Management of Stable COPD
MID ESSEX LOCALITY
This guideline should only be used in patients where a diagnosis of COPD has been made. Consider diagnosis of
COPD in anyone > 35 and who is a smoker / ex-smoker with any of the following symptoms and no clinical features
of asthma: Spirometry should be done and look for evidence of airways obstruction (FEV1/FVC <0.7)
Chronic cough
Breathlessness on exertion
Regular sputum production
Wheeze
Frequent winter bronchitis
Increasing disease severity
Table 1 In All Patients consider:















Use of self-management plan.
Smoking Cessation should be offered at each opportunity*
Regular review to include Spirometry, inhaler technique and compliance
Annual Flu Vaccination
One off Pneumococcal Vaccination – as per green book guidelines
Review the effectiveness of treatment by measuring symptom improvement, effect on ADL, exercise
capacity and speed of symptom relief
Treat exacerbations accordingly with oral steroids and/or antibiotics-consider incorporating this in self management plan. See separate guidelines on Exacerbations (link).
Pulse Oximetry should be available to assess and monitor LTOT and also monitoring of severe exacerbations
Pulmonary Rehab if symptomatic*
Bone protection if 3 or more courses of oral steroids per annum or regular high dose inhaled corticosteroids
Depression screening
Dietetic review as appropriate
Oxygen Therapy (Contact Specialist Services) *
Nebuliser therapy (following assessment by COPD team)
Palliative Care (prescribe opioids as per treatment table overleaf)
*Good evidence for prognostic benefit
Overleaf is a treatment chart detailing drug choices according to severity of patient symptoms. In all cases, consider
the following advice:
 Choose a drug based on the person’s symptomatic response and preference, the drug’s licensed indications and
side effects, potential to reduce exacerbations, cost and appropriateness of device.
 Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids.
 Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD
treated with inhaled corticosteroids and be prepared to discuss this with patients.
 Review medication at each stage and every 3 months for severe COPD. CHANGE or STOP therapy that fails to
achieve desired outcome AT ANY STAGE despite appropriate inhaler technique.
 Consider rapid acceleration of treatment if frequent exacerbations.
Criteria for referral to the Respiratory specialist team;
Frequent exacerbations (patients not known to specialist services), Severe/very severe COPD, for Pulmonary
Rehab MRC 2 and above, Unstable COPD patients (not exacerbated) can be referred to the Community
Respiratory Services clinic.
Useful contacts:
COPD
treatment
Contact Oxygen Team if Sats < 92%
(notassessment
exacerbated) andTelephone
0300options
303 2596 Fax 0300 303 9987
Referral Respiratory Team
Telephone 0300 303 2597 Fax 0300 303 9985
Refer Pulmonary Rehabilitation
Telephone 0300 303 2597 Fax 0300 303 9985
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Combined assessment of COPD
MID ESSEX LOCALITY
The following chart should be used to assess where in the treatment pathway a patient is and combines symptomatic
assessment, spirometry and risk of exacerbations.
3
2
1
C
D
≥2
Initial advice refer to table 1
Long acting antimuscarinic agent
(LAMA)
OR LABA + Inhaled corticosteroid
(ICS) combo - Give steroid card for
high dose inhalers
Initial advice refer to table 1
ICS + LABA combo
AND
LAMA
Give steroid card for high dose
inhalers
Alternative: LABA + LAMA
combination where ICS not
appropriate
Alternative: LABA + LAMA
combo where ICS not
appropriate
A
B
Initial advice refer to table 1
Some patients may not need
treatment
If treatment required:
Short Acting Beta Agonist (SABA)
May continue at all stages
Or
Short Acting antimuscarinic agent
(SAMA)
CAT < 10, mMRC 0-1
Initial advice refer to table 1
LABA + LAMA combination
Alternative if intolerant to one
of the components in the
combination inhaler :
Long acting beta agonist (LABA)
OR
Long acting antimuscarinic
agent (LAMA)
Stop SAMA if LAMA used
CAT ≥ 10, mMRC ≥ 2
SYMPTOMS & BREATHLESSNESS
See Appendix 1 for inhaler table and choices
Refer to Management of COPD exacerbations pathway
Patient
Risk & Symptoms GOLD
Exacerbations per year
Group
A
Low risk, less
1 or 2
0-1 no hospitalisation
symptoms
B
Low risk, more
1 or 2
0-1 no hospitalisation
symptoms
C
High risk, less
3 or 4
≥ 2 or ≥ 1 with
symptoms
hospitalisation
D
High risk, More
3 or 4
≥ 2 or ≥ 1 with
symptoms
hospitalisation
CAT
score
< 10
mMRC
grade
0-1
≥ 10
2
< 10
0-1
≥ 10
≥2
Or ≥ 1 hospital admission
1 – not hospitalised
RISK - EXACERBATION HISTORY
RISK
GOLD Classification of Airflow Limitation
4
0
Classification of severity
of airflow limitation in
COPD in patients with
FEV1/FVC <0.7
FEV1
Predicted
GOLD 1
≥ 80%
Mild
GOLD 2
50-79%
Moderate
GOLD 3
30-49%
Severe
GOLD 4
< 30%
Very Severe
CAT score = COPD
Assessment Test
mMRC = modified
Medical Research Council
Dyspnoea Score
PALLIATIVE CARE
Opioids; use when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other
medical therapy.
Benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness. Provide access to
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multidisciplinary
palliative care teams and hospices.
Table 2 Inhaler treatment pathway
Always prescribe by brand to avoid the incorrect inhaler device
from being supplied to patients
METERED DOSE INHALER
“Slow and steady” inspiration
Pressurised MDI
GOLD treatment
pathway in COPD ↓
Consider using an aero-chamber
if having difficulty co-ordinating
actuation with inhalation.
MID ESSEX LOCALITY
Respimat
DRY POWDER INHALER
“Quick and deep”
inspiration
Ellipta
Soft mist MDI
Multidose DPI
1st choice: Salbutamol
SABA
OR
SAMA
1 – 2 puffs up to FOUR times a
day when required
None available use salbutamol /ipratropium MDI
A,B,
C,D
2nd choice : Ipratropium
ATROVENT®
20 micrograms
1 – 2 puffs up to FOUR times a
day when required for
breathlessness
LABA
B
SEREVENT®
Salmeterol
25micrograms 2 puffs TWICE a
day
LAMA
B, C &
D with
LABA/
ICS
None available use Spiriva
Respimat
Stop
SAMA
LABA + LAMA
combination
inhaler
B,C &
D
STRIVERDI® Olodacterol
2.5microgram
5 micrograms (2 puffs) ONCE a
day
SPIRIVA® RESPIMAT
Tiotropium 2.5mg
5micrograms ( 2 puffs) ONCE a
day
None available use Spiolto
Respimat
(where ICS not
appropriate)
None available use
Salmeterol or device
SPIOLTO® Tiotropium
2.5microgram + olodacterol
2.5microgram
2puffs ONCE a day
INCRUSE® Umeclidinium 55
micrograms
1 inhalation ONCE a day
ANORO® Umeclidinium
55micrograms + vilanterol
22 micrograms
Inhale ONCE daily
ICS + LABA
combination
inhaler
Steroid card for
high doses
Rinse mouth with
water after use
C&D
Fostair®
Beclomethsone/formoterol
(100/6)
2 puffs TWICE a day
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None available use FOSTAIR
MDI
RELVAR® Fluticasone +
vilanterol 92 micrograms/22
micrograms
1 inhalation ONCE a day
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Inhaler treatment pathway in COPD
MID ESSEX LOCALITY
Choice of device for patients is the most important factor to ensure maximum patient benefit.
Due to the increasing number of drugs, combinations and inhaler devices, for safety reasons those on formulary for
COPD has been restricted (see table 2 previous page). Where patients’ medication changes along the pathway
theyshould remain on same/similar device type unless compliance issues due to use of the inhaler device have been
identified.


Metered dose inhaler or Respimat® - Aerosol devices of choice
Ellipta® device – Dry powder inhaler device of choice
These have been selected based on the following criteria:
1) Range of drugs available in these devices required where
symptoms escalate
2) Cost
3) Ease of use – co-ordination and manual dexterity
i.
MDIs – use of aerochamber, haleraid will improve
patient co-ordination
ii.
Respimat® – patients with dexterity issues may require
help with initial loading the canister of a new inhaler
4) Feedback mechanism when inhaled
It is hoped that having a smaller range of devices recommended in COPD will allow clinicians to gain more in depth
knowledge of these inhalers. So that they can better support patients
Existing prescribing
 Patients on devices not listed may remain on them where symptoms are stable and the patient is managing
well on the inhaler device.
 Where patients are being reviewed for potential medication change due to a change in symptoms, consider
switching to a preferred device.
 Review patients on triple therapy (ICS + LABA combination & LAMA e.g. Fostair 100/6 MDI and Seebri
Breezhaler (Glycopurronium) 44micrograms) where FEV ≥50% and had less than 2 exacerbations in the last
12 months. Consider:
o Step wise reduction of the ICS then maintain on LABA/LAMA combined inhaler
o Or straight to maintenance with a LABA/LAMA combined inhaler
Always prescribe by brand to avoid the incorrect inhaler device from being dispensed to patients. Refer
to prescribing policy on Inhalers (link)
Check current BNF and summary of product characteristics for full prescribing information, cautions and
contraindications http://www.medicines.org.uk/emc
Ensure patients are following the common 7 simple steps when using their inhalers:
1) Prepare inhaler e.g. remove cap from the mouthpiece
2) Prime/load the dose e.g. shake the inhaler, push back cap fully
3) Breathe out as far as comfortable (not into the mouthpiece)
4) Put lips around mouthpiece and ensure lips are sealed
5) Breathe in correctly according to inhaler device type (see table)
6) Remove inhaler from mouth and hold breath for 10 seconds or as long as comfortably possible
7) Repeat if needed and finish.
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MID ESSEX LOCALITY
Title
Document reference
Author
Consulted with
Management of stable COPD
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Natalie Prior, Pharmacist, Mid Essex CCG
Dr Keith Hattotuwa, Consultant Physician and Senior Lecturer in Respiratory
Medicine
Kim Blyth, Respiratory Pharmacist MEHT
Reference:
Global Strategy for Diagnosis, Management, and Prevention of COPD
http://goldcopd.org/gold-2017-global-strategy-diagnosis-managementprevention-copd/
Chronic obstructive pulmonary disease: Management of chronic obstructive
pulmonary disease in adults in primary and secondary care (partial update) CG101
Published date: June 2010
Approved by
Date approved
Next review date
Previous version
January 2013
July 2015
November 2015
April 2016
Mid Essex Area Prescribing Committee
November 2016
November 2018
Key changes
Format changes
Criteria for Pulmonary Rehab changed to MRC 2 and above
Addition of GOLD table and inhaler table
Minor change – November 2015 change in duaklir genuair device
Minor change – April 2016 contact numbers and fax for COPD and oxygen team
updated
Removal of turbohaler, Accuhaler, breezhaler and Genuair from the guidelines.
Addition of Spiolto and Striverdi Respimat (new formulary applications)
Update reference with latest GOLD 2017
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