasis), and mild dependent edema that may be seen in absence of right heart failure

4. Laboratory 



a. Chest radiographyDiagnostic only of severe emphysema but essential to exclude other lung diseases

b. Spirometry (pre- and postbronchodilation)Essential to confirm presence and reversibility of airflow obstruction and to quantify maximum level of ventilatory function (ATS 1995)

c. Lung volumesMeasurement of more than forced vital capacity is not necessary except in special circumstances (e.g., presence of giant bullae)

d. Carbon monoxide diffusing capacityUnnecessary except in special instances (e.g., dyspnea out of proportion to severity of airflow limitation)

e. Arterial blood gases are not needed in staged mild disease, but remain the standard for determining the need for oxygen therapy

f. Alpha₁-antitrypsin (AAT)AAT deficiency accounts for less than 1 percent of COPD. Obtain a serum AAT level to screen for AAT deficiency in the following situations:

• Chronic bronchitis with airflow obstruction in a never smoker
  
  
• Bronchiectasis, especially in the absence of clear risk factors for the disease
  
  
• Premature onset of COPD with moderate or severe impairment before age 50
  
  
• A predominance of basilar emphysema; development of unremitting asthma, especially in a patient under age 50
  
  
• A family history of AAT deficiency or of COPD onset before age 50
  
  
• Cirrhosis without apparent risk factors (ATS 1995). If diagnosis of COPD or asthma is made, refer to specialist for recommendations for therapy.

D. Acute Exacerbation of COPD - Acute exacerbation is defined as a recent deterioration of the patient's clinical and functional state that is due to worsening of their COPD. Typical symptoms and signs of COPD exacerbation are listed below (adapted from the European Respiratory Society Consensus Statement, Siafakas 1995).

• Worsening dyspnea, sometimes at rest
• Increased cough
• Increased sputum production, often with change in character from mucoid to purulent
• Development or increase in wheezing
• Loss of energy
• Fever
• Increased respiratory rate
• Tachycardia
• Increased cyanosis
• Use of accessory muscles
• Peripheral edema
• Loss of alertness
• Worsening airflow obstruction by FEV₁ or peak expiratory flow rate
• Worsening of arterial blood gases or pulse oximetry O₂ saturation.

E. Are Symptoms Optimal for Patient Since Last Visit (Symptoms on Usual Daily Activities)? - Client may exhibit symptoms of dyspnea and/or wheezing. Dyspnea may be at rest or disproportionate to the degree of breathlessness expected for a given activity.

F. Does Patient Have Symptoms of Apnea?

Symptoms of sleep apnea include:
• Excessive daytime sleepiness
• Interferes with activities of daily living
• Heavy snoring
• Observed apnea during sleep
• Choking during sleep
• Morning headaches
• Memory loss
• Cardiac arrhythmias during sleep
• Unexplained impotence

1. Smoking Cessation - All smokers should be strongly advised to quit. Smoking cessation results in a small improvement in lung function and a slowing of the rate of decline to approximately that seen in never smokers of the same age. Patients not willing to quit should receive a motivational intervention to promote subsequent quitting attempts. The smoker willing to make a quit attempt should be assisted by being asked to set a quit date, providing self-help materials, encouraging nicotine replacement therapy, and referring to intensive treatments when appropriate. All patients attempting to quit should have follow-up contact scheduled. (For additional details, See Module D, Collaborative Self-Management for patients with Asthma/COPD, and see also DHHS Guidelines on Smoking Cessation 1996, Agency for Health Care Policy and Research Centers for Disease Control and Prevention 1996).

2. Pneumoccocal Vaccination is Recommended - The Advisory Committee on Immunization Practices (CDC 1997) recommends vaccination for all patients with COPD and emphysema. Patients age less than 65 who were vaccinated or more than 5 years previously should be revaccinated. When the status of previous vaccination is unsure, vaccination is indicated.

However, the evidence for the efficacy of pneumococcal vaccination in patients with COPD is inconclusive. One small randomized controlled trial failed to demonstrate vaccine efficacy for pneumococcal infection-related or other medical outcomes in the heterogeneous group of subjects labeled as high-risk. Case-controlled trials suggest an effectiveness of 65 to 84 percent among high-risk patients that have included those with COPD.

3. Annual Influenza Vaccination - Annual influenza vaccination is recommended for individuals with chronic pulmonary disease unless contraindications due to severe anaphylactic hypersensitivity to egg protein. Influenza vaccination has been shown to be 30 to 80 percent effective in preventing illness, complications, and death in high-risk populations. Pneumococcal and influenza vaccines can be administered concurrently at different sites without increasing side effects.

Patients with COPD should avoid environmental exposures that exacerbate their symptoms (e.g., occupational exposures, second-hand smoke, air pollution).

4. Nutritional Counseling--Should include good dietary habits and encourage weight to approximate ideal body weight. If malnourished, attempts should be made to restore nutritional balance with several small meals a day to help maintain caloric needs but avoid undue dyspnea. Forced nutrition or special diets are not recommend.

5. Pulmonary Rehabilitation--Referrals are indicated in patients on optimal medical therapy and who:

1. Continue to display severe respiratory symptoms, including dyspnea
2. Have had several emergency room or hospital admissions per year
3. Exhibit limited functional status, restricting activities of daily living
4. Experience impairment in quality of life.

H. Be Aware of Precautions and Recommendations for Use of Medications and Aerosols

1. Precautions when Using Inhaled Beta2-Agonist 


a. Watch for nonimprovement or paradoxical deterioration with aerosol use.

b. Use spacers to improve compliance.

c. Avoid overuse; check number of metered dose inhalers (MDIs) used per month against number of puffs per MDI (200 to 300+, depending on brand).

d. Instruct client on maximum number of puffs per day (usually 8 to 12) and on number allowed during an exacerbation (e.g., 12 to 24 over 3 to 4 hours) before additional intervention is required.

e. If a long-acting agent is used, caution client that frequent use must be avoided.

f. Home updraft nebulizers with inhalant solutions providing large dosages are rarely needed.



2. Precautions when Using Theophylline 


a. Initiate treatment with a low dose (e.g., 400 mg/day) and adjust after a few days.

b. Reduce dosage if drug clearance is likely to be impaired because of illness, liver malfunction, or concomitant drugs.

c. Do not allow any additional theophylline preparation to be taken.

d. Drug must be taken at the same time each day with respect to meals.

e. When symptoms change, acute illness develops, new drugs are added, or symptoms suggestive of toxicity develop, check serum level of theophylline.

f. Aim for a serum level of 5 to 12 g/ml; adjust dosage and follow serum level when indicated.



3. Precautions when Using Ipratropium 


a. Clients should generally use a spacer and should avoid spraying into eyes.

b. Be prepared to increase dose if necessary from 2 to 3 puffs 3 to 4 times a day to 6 to 8 puffs 3 to 4 times a day, if tolerated.

c. Caution client that onset of effect is relatively slow; additional doses should not be taken for acute symptom relief.

d. Monitor for side effects, e.g., tachycardia, dry mouth, glaucoma, prostatism, or bladder neck obstruction.

 
4. Precautions when Using Oral Steroids 


a. Reduce dosage to lowest effective daily dose or to alternate-day dosing as quickly as symptoms allow.

b. Monitor for hypertension, diabetes, weight gain, mental changes, infections, central polar cataracts, skin thinning, purpura, osteoporosis, and osteonecrosis.

c. Distinguish psychological benefit from true pulmonary benefit by following forced expiratory volume in 1 second (FEV₁) for 2 weeks after initiating therapy.

d. Administer prophylactic calcium therapy to women; treat osteoporosis appropriately.

e. Steroid-dependent clients require steroid coverage during any crisis for many months after stopping steroids.

f. Repeatedly evaluate client to determine whether steroid therapy can be discontinued.



5. Precautions when Using Aerosol Steroids 


a. Seek objective evidence of the value of this therapy, because its use may decrease compliance with other aerosol usage.

b. Use a spacer; monitor for oral thrush and laryngeal dysfunction.

c. Be aware that aerosol steroid side effects may occur in skin, bone, etc.

d. When introducing aerosol steroids in a client on an oral steroid, wean slowly off the oral drug.

6. Recommendation - The fewest inhalers with the fewest inhalations at the least frequent interval consistent with a client's inhaler needs should be used to improve compliance. A similar principle applies to oral medications.

7. Recommendation - MDI with, if necessary, a spacer is preferred unless not recommended by manufacturer; a hand-held nebulizer should be used only if client unable to use an MDI.

Nebulizers generally require between 2 and 12 times as much inhaled beta2-agonist to produce the same effect as an MDI, depending on the nebulizer used. Adherence with nebulizers is similar to that with MDI. There is no obvious advantage in using a nebulizer in a stable COPD client who can properly use an MDI.