Chronic obstructive pulmonary disease. Family physicians' role in management.

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750 Canadian Family Physician • Le Médecin de famille canadien dVOL 50: MAY • MAI 2004

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Surveillance médicale Chronic obstructive pulmonary disease

Family physicians’ role in management

Alan Kaplan, ^MD, ^CCFP⁽^EM⁾

W

ith the release of new Canadian Chronic Obstructive Pulmonary Disease (COPD) Guidelines, I thought it would be helpful to describe family physicians’ role in oﬃ ce management of this common disease. Th e guidelines can be found in their entirety at http://www.pulsus.

com/Respir/10_SA/supp_A_master.pdf.

The prevalence of COPD is increasing. It is currently the fifth most common cause of death;

by 2020, it will rise to third.¹ It is a frequent cause of disability and lost years of productiv- ity. The largest costs incurred in COPD are for hospital admissions

a n d e m e r g e n c y care. Family physicians can inter- vene in this disease to reduce morbid- ity and effectively manage care.

Deﬁ nition

Chronic obstructive pulmonary disease is a respiratory dis- order, largely caused by smoking, that is characterized by pro- gressive, partially reversible airway obstruction, systemic manifestations, and exacerbations that increase in frequency and severity.

Screening

Family physicians are well situated to identify and diagnose COPD. Screening smokers has been proven eﬀ ective.² If physicians could identify the smokers at highest risk of COPD, those who are rapdily losing lung function (thought to be about 20% of smokers who smoke 20 packs a year), and get them to stop smoking, huge costs would be avoided. Smoking cessation at any age will beneﬁ t patients, however (Figure 1), and is the only inter- vention that has been proven to delay or halt progression of COPD.

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Figure 1. Eﬀ ects of smoking and stopping smoking on forced expiratory volume in 1 second (FEV₁)

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Diagnosis

Diagnosis of COPD is made through spirometry.

Diagnosis requires a postbronchodilator FEV₁/FVC of < 0.7 and a FEV₁ predicted at <80%. A 30-second COPD test has been developed by researchers in Ottawa, Ont. If patients answer yes to the following ﬁ ve questions, they likely have COPD.

• Do you smoke currently or have you smoked cigarettes?

• Do you cough regularly?

• Do you bring up mucous regularly?

• Do even simple chores make you breathless?

• Do you get frequent colds that persist longer than those of other people you know?

Goals of management

Canada’s new COPD guidelines^3,4 aim:

• to prevent disease progression (smoking cessation),

• to alleviate breathlessness and other respiratory symptoms,

• to improve exercise tolerance,

• to prevent and treat exacerbations,

• to improve health status, and

• to reduce mortality.

Assessing severity

Severity of COPD can be assessed on a symp- tom scale or by measuring lung function.

Figure 2 shows the Medical Research Council’s dyspnea scale⁵ that classiﬁ es severity based on patients’ symptoms. Th is scale is user-friendly

for family physicians. Previous guidelines classiﬁ ed disease based on spirometric measurements of lung function alone. Table 1⁴ shows classiﬁ cation of COPD by symptoms and disability.

Pharmacologic therapy

Th erapy depends on symptoms and disease severity. Begin with short-acting bronchodilators (such as salbutamol, terbutaline, ipratropium, or a salbutamol-ipratropium combination) as needed, but once they are being used regularly, add long-acting bronchodilators (Figure 3⁴). Tiotropium (a long-acting anticholinergic drug) and long-acting β₂-agonists, such as salmeterol or formoterol, are current choices.

Inhaled corticosteroids are indicated if patients respond well to steroids or have poor lung function and have frequent exacerbations.

Table 1. Classiﬁ cation of chronic obstructive pulmonary disease (COPD) by symptoms and signs

STAGE OF DISEASE SYMPTOMS AND SIGNS

At risk* Asymptomatic smoker, former smoker, chronic cough and sputum with postbronchodilator FEV₁/FVC of ≥0.7 or FEV₁ 80% predicted Mild Shortness of breath from COPD with strenuous exercise, when hurrying on level ground, or when walking up a slight hill (Grade 1-2) Moderate Shortness of breath from COPD causing patient to walk slower than people of same age on level ground or stop after walking about 1000 m

(or after a few minutes) on level ground (Grade 3-4)

Severe Shortness of breath from COPD leaving patient too breathless to leave the house or breathless after dressing or undressing (Grade 5), chronic respiratory failure, or clinical signs of right heart failure

FEV₁—forced expiratory volume in 1 sec, FVC—forced vital capacity

*Patient does not yet fulﬁ ll criteria for diagnosis of COPD.

Adapted from O’Donnell et al.⁴

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Figure 2. Assessing disability in patients with chronic obstructive pulmonary disease using the Medical Research Council dyspnea scale⁵

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Patients who respond to steroid therapy

Patients with continuing symptoms, who are not smoking and are optimally treated with bronchodilators, can be challenged with either 30-mg/d of prednisone for 2 weeks or 500 µg of ﬂ uticasone or equivalent twice daily for 3 months. If repeat FEV₁ testing shows a 20% improvement with at least 180 mL, patients are deﬁ ned as steroid responders.

The ISOLDE⁶ trial showed that people with moderate-to-severe COPD who used 500 µg of ﬂ uticasone twice daily had fewer and milder exacerbations. Th us, physicians can consider adding inhaled steroids to the daily regimen of patients with moderate- to-severe COPD and recurrent exacerbations, even if they do not respond to steroids.

Nonpharmacologic therapy

Nutrition. Patients who are under- nourished have a much poorer prognosis with COPD. Th ey have less muscle mass, less ability to clear secretions, and less resistance to exacerbations than well nourished people. Th ey have been working so hard to breathe they have

depleted their reserves. Nutritional supplements and sufficient protein intake will help these patients.

Pulmonary rehabilitation. Formalized therapy has been shown to:

• improve and maintain skeletal and respiratory muscles,

• increase endurance during exertion,

• lessen dyspnea,

• aid in clearance of secretions

• decrease hospitalizations during exacerbations, and

• encourage patients to stay active mentally and physically.

Even if there are no formal programs in your area, exercise and muscle training have these beneﬁ ts.

Surgery. Surgical treatments for severe disease, such as lung transplants and lung reduction surgery, have been used with some success. Th e justiﬁ - cation is that, because large bullae might not allow the rest of the lung to expand and function prop- erly, removing the bullae will improve the function of the rest of the lung.

Oxygen

Th e only thing that has been shown to decrease mortality in COPD is long-term oxygen therapy. Level I, grade A support for domiciliary oxygen is admin- istration 15 hours or more daily to achieve oxygen saturation of ≥ 90% for stable COPD patients with severe hypoxemia (PaO₂ ≤ 55 mm Hg) or for patients with hypoxia at PaO₂≤ 60 mm Hg plus ankle edema and cor pulmonale or hematocrit at ≥ 56%.

Prevention and treatment of exacerbations

Inhaled steroids and tiotropium have been shown to decrease depleted their reserves. Nutritional supplements and sufficient protein intake will help these patients.

Pulmonary rehabilitation therapy has been shown to:

• improve and maintain skeletal and respiratory muscles,

• increase endurance during exertion,

• lessen dyspnea,

• aid in clearance of secretions

• decrease hospitalizations during exacerbations, and

• encourage patients to stay active mentally and physically.

Even if there are no formal programs in your area, exercise and muscle training have these beneﬁ ts.

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Figure 3. Pharmacotherapy for patients with chronic obstructive pulmonary disease

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VOL 50: MAY • MAI 2004d Canadian Family Physician • Le Médecin de famille canadien 755 exacerbations. Inﬂuenza and pneumococcal vac-

cination are also key strategies in prevention of exacerbations.

Once an exacerbation occurs, administer anti- biotics. If patients have increased sputum, sputum purulence, and fever with increased shortness of breath, they likely have a bacterial infection. Choice of antibiotic depends on severity of illness, comor- bidities, and antibiotic exposure. Physicians should increase bronchodilator dosage, assess oxygenation, and prescribe a short course of systemic steroids for all but the mildest exacerbations.

Conclusion

Suspect COPD, screen for it with spirometry, and make the diagnosis. Early diagnosis can markedly change prognosis, quality of life, and outcome.

Increase your eﬀorts to get patients to stop smoking. Ensure patients have adequate immunization, nutrition, and rehabilitation. Medication can help;

treatment regimens are more eﬀective with long- acting bronchodilators. Family physicians are the cornerstone of the Canadian health care system; we can make a diﬀerence for patients with COPD.

Dr Kaplan is a family physician and emergency physician in Richmond Hill, Ont. He is Chair of the Family Physician Airways Group of Canada (FPAGC).

Information on the FPAGC can be found on their website at http://www.fpagc.com/.

References

1. Murray CJ, Lopez AD. Alternate projections of mortality and disability by cause 1990-2020:

global burden of disease study. Lancet 1997;349:1498-504.

2. Van den Boom G, van Schayck CP, van Mollen MP, Tirimanna PR, den Otter JJ, van Grunsven PM, et al. Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program.

Am J Respir Crit Care Med 1998;158:1730-8.

3. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS, GOLD Scientiﬁc Committee.

Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001;163:1256-76.

4. O’Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk D, Balter M, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2003. Can Respir J 2003;10(Suppl A):11A-65A.

5. Fletcher CM, Elmes PC, Wood CH. The signiﬁcance of respiratory symptoms and diagnosis of chronic bronchitis in a working population. BMJ 1959;1:257-66.

6. Burge PS, Calverley PMA, Jones PW, Spencer S, Anderson JA, Maslen TK. Randomised, double blind, placebo controlled study of ﬂuticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial. BMJ 2000;320:1297-303.

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Chronic obstructive pulmonary disease. Family physicians' role in management.

FP Watch

Surveillance médicale Chronic obstructive pulmonary disease

Family physicians’ role in management

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Deﬁ nition

Screening

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Diagnosis

Goals of management

Assessing severity

Pharmacologic therapy

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Patients who respond to steroid therapy

Nonpharmacologic therapy

Oxygen

Prevention and treatment of exacerbations

Conclusion

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