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Management of COPD
Salbutamol MDI 100mcg
Salbutamol MDI 100mcg
Ipratropium MDI 20mcg
Ipratropium MDI 20mcg
Tiotropium Handihaler 18mcg (1 capsule) inhaled
Tiotropium Handihaler 18mcg (1 capsule) inhaled
daily OR Tiotropium Respimat 2.5mcg/dose TWO
daily OR Tiotropium Respimat 2.5mcg/dose TWO
(Stop Ipratropium but continue with Salbutamol prn) (Stop Ipratropium but continue with Salbutamol prn) Salmeterol 25mcg inhaler 2 puffs bd or
Seretide 500 Accuhaler ONE puff bd or
Salmeterol 50mcg Accuhaler 1 puff bd or Formoterol
Symbicort Turbohaler 12/400 ONE puff bd or
12mcg/dose 1 puff bd and increase to 2 puffs bd if
Symbicort 6/200 TWO puffs bd
(These are the only preparations currently licensed in
Consider Pulmonary Rehab. If MRC score 3-5 and on optimal medication
Medicine Review to be arranged;
Arrange review depending on COPD severity and risk rating Check adherence (compliance) with all prescribed medicines Check inhaler technique & concordance regularly & use a spacer where possible Review symptom control, number of COPD exacerbations in last 12/12 Measurement / basic data
Frequent Exacerbations
Is the treatment working?
FEV1 absolute & % predicted
Check for co morbidities
Cardiac failure / IHD (consider beta blockers in this case as they reduce death rates by 30% in COPD  <20 increased mortality – nutritional advice  >35 consider also sleep apnoea Consider unusual organism
Taking lots of medicines is difficult, so if Check for Acid-Fast Bacillus (AFB), Pseudomonas there is no benefit from a new treatment – it 2 saturation
Exacerbation Frequency
Consider wrong diagnosis?
 Frequent exacerbation need a treatment and diagnostic review If the treatment is not working review the MRC dysnoea score
Score of 3, 4, 5 refer to pulmonary rehabilitation Advise to stop and active referral to smoking cessation services Consider adherence to therapy
Check inhaler technique
Triple therapy (LABA +LAMA + ICS) - Triple therapy for exceptional use only
Undertake diagnostic review before commencing triple therapy. It remains unclear whether there is benefit from using triple combination of two long acting
bronchodilators and corticosteroid. Use only in severe disease in the presence of persistent exacerbations despite other treatment. (NICE 2010)
If no clinical benefit after 2 months STOP one of the drugs.
Side effects
Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated with high dose (particularly at the
2000microgram beclomethasone or equivalent dose) inhaled corticosteroids and be prepared to discuss with patients
Smoking - Stopping smoking remains the most effective treatment
Offer help to stop smoking at every opportunity
Combine pharmacotherapy with appropriate support as part of a programme
Mucolytics
Mucolytic drug therapy should be considered on patients with a chronic cough productive of sputum
Mucolytic therapy should be continued if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production)
Do not routinely use mucolytics to prevent exacerbations in people with stable COPD but they can be considered instead of inhaled corticosteroids
Theophylline
Offer only after inhaler therapy has been optimised. Caution with interactions
Reference:
NICE Guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care, Clinic Guidance 101 Version 1: September 2012
Derbyshire Guidelines
Review: September 2013

Source: http://www.peninsulacommunityhealth.co.uk/Downloads/Services/Repiratory%20Resources/Management%20of%20COPD%20Guidlines.pdf