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Overview of management
- Assessment
- Assess the severity of chronic obstructive pulmonary disease (COPD) according to the reduction in forced expiratory volume in 1 second (FEV1), degree of breathlessness according to the Medical Research Council dyspnoea scale, body mass index, and presence of cor pulmonale.
- Document the person's smoking history, encourage smokers to stop, and offer smoking cessation treatment.
- Assess for anxiety or depression in people who are hypoxic or have severe dyspnoea.
- Check the full blood count, and arrange other investigations as appropriate.
- Referral
- Consider referral:
- To a respiratory specialist, for assessment for oxygen therapy.
- For pulmonary rehabilitation.
- To a physiotherapist.
- To social services and occupational therapy.
- Treatment
- Advice
- Managing cor pulmonale
- Follow up
- Follow up all people with COPD; the frequency of follow up depends on the severity of disease.
- Discussing end-of-life issues
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- In a review of the evidence on influenza and pneumococcal vaccinations, NICE cited two retrospective cohort studies (involving three analyses), which found that influenza and pneumococcal vaccinations were associated with reductions in both hospitalization and death rates in elderly people with chronic lung disease.
How should I assess a person with COPD?
How should I assess the severity of COPD?
- Assess the degree of airflow obstruction according to the reduction in post-bronchodilator forced expiratory volume in 1 second (FEV1) on spirometry and classify as follows:
- Stage 1 — mild: FEV1 80% of predicted value or higher (symptoms must be present).
- Stage 2 — moderate: FEV1 50–79% of predicted value.
- Stage 3 — severe: FEV1 30–49% of predicted value.
- Stage 4 — very severe: FEV1 less than 30% of predicted value.
- Assess the degree of breathlessness according to the Medical Research Council dyspnoea scale.
- Calculate the person's body mass index (weight in kg/height in m2). See Nutrition.
- Assess for the presence of cor pulmonale — features include:
- Peripheral oedema.
- Raised jugular venous pressure.
- Systolic parasternal heave.
- A loud pulmonary second heart sound (over the second left intercostal space).
- Widening of the descending pulmonary artery on chest X-ray.
- Right ventricular hypertrophy on electrocardiography.
Medical Research Council dyspnoea scale
Table 1. Medical Research Council (MRC) dyspnoea scale.
Grade | Level of activity |
|---|
1 | Not troubled by breathlessness except during strenuous exercise |
2 | Short of breath when hurrying or walking up a slight hill |
3 | Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace |
4 | Stops for breath after walking about 100 m or after a few minutes on the level |
5 | Too breathless to leave the house, or breathless when dressing or undressing |
|
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE states that severity assessment is important because it has implications for treatment and relates to prognosis, but no single measure can adequately assess the true severity of COPD in an individual. Although spirometry alone may underestimate the impact of the disease in some people and overestimate it in others, spirometry can be used to assess the severity of airflow obstruction and to guide treatment and predict prognosis.
- Different definitions of severity of airflow obstruction are recommended in the updated 2010 NICE guideline compared with the previous 2004 NICE guideline. Definitions of severity are now in line with other national and international guidelines.
- Body mass index (BMI) reflects the impact of the disease in an individual and predicts prognosis. Evidence from cohort studies reviewed by NICE found that being underweight (BMI less than 20 kg/m2) was associated with increased mortality.
- Features of cor pulmonale are based on observational studies and the opinion of the NICE guideline development group.
- Several additional investigations recommended by NICE to assess severity are not feasible in primary care, and so are not recommended by CKS. These include transfer factor for carbon monoxide (TLCO), partial pressure of oxygen in arterial blood (PaO2), BODE index (a multidimensional index incorporating BMI, airflow obstruction, dyspnoea, and exercise capacity), and exercise capacity.
- Specialist equipment is required to measure TLCO and PaO2.
- A calculator or score sheet for the BODE index does not seem to be available online without subscription.
- Substantial resources, including resuscitation equipment, are required to undertake a formal assessment of exercise capacity (that is, the 6-minute walk test) [American Thoracic Society Committee, 2002].
- The DOSE index was recommended by two CKS reviewers. It is a composite index of severity of COPD for use in primary care that has four components: dyspnoea (D), measured using the MRC dyspnoea scale; airflow obstruction (O) according to FEV1; smoking status (S); and exacerbation frequency (E). Although the DOSE index is valid and feasible for use in primary care, it has not been included in CKS recommendations because it is unclear how it should be used to guide management. NICE recommends that a multidimensional assessment should be developed for use in primary care settings, but also states that 'any multidimensional assessment index would need to be subjected to health economic evaluation'.
- NICE also recommends an assessment of health status; however, CKS could find no specific details of what measures this should include or how they would affect management.
What other assessments should I do in a person with COPD?
- Document whether the person smokes or is an ex-smoker, and the number of pack-years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked).
- Assess for the presence of anxiety or depression in people who are hypoxic or have severe dyspnoea. See the CKS topic on Depression.
- Be alert for the presence of depression in all people with chronic obstructive pulmonary disease.
- Do the following investigations:
- Pulse oximetry to assess the need for oxygen therapy if cyanosis or cor pulmonale is present, or if FEV1 (forced expiratory volume in 1 second) is less than 50% predicted normal.
- Full blood count to identify anaemia or secondary polycythaemia (erythrocytosis).
- Electrocardiography to assess cardiac status if the person has features of cor pulmonale.
- Sputum culture to identify organisms if sputum is persistently present and purulent.
Basis for recommendation
These recommendations are based on expert opinion in the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
When should I refer a person with COPD?
When should I refer a person with COPD to a respiratory specialist?
- If lung cancer is suspected, refer the person urgently to a respiratory specialist to be seen within 2 weeks — see the CKS topic on Lung cancer - suspected.
- If the person with chronic obstructive pulmonary disease (COPD) reports haemoptysis, suspect lung cancer and refer urgently.
- Other reasons for referral to a respiratory specialist include:
- Diagnostic uncertainty.
- Referral may be needed for this reason for black and Asian people, for whom normal ranges for forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) are not known.
- COPD that is very severe (for example FEV1 less than 30% predicted) or worsening (rapid decline in FEV1).
- Continued smoking, if the primary healthcare professional considers that referral would increase the likelihood of smoking cessation.
- The person with COPD requests a second opinion.
- Cor pulmonale.
- Dysfunctional breathing (abnormal breathing patterns associated with anxiety).
- Onset of symptoms at an age younger than 40 years, or a family history of alpha1-antitrypsin deficiency.
- Frequent infections.
- Symptoms disproportionate to lung function.
- For pulmonary rehabilitation (for a person who considers themselves functionally disabled by COPD), if direct referral is not possible.
- For assessment of the need for:
Basis for recommendation
These recommendations are based on two National Institute for Health and Clinical Excellence (NICE) guidelines: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010] and Referral guidelines for suspected cancer [NICE, 2005].
- The NICE guidelines on referral for suspected cancer and the NICE chronic obstructive pulmonary disease (COPD) guideline differ slightly in their guidance on the management of a person with haemoptysis.
- The NICE guidelines on referral for suspected cancer indicate that a single episode of haemoptysis necessitates an urgent chest X-ray and non-urgent referral if the chest X-ray shows no signs of lung cancer, whilst only persistent haemoptysis or chest X-ray signs of possible lung cancer require urgent referral [NICE, 2005].
- The NICE COPD guideline recommends referral for specialist advice if a person with COPD develops haemoptysis to exclude lung cancer [NICE, 2010].
- Given that urgent referral is required if lung cancer is suspected, CKS recommends urgent referral if a person with COPD reports haemoptysis. This recommendation is supported by several CKS reviewers.
- The other indications for referral were originally developed by the British Thoracic Society [British Thoracic Society, 1997] and were augmented by the NICE COPD guideline development group [National Clinical Guideline Centre, 2010].
- Precise definitions of 'dysfunctional breathing' are scarce in the published literature; the definition here is based on a study of the prevalence of this problem in people with asthma [Thomas et al, 2001].
When should I refer a person with COPD for pulmonary rehabilitation?
- Refer for pulmonary rehabilitation if the person considers themselves functionally disabled by chronic obstructive pulmonary disease (usually Medical Research Council dyspnoea scale grade 3 or above), or has had a recent hospitalization for an acute exacerbation.
- Availability and content vary. Most programmes are hospital based, and referral to a specialist respiratory unit may be needed to access services. However, direct access from primary care is possible in some areas.
- Inform the person that pulmonary rehabilitation improves quality of life and exercise capacity, and reduces breathlessness. However, commitment is required to gain these benefits.
- Programmes usually involve 2–3 sessions/week and last for 6–12 weeks.
- It is recommended that the rehabilitation process should involve physical training; disease education; and nutritional, psychological, and behavioural interventions tailored to the individual's needs. The aim is to optimize the person's physical and social performance, and to try to break the cycle of worsening breathlessness, reduced physical activity, and reduced fitness.
- Do not refer for pulmonary rehabilitation people who cannot walk, have unstable angina, or have had a recent myocardial infarction.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- Evidence reviewed by NICE from a Cochrane systematic review suggests that pulmonary rehabilitation improves health-related quality of life and exercise capacity. NICE also found evidence that pulmonary rehabilitation is cost effective in the outpatient setting compared with usual care.
- The recommendations to refer people who consider themselves functionally disabled by chronic obstructive pulmonary disease (COPD), and that this is equivalent to Medical Research Council breathlessness scale grade 3, are based on the expert opinion of the NICE guideline development group, augmenting a British Thoracic Society statement [British Thoracic Society, 2001].
- Evidence reviewed by NICE from one systematic review and one subsequent randomized controlled trial found that, compared with usual care, people with an exacerbation of COPD who received pulmonary rehabilitation within 1 month of hospitalization had a significantly decreased risk of readmission to hospital and significantly improved exercise capacity and health-related quality of life.
- The information that direct access from primary care is possible in some areas is derived from Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England [DH, 2010].
When should I refer a person with COPD for assessment for long-term oxygen therapy?
- Inappropriate oxygen therapy in people with chronic obstructive pulmonary disease (COPD) may cause respiratory depression. Do not start long-term oxygen therapy (LTOT) without a specialist assessment.
- Refer the person with COPD to a respiratory specialist for assessment for LTOT if they have any of the following:
- Oxygen saturation less than or equal to 92% breathing air.
- Ensure that pulse oximetry is available.
- Very severe airflow obstruction (forced expiratory volume in 1 second [FEV1] less than 30% predicted).
- Cyanosis.
- Secondary polycythaemia (erythrocytosis).
- Peripheral oedema.
- Raised jugular venous pressure.
- Consider referring people with severe airflow obstruction (FEV1 30–49% predicted) for assessment for the need for LTOT.
- Optimize medical treatment before referral.
- Warn people using oxygen not to smoke because of the risk of fire or explosion.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE based its recommendations on long-term oxygen therapy on evidence from a Royal College of Physicians report.
- NICE based the indications for referral for assessment on expert opinion.
When should I refer a person with COPD for assessment for ambulatory oxygen?
- Inappropriate oxygen therapy in people with chronic obstructive pulmonary disease may cause respiratory depression.
- Refer to a respiratory specialist for assessment for ambulatory oxygen therapy (portable oxygen) people on long-term oxygen therapy who wish to continue oxygen therapy outside the home.
- Warn people using oxygen not to smoke because of the risk of fire or explosion.
Basis for recommendation
These recommendations are based on expert opinion in the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE states that ambulatory oxygen therapy can be used to ensure that people who require long-term oxygen therapy (LTOT) and leave their home on a regular basis receive oxygen for sufficient hours to gain the benefits of LTOT.
- NICE did not identify any evidence on the effectiveness of ambulatory oxygen for people with exercise desaturation; this recommendation is based on the opinion of the guideline development group.
When should I refer a person with COPD for assessment for short-burst oxygen?
- Inappropriate oxygen therapy in people with chronic obstructive pulmonary disease may cause respiratory depression.
- Refer to a respiratory specialist for assessment for short-burst oxygen therapy (as-required intermittent use of supplemental oxygen for periods of 10–20 minutes to relieve breathlessness):
- People not eligible for LTOT who have episodes of severe breathlessness not relieved by other treatments.
- Referral for assessment may not be necessary or appropriate when short-burst oxygen is being used for terminal care (in the last days of life).
- Warn people using oxygen not to smoke because of the risk of fire or explosion.
Basis for recommendation
These recommendations are mainly based on expert opinion and evidence from quasi-experimental studies reviewed in the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- In addition, the statement that referral for assessment may not be necessary or appropriate when short-burst oxygen is being used for terminal care (in the last days of life) is based on what CKS considers to be good clinical practice.
When should I refer a person with COPD to other professionals in the multidisciplinary team?
- Consider referring people with excessive sputum to a physiotherapist to learn the use of positive expiratory pressure masks and the active cycle of breathing technique.
- Consider referring people to social services and occupational therapy if they have difficulties with activities of daily living or disability.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
Referral to a physiotherapist
- The recommendations on the indications and reasons for referral to a physiotherapist are based on evidence from one small randomized controlled trial and one small quasi-experimental study reviewed by NICE.
Referral to social services and occupational therapy
- This recommendation is based on the opinion of the NICE guideline development group.
How can I support a person with COPD to stop smoking?
- Encourage smokers with chronic obstructive pulmonary disease (COPD) to stop smoking.
- If the person is not willing to stop smoking, advise them to cut down, as this may still have some symptomatic benefit.
- Document an up-to-date smoking history for people with COPD.
- This should include pack-years smoked, which is the number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked.
- Unless contraindicated, offer nicotine replacement therapy, varenicline, or bupropion, as appropriate, to people who are planning to stop smoking.
- Drug treatments should be combined with an appropriate support programme to optimize smoking quit rates for people with COPD.
- For more information, see the CKS topic on Smoking cessation.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- The evidence suggests that smoking cessation (at any age) reduces the rate of decline of forced expiratory volume in 1 second (FEV1), improves symptoms (cough, wheeze, and sputum production), and increases survival in people with chronic obstructive pulmonary disease (COPD).
- Getting people with COPD to stop smoking is one of the most important interventions [National Clinical Guideline Centre, 2010].
What drug treatment should I offer a person with COPD?
What inhaled treatments should I offer a person with COPD whose FEV1 is 50% predicted or greater?
- If the person is breathless and has exercise limitation:
- If the person prescribed a SABA or SAMA remains breathless or has exacerbations, offer either of the following:
- A SABA (as required) may be continued at all stages.
- If a person taking a LABA remains breathless or has exacerbations:
- Consider changing to a LABA plus an inhaled corticosteroid (ICS) in a combination inhaler. If an ICS is declined or not tolerated, consider a LAMA plus a LABA.
- An ICS should not be used as monotherapy in COPD.
- If a person taking a LABA plus an ICS remains breathless or has exacerbations:
- If a person taking a LAMA remains breathless or has exacerbations:
- Consider adding a LABA plus an ICS (in a combination inhaler).
- For an algorithm on the use of inhaled treatments, see the NICE quick reference guide.
- Consider using a mucolytic or theophylline (methylxanthine).
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- Short-acting bronchodilators compared with placebo
- The evidence for short-acting bronchodilators compared with placebo in chronic obstructive pulmonary disease (COPD) is mainly from small, short-term randomized controlled trials. However, results show a short-term improvement in breathlessness, quality of life, and lung function.
- Long-acting beta-2 agonists (LABAs) compared with placebo
- The evidence suggests a general improvement in lung function, quality of life, and symptoms, and a reduction of exacerbation rates, when LABAs are compared with placebo.
- Long-acting muscarinic antagonists (LAMAs) compared with placebo
- The evidence suggests that LAMAs are superior to placebo in reduction of exacerbation rates. There was also a general improvement in lung function, quality of life, and symptoms in people with COPD treated with LAMAs compared with placebo.
- LAMAs compared with a short-acting muscarinic antagonists (SAMA)
- The evidence suggests an improvement in quality of life and symptoms, and reduction of exacerbation rates, when long-acting bronchodilators are compared with a SAMA (ipratropium bromide). Cost-utility studies (with limitations) comparing treatment with tiotropium and ipratropium in people with stable COPD show that once-daily tiotropium is more cost effective and may improve adherence.
- LABAs compared with LAMAs
- The evidence shows that LABAs and LAMAs are similar in improving quality of life and symptoms. Nevertheless, a LAMA (tiotropium) seems to be slightly better at reducing exacerbation rates and improving lung function compared with LABAs (salmeterol and formoterol). NICE suggests that both classes are equally effective for initial maintenance bronchodilator therapy in people with COPD whose forced expiratory volume in 1 second (FEV1) is 50% or greater.
- Inhaled corticosteroids (ICS) as monotherapy
- In the updated COPD guideline, NICE no longer makes any specific recommendations on the use of ICS as monotherapy in people with COPD.
- The recommendation to avoid the use of ICS as monotherapy in COPD is based on evidence from a systematic review that ICS alone has no effect on exacerbation rates in people with mild COPD (defined as FEV1 greater than 50%), and that there is no significant difference in mortality between ICS (when used as monotherapy) and placebo.
- Furthermore, there are no preparations containing only ICS that are licensed for use in COPD in the UK. The Medicines and Healthcare products Regulatory Agency recommends that ICS should not be used alone in COPD [MHRA, 2009]. They undertook a literature review of published and unpublished trials which found LABA plus ICS combinations to have greater efficacy than either LABAs or ICS alone in every study.
- LABA plus ICS compared with LABAs alone
- There is evidence to suggest that overall, compared with LABAs alone, people with COPD taking LABAs plus ICS have a significant increase in post-dose FEV1, and improvement in health-related quality of life. They also have fewer exacerbations. Economic studies found that LABA plus ICS is more cost effective than LABA alone in people with COPD with FEV1 less than 50% predicted.
- LABA plus ICS plus LAMA (triple therapy) compared with LABA plus LAMA
- The evidence shows that there is no significant difference between triple therapy (tiotropium plus fluticasone plus salmeterol) and tiotropium plus salmeterol in clinical outcome (breathlessness, exacerbation, mortality, pneumonia, myocardial infarction, or acute arrhythmia) in people with moderate to severe COPD. A cost-effectiveness study found triple therapy not to be more cost effective than LAMA plus LABA.
What inhaled treatments should I offer a person with COPD whose FEV1 is less than 50% predicted?
- If the person is breathless and has exercise limitation:
- If the person prescribed a SABA or SAMA remains breathless or has exacerbations, offer either of the following:
- A SABA (as required) may be continued at all stages.
- If the person remains breathless or has exacerbations despite treatment with a LABA plus an ICS or a LAMA alone:
- Treat with triple therapy: a LABA plus an ICS (in a combination inhaler) and a LAMA.
- For an algorithm on the use of inhaled treatments, see the NICE quick reference guide.
- Consider using a mucolytic or theophylline (methylxanthine).
Basis for recommendation
These recommendations are mainly based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- Short-acting bronchodilators compared with placebo
- The evidence for short-acting bronchodilators compared with placebo in people with chronic obstructive pulmonary disease (COPD) is mainly from small, short-term randomized controlled trials. However, results show a short-term improvement in breathlessness, quality of life, and lung function compared with placebo.
- Long-acting beta-2-agonists (LABAs) compared with placebo
- The evidence suggests a general improvement in lung function, quality of life, and symptoms, and a reduction of exacerbation rates, when LABAs are compared with placebo.
- Long-acting muscarinic antagonists (LAMAs) compared with placebo
- The evidence suggests that LAMAs are superior to placebo in reduction of exacerbation rates. There was also a general improvement in lung function, quality of life, and symptoms in people with COPD treated with LAMAs compared with placebo.
- LAMAs compared with short-acting muscarinic antagonists (SAMAs)
- The evidence suggests an improvement in quality of life and symptoms, and reduction of exacerbation rates when LAMAs are compared with SAMA (ipratropium bromide). Cost-utility studies (with limitations), comparing treatment with tiotropium and ipratropium in people with stable COPD, show that once-daily tiotropium is more cost effective and may improve adherence.
- Inhaled corticosteroids (ICS) as monotherapy
- In the updated COPD guideline, NICE no longer makes any specific recommendations on the use of ICS as monotherapy in people with COPD.
- Although there is evidence from a systematic review that ICS reduce the exacerbation rate by 25% compared with placebo in people with more severe COPD (mean forced expiratory volume in 1 second [FEV1] less than 50% predicted), there was no significant difference in mortality. More important, the Medicines and Healthcare products Regulatory Agency undertook a literature review of published and unpublished trials which found LABA plus ICS combinations to have greater efficacy than either LABA or ICS alone in every study, and they recommend that ICS should not be used alone in COPD [MHRA, 2009].
- There are no preparations containing only ICS that are licensed for use in COPD in the UK.
- LABA plus ICS compared with LABA alone
- There is evidence to suggest that overall, compared with LABAs alone, people with COPD taking LABA plus ICS have a significant increase in post-dose FEV1, and improvement in health-related quality of life. They also have fewer exacerbations. Economic studies show that LABA plus ICS is more cost-effective than LABA alone in people with COPD whose FEV1 is less than 50% predicted.
- LABA plus ICS compared with LAMA alone
- The evidence suggests a small and clinically insignificant improvement in quality of life in people with COPD (FEV1 less than 50%) on LABA plus ICS, compared with LAMA alone. Exacerbation rates were similar between the two groups and were not clinically significant.
- There is no evidence to favour LAMA plus ICS over LAMA alone or vice versa. Either regimen can be used for initial maintenance treatment in people with COPD whose FEV1 is less than 50% [National Clinical Guideline Centre, 2010].
- LABA plus ICS plus LAMA (triple therapy) compared with LABA plus ICS and LAMA alone
- Evidence suggests that LABA plus ICS or LAMA alone is more cost effective than triple therapy. However, triple therapy is more effective (highest quality-adjusted life-years). Owing to the limitations of the studies, NICE concluded that LABA plus ICS or LAMA alone should be offered as initial maintenance treatment to people with COPD whose FEV1 is less than 50%.
- Triple therapy is recommended if symptoms or exacerbations persist because it is more effective in terms of exacerbation reduction and symptom relief [National Clinical Guideline Centre, 2010].
When should I treat someone with COPD with a mucolytic?
- If a person with stable chronic obstructive pulmonary disease (COPD) develops a chronic cough productive of sputum:
- Consider prescribing a mucolytic.
- Continue a mucolytic if there is symptomatic improvement (for example reduction in frequency of cough and sputum production).
- Mucolytics should not be used routinely to prevent exacerbations in people with stable COPD.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE found evidence from a systematic review and three additional randomized controlled trials that mucolytics reduce exacerbation frequency and duration of disability in people with chronic bronchitis or chronic obstructive pulmonary disease (COPD). However, the quality of the evidence was low or very low, and benefits may occur only in people who are not receiving other maintenance treatments (for example inhaled corticosteroids). In view of this, the NICE guideline development group was concerned that a positive recommendation for the use of mucolytics purely to prevent exacerbations may preclude the use of other therapies which have a stronger evidence base, and incorrectly imply that mucolytics should be the first-line treatment for exacerbation prevention.
- The recommendation by NICE to only treat people with stable COPD who have a chronic cough productive of sputum seems to be based on evidence from a cost-effectiveness analysis that mucolytics are cost-effective in people with chronic bronchitis (regular cough with sputum production).
When should I treat someone with COPD with a theophylline (methylxanthine)?
- If a person with stable chronic obstructive pulmonary disease (COPD) is still symptomatic after a trial of short-acting and long-acting bronchodilators (with or without inhaled corticosteroids), or cannot use inhaler devices successfully:
- Consider prescribing oral theophylline.
- Theophylline has a narrow therapeutic window, and plasma levels should be monitored closely.
- Particular caution needs to be taken when prescribing theophylline to elderly people because of differences in pharmacokinetics, increased likelihood of comorbidities, and the use of other medications.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- There is evidence that theophylline improves lung function, but it does not result in a statistically significant difference in symptoms (wheeze, dyspnoea, or walking distance), use of rescue medication, or exacerbation frequency compared with placebo.
- The higher rate of adverse effects with theophylline needs to be balanced against any benefits.
When should I treat someone with COPD with oral corticosteroids?
- Do not start oral corticosteroids for maintenance treatment of chronic obstructive pulmonary disease (COPD) in primary care.
- Maintenance use of oral corticosteroids in COPD is not normally recommended.
- Refer to a respiratory specialist if long-term treatment is being considered.
- If a person is already taking oral corticosteroids for maintenance treatment which were not started by a specialist, refer to a respiratory specialist to assess the need for continuing treatment.
- If a person is started on long-term oral corticosteroids in secondary care, ensure that they are monitored for the development of osteoporosis and/or given appropriate prophylaxis.
- People 65 years of age or older, and people younger than 65 years of age with a previous fragility fracture, should be started on prophylactic treatment without the need for prior dual energy X-ray absorptiometry.
- See the CKS topic on Osteoporosis - preventing steroid-induced.
Basis for recommendation
These recommendations are based on expert opinion in the the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease (COPD) in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE identified a meta-analysis of 10 randomized controlled trials that compared oral corticosteroids with placebo. However, NICE concluded that owing to methodological limitations, this study did not establish the effects of sustained oral corticosteroid treatment on either forced expiratory volume in 1 second (FEV1) or more patient-oriented clinical outcomes. The study also did not establish the potential long-term adverse effects of sustained treatment.
- On the basis of the opinion of the guideline development group, NICE concluded that:
- No published studies were found that establish which people with COPD, if any, benefit from long-term oral steroid therapy.
- There is a small group of people who experience frequent exacerbations or severe breathlessness for whom long-term oral steroid treatment is the only pragmatic management.
- Some people with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation.
- NICE did not update the evidence on oral corticosteroids for stable COPD; CKS identified a subsequent Cochrane systematic review of 24 randomized controlled trials [Walters et al, 2005]. Although FEV1 increased significantly in people taking high-dose oral corticosteroids compared with those taking placebo, there were no clinically important differences in health-related quality of life. The authors concluded that no evidence supports the long-term use of oral corticosteroids at doses of 15 mg or lower, and that potentially harmful adverse effects of higher doses prevent recommending their use.
- The recommendation to refer the person to a respiratory specialist to assess the need for continuing treatment if the person is already taking oral corticosteroids for maintenance treatment that was not started by a specialist is based on what CKS considers to be good clinical practice.
- Recommendations on osteoporosis monitoring and prophylaxis by NICE were based on guidelines from the Royal College of Physicians (RCP) on the prevention and treatment of osteoporosis [RCP, 1999]. The RCP has also published specific guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis [RCP, 2002], which form the basis for the CKS topic on Osteoporosis - preventing steroid-induced.
What information should self-management plans offer for people with COPD?
- People with chronic obstructive pulmonary disease (COPD) should have a verbal and/or written self-management plan that provides personalized advice on:
- How to recognize the early signs of an exacerbation and respond appropriately.
- Lifestyle and medication issues to prevent exacerbations.
- Discuss and provide written information to all people with COPD on diet and exercise, and smoking cessation (if necessary).
- For people who have frequent exacerbations, provide a structured, written action plan on:
- How to recognize when COPD is getting worse (increased breathlessness, more sputum, coloured sputum, and/or fever).
- How to initially increase the use of short-acting bronchodilators, and if there is no response, when to contact a primary healthcare professional.
- If a person has a supply of medication at home, provide written information advising them:
- To start oral corticosteroid therapy if their increased breathlessness interferes with activities of daily living.
- To start antibiotics if sputum becomes discoloured or increases in volume.
- To contact a primary healthcare professional if they start treatment or are uncertain about whether to start treatment.
Basis for recommendation
These recommendations are based on expert opinion and evidence reviewed in the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010].
- NICE identified a Cochrane systematic review (three RCTs, 367 participants) which showed that people with self-management plans had better recognition of an exacerbation and reacted appropriately. Unfortunately, this behaviour did not result in any benefit in healthcare utilization, symptoms, quality of life, functional capacity, mental health, or mortality. The studies included were small and of poor quality.
- Two subsequent randomized controlled trials identified by CKS (298 participants) also confirmed these findings, and added that there was no difference in exacerbation rates [McGeoch et al, 2006; Wood-Baker et al, 2006].
- Despite the lack of evidence, experts believe that self-management plans are useful in the management of chronic obstructive pulmonary disease.
- The recommendation that a person with a supply of medications at home should contact a primary healthcare professional if they start treatment is based on feedback from CKS expert reviewers. They suggest that a review should be done in any case:
- To ensure that the patient understood what they are doing.
- To ensure that medications are taken appropriately.
- To record the exacerbation.
- To review the time antecedent to the exacerbation to see if any other preventative factor might have been helpful.
- To re plenish home stocks of oral steroids/antibiotics.
How should I manage nutritional needs in a person with COPD?
- Calculate the person's body mass index (BMI).
- BMI is calculated as weight in kg/height in m2.
- The normal range of BMI is 20–25 kg/m2.
- If the person's BMI is less than 20 kg/m2 or more than 25 kg/m2 or is changing over time, or there is a weight change of 3 kg or more (loss or gain) in an elderly person, refer for dietetic advice (if available).
- People with a low BMI should be given nutritional supplements (after specialist advice) and encouraged to take regular exercise to augment the effects of nutritional supplementation.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE found evidence from nine cohort studies that in people with COPD, low body mass index (BMI) is associated with worse outcomes (including mortality) compared with those with normal BMI. Weight loss in people with a low BMI is associated with poorer survival, weight gain in people with a low or normal BMI is associated with increased survival, and weight loss or no weight change is associated with increased survival in people with high BMI.
- NICE also cited evidence from a Cochrane systematic review that nutritional supplements have no significant benefit; it is unclear on what the NICE guideline development group has based the recommendation that people with COPD whose BMI is low should be given nutritional supplements to increase their total calorific intake.
- The recommendation to encourage people taking nutritional supplements to take exercise to augment the effects of the supplements is based on the opinion of the NICE guideline development group.
What advice should I give to someone with COPD?
What should I advise a person with COPD about their medications?
- Explain that the purpose of most treatments for chronic obstructive pulmonary disease (COPD) is to control symptoms or to reduce the rate of exacerbations, but that only smoking cessation has been shown to slow the decline in lung function.
- Explain that the effectiveness of treatments to control symptoms will vary among individuals.
- Discuss the person's perceived clinical improvements and let the person's preference guide treatment decisions.
- Always consider stopping a treatment if no benefits are seen after an adequate trial period.
- Stress the importance of correct use of maintenance medication.
- Explain when and how to use inhalers, and demonstrate the correct technique for using them. For more information, see Delivery systems.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- Poor adherence to medication is common in people with COPD, with about half underusing their maintenance medication and a similar proportion overusing their medication during exacerbations (which may be particularly dangerous if the person is taking aminophylline or theophylline) [Canadian Thoracic Society Workshop Group, 1992].
What should I advise a person with COPD about exercise?
- Encourage the person to exercise at their own level — to become a little short of breath, but not to overstrain themselves.
- If they are mobile, they should aim to walk for 20–30 minutes, 3–4 times per week.
- If they are immobile, encourage them to do upper-limb activities, such as twisting and arm stretches.
- Seek advice from a rehabilitation professional (physiotherapist) on exercise programmes for people who are very symptomatic.
- Provide written instructions if necessary.
- For more information, see the literature provided by the British Lung Foundation.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010] and advice from the British Lung Foundation about living with chronic obstructive pulmonary disease (COPD).
What should I advise a person with COPD about air travel?
- Advise the person with chronic obstructive pulmonary disease (COPD) who is considering air travel that they will need a fitness-to-fly assessment.
- If the person has known bullous disease, warn them that they are at theoretical increased risk of pneumothorax during air travel.
- Refer people on long-term oxygen therapy or who have a forced expiratory volume in 1 second (FEV1) less than 50% to a specialist. A hypoxic challenge test may be appropriate.
- Advise people with COPD to:
- Carry inhalers in hand luggage.
- Inform the airline if they require wheelchairs for transport to and from the aeroplane.
- Keep mobile during the flight if possible. Leg exercises should be done as often as possible during the flight.
- Avoid smoking and alcohol before and during air travel.
- Inform the airline (when booking the holiday) if they require oxygen.
- People who have ambulatory oxygen may be able to use their own oxygen, but they must inform the airline before flying, and a fee may be charged.
- People requiring oxygen should request a seat near the toilets to avoid long walks.
- Provide written information.
- For further information, see www.brit-thoracic.org.uk, www.lunguk.org, and www.european-lung-foundation.org.
Fitness-to-fly assessment
- If a person has respiratory disease, the only absolute contraindications to air travel are:
- Pneumothorax — airline companies suggest waiting 6 weeks after recovering from a pneumothorax before flying.
- Bronchogenic cyst.
- Severe pulmonary hypertension.
- Clinically unstable respiratory disease.
- The aim of pre-flight assessment is to identify people who are likely to develop respiratory symptoms (such as hypoxia) during air travel. The two main methods of pre-flight assessment are:
- The walking test — this is a good measure of cardiopulmonary reserve to exercise (although it is not always feasible to do this at the GP's surgery).
- The 50-metre walking test was put forward by the airline industry and involves asking the person whether they can walk for 50 metres on the flat. The 50-metre walking test has not yet been standardized and can be inaccurate, as many people cannot accurately assess distance.
- The 6-minute walking test (which involves asking the person to walk for 6 minutes) is a standardized and validated test recommended by the British Thoracic Society to evaluate the fitness to fly in people with COPD.
- If the person can perform the walking test, they are probably fit to travel. However, if the person cannot complete the test or develops severe breathlessness, further tests are needed, as they may require oxygen supplementation during the flight.
- Pulse oximetry — saturation measured by pulse oximetry can be used to identify people who will definitely require oxygen supplementation during the flight.
- If the person's oxygen saturation is 95% or greater, they do not need oxygen for flying, and there is no need for a referral to a respiratory specialist.
- If the person's oxygen saturation is 92% or less and they have no other contraindications, they must travel with supplemental oxygen. Refer to a respiratory specialist for assessment for supplemental oxygen.
- If the person's oxygen saturation is greater than 92% but less than 95%, they should be referred to a respiratory specialist for further evaluation. This may include a hypoxic challenge test, after which a decision will be made on whether oxygen is required while flying.
- A fitness-to-fly assessment should also include taking a history focusing on previous flying experience — this will help identify ways to make the flight as comfortable as possible for the person.
Hypoxic challenge test
- The hypoxic challenge test is the gold standard for pre-flight assessments, and is performed in secondary care.
- It involves measuring the person's response to a simulated aircraft cabin environment.
- In this investigation, the person is exposed to an inspired oxygen tension of 15 kPa, which is the expected worst-case scenario for the aircraft passenger. This can be achieved by two methods:
- Administering 15% oxygen in nitrogen using a face mask and non-rebreathing circuit.
- Filling a body plethysmograph with 15% oxygen — a modification of this technique involves placing a hood over the person's head and shoulders which is ventilated with a constant supply of 15% oxygen. Alternatively, 15% oxygen can be administered by using a 40% Venturi mask with nitrogen as the driving gas (the Venturi mask dilutes the nitrogen with air, producing 15% oxygen).
- During the hypoxic challenge test, the person is monitored continuously with pulse oximetry to prevent severe hypoxaemia. Blood gas tensions are measured before and after the hypoxic exposure.
- Some experts recommend electrocardiographic monitoring to detect asymptomatic arrhythmias.
- A predicted PaO2 of 6.6 kPa is used as the cut-off value below which supplemental oxygen is recommended for air travel.
Basis for recommendation
Advice about flying
These recommendations are based on the British Thoracic Society (BTS) guidelines on managing people with respiratory disease who are planning air travel [British Thoracic Society, 2004] and on expert opinion from review articles [Johnson, 2003; Tzani et al, 2010].
- Arterial oxygen levels fall in healthy air travel passengers, and altitude will exacerbate hypoxaemia in people with chronic obstructive pulmonary disease (COPD), especially if they are hypoxic at sea level.
- People with large bullae may be at risk of pneumothorax, but there is no evidence to indicate at what volume (size of bullae) it is considered unacceptable to travel [British Thoracic Society, 2004].
- For more information, see www.brit-thoracic.org.uk.
Fitness to fly assessment
This information is based on the BTS guidelines on managing passengers with respiratory disease planning air travel [British Thoracic Society, 2004] and on expert opinion from review articles [Johnson, 2003; Tzani et al, 2010].
Hypoxic challenge test
This information is based on expert opinion from review articles [Johnson, 2003; Tzani et al, 2010].
What should I advise a person with COPD about driving?
- For both group 1 (car or motorcycle) or group 2 (lorry or bus) entitlement:
- The Driver and Vehicle Licensing Agency (DVLA) need not been informed unless attacks are associated with disabling giddiness, fainting, or loss of consciousness.
- If the DVLA need to be notified, advise the person that it is their responsibility to do so.
- The latest information from the DVLA regarding medical fitness to drive can be obtained at www.dvla.gov.uk/medical/ataglance.
Basis for recommendation
This information on medical rules is from the Driver and Vehicle Licensing Agency's guidance for medical practitioners, At a glance guide to the current medical standards of fitness to drive [DVLA, 2010].
How should I manage a person with cor pulmonale?
- Consider the possibility of other causes of peripheral oedema, including congestive heart failure and chronic thromboembolic disease.
- If cor pulmonale is the most likely diagnosis, refer the person to a respiratory specialist for assessment for the need for long-term oxygen therapy (if not recently assessed, or already receiving it), confirmation of the diagnosis, and optimization of medical therapy.
- If necessary, treat oedema symptomatically with a diuretic, for example furosemide 20 mg once daily, increasing if necessary to 40 mg once daily.
- Check serum electrolytes soon after starting or increasing the dose.
- The following should not be used to treat cor pulmonale, but may be used for other indications.
- Angiotensin-converting enzyme inhibitors.
- Calcium-channel blockers.
- Alpha-blockers.
- Digoxin (unless there is atrial fibrillation).
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE reviewed evidence from one randomized controlled trial and two controlled studies without randomization, which found benefits from long-term oxygen therapy for people with cor pulmonale.
- NICE found insufficient evidence to recommend changing the current clinical practice of using diuretics to control peripheral oedema in people with cor pulmonale.
- CKS found no published evidence to indicate appropriate starting or maximum dosages of diuretics. The recommended starting dosage, titration, and monitoring are based on expert opinion from CKS reviewers.
- NICE reviewed the evidence for other treatments (angiotensin-converting enzyme inhibitors, calcium-channel blockers, alpha-blockers, and digoxin); studies either had methodological limitations or found no benefit in symptoms of COPD or cor pulmonale from active treatment.
How should I follow up a person with COPD?
- Frequency of follow up
- Follow up people with very severe (stage 4) chronic obstructive pulmonary disease (COPD) at least twice per year.
- Follow up people with mild, moderate, or severe (stages 1–3) COPD at least once a year.
- In all people with COPD, assess or measure (and record) the following at follow up:
- In addition to the above, in people with very severe (stage 4) COPD, assess or measure and record the following at follow up:
- Oxygen saturation.
- Ensure that pulse oximetry is available.
- Need for referral for assessment for long-term oxygen therapy.
- Presence of depression. See the CKS topic on Depression.
Basis for recommendation
These recommendations are based on expert opinion in the National Institute for Health and Clinical Excellence (NICE) guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].
- NICE found no data to guide decisions on how frequently people with chronic obstructive pulmonary disease (COPD) should be reviewed. NICE indicates that this will vary according to individual circumstances and the severity of the person's disease.
- A subsequent cluster randomized controlled trial found no difference in quality of life or other health outcomes for people with asthma or COPD managed in primary care who had more 3-monthly spirometry and regular medical reviews compared with those who had annual spirometry or usual care [Abramson et al, 2010]. Around a quarter of the people had COPD; the trial may have been underpowered to detect a significant difference in this subgroup.
- Many of the recommendations are derived from statements made in the British Thoracic Society COPD guidelines [British Thoracic Society, 1997].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Short-acting beta2-agonist: inhalers +/- spacer device
Age from 16 years onwards
Salbutamol 100mcg MDI: 1 to 2 puffs up to 4 times a day
Salbutamol 100micrograms/actuation inhaler CFC free
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Airomir 100mcg Autohaler: 1 to 2 puffs up to 4 times a day
Airomir 100micrograms/actuation Autohaler
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Salamol 100mcg Easi-Breathe: 1-2 puffs up to 4 times a day
Salamol Easi-Breathe 100micrograms/actuation inhaler
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Multi-therapy: Airomir 100mcg MDI + AeroChamber Plus
Airomir 100mcg MDI: 1 to 2 puffs up to 4 times a day
Airomir 100micrograms/actuation inhaler
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
AeroChamber Plus spacer device
AeroChamber Plus
Use to aid inhalation.
Supply 1 spacer.
Multi-therapy: Ventolin 100mcg MDI + Volumatic
Ventolin 100mcg MDI: 1 to 2 puffs up to 4 times a day
Ventolin Evohaler 100micrograms/actuation
Inhale one to two puffs up to four times a day using the spacer, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Volumatic
Use to aid inhalation.
Supply 1 spacer.
Terbutaline 500mcg Turbohaler: 1 puff up to 4 times a day
Terbutaline 500micrograms/actuation dry powder inhaler
Inhale one puff up to four times a day, when required to relieve breathlessness.
Supply 1 100 dose inhaler.
Short-acting beta2-agonist: nebules and respules
Age from 16 years onwards
Salbutamol nebules: 2.5mg up to four times a day
Salbutamol 1mg/ml nebuliser liquid 2.5ml unit dose vials
Inhale the contents of one nebule (2.5mg) using the nebuliser up to four times a day, or as directed by your doctor.
Supply 20 2.5ml nebules.
Salbutamol nebules: 5mg up to four times a day
Salbutamol 2mg/ml nebuliser liquid 2.5ml unit dose vials
Inhale the contents of one nebule (5mg) using the nebuliser up to four times a day, or as directed by your doctor.
Supply 20 2.5ml nebules.
Terbutaline respules: 5mg to 10mg up to four times a day
Terbutaline 2.5mg/ml nebuliser liquid 2ml unit dose vials
Inhale the contents of one (5mg) or two (2 x 5mg) respule(s) using the nebuliser up to four times a day, or as directed by your doctor.
Supply 40 2ml respules.
Short-acting antimuscarinic: inhaler +/- spacer device
Age from 16 years onwards
Ipratropium CFC-free MDI: 1 to 2 puffs up to 4 times a day
Ipratropium bromide 20micrograms/actuation inhaler CFC free
Inhale one to two puffs three to four times a day.
Supply 1 200 dose inhaler.
AeroChamber Plus spacer device: for use with Atrovent inhaler
AeroChamber Plus
Use to aid inhalation.
Supply 1 spacer.
Short-acting antimuscarinic (ipratropium): nebules
Age from 16 years onwards
Ipratropium nebules: 250mcg up to four times a day
Ipratropium bromide 250micrograms/ml nebuliser liquid 1ml unit dose vials
Inhale the contents of one vial (250micrograms) using the nebuliser up to four times a day.
Supply 20 1ml vial.
Ipratropium nebules: 500mcg up to four times a day
Ipratropium bromide 250micrograms/ml nebuliser liquid 2ml unit dose vials
Inhale the contents of one vial (500micrograms) using the nebuliser up to four times a day.
Supply 20 2ml vials.
Long-acting antimuscarinic (tiotropium): preparations
Age from 18 years onwards
Tiotropium Combopack: 18micrograms once a day
Tiotropium bromide 18microgram inhalation powder capsules with device
Inhale the contents of one capsule once a day.
Supply 1 combopack.
Tiotropium capsules refill pack: 18micrograms once a day
Tiotropium bromide 18microgram inhalation powder capsules
Inhale the contents of one capsule once a day.
Supply 30 capsules.
Tiotropium solution for inhalation: 5micrograms once a day
Tiotropium bromide 2.5micrograms/dose solution for inhalation cartridge with device CFC free
Inhale two puffs once daily.
Supply 1 Device.
Combivent nebuliser UDV
Age from 16 years onwards
Combivent nebuliser solution UDV: 2.5mL three to four times a day.
Combivent nebuliser liquid 2.5ml UDVs
Inhale the contents of one vial (2.5mL) using the nebuliser three to four times a day.
Supply 120 Vials.
Long-acting beta2-agonist: inhalers +/- spacer device
Age from 16 years onwards
Formoterol CFC-free MDI: Atimos Modulite 12mcg twice a day
Formoterol 12micrograms/dose inhaler CFC free
Inhale one puff twice a day.
Supply 1 100 dose inhaler.
AeroChamber Plus spacer device
AeroChamber Plus
Use to aid inhalation.
Supply 1 spacer.
Formoterol DPI: Foradril 12mcg twice a day
Formoterol 12microgram inhalation powder capsules with device
Inhale one puff twice a day.
Supply 1 60 dose inhaler.
Formoterol
DPI: Oxis Turbohaler once or twice a day
Oxis Turbohaler 12
Inhale one puff once or twice a day.
Supply 1 60 dose inhaler.
Salmeterol CFC-free MDI: 50mcg twice a day
Salmeterol 25micrograms/actuation CFC-free inhaler
Inhale two puffs twice a day.
Supply 1 120 dose inhaler.
Volumatic spacer device: for use with Serevent inhaler
Volumatic
Use to aid inhalation.
Supply 1 spacer.
Salmeterol DPI: Powder blisters + device 50mcg twice a day
Salmeterol 50microgram inhalation powder blisters with device
Inhale the contents of one blister twice a day.
Supply 15 4-blister disks.
Salmeterol DPI: Accuhaler 50mcg twice a day
Salmeterol 50micrograms/actuation dry powder inhaler
Inhale one puff twice a day.
Supply 1 60 dose inhaler.
Age from 18 years onwards
Formoterol DPI: Easyhaler 12mcg twice a day
Formoterol Easyhaler 12micrograms/dose dry powder
Inhale one puff twice a day.
Supply 1 120 dose inhaler.
Inhaled corticosteroids +/- spacer device
Age from 16 years onwards
Beclometasone CFC-free MDI (Clenil): 400mcg twice a day
Clenil Modulite 200micrograms/dose inhaler
Inhale two puffs twice a day using the spacer.
Supply 1 200 dose inhaler.
Beclometasone CFC-free MDI (Clenil): 500-1000mcg twice a day
Clenil Modulite 250micrograms/dose inhaler
Inhale two to four puffs twice a day, using the spacer
Supply 2 200 dose inhaler.
Beclometasone CFC-free MDI (Qvar): 200mcg twice a day
Qvar 100 inhaler
Inhale two puffs twice a day.
Supply 1 200 dose inhaler.
Beclometasone CFC-free MDI (Qvar): 200-400mcg twice a day
Qvar 100 inhaler
Inhale two to four puffs twice a day.
Supply 2 200 dose inhaler.
Fluticasone CFC-free MDI: 250-500mcg twice a day
Fluticasone 250micrograms/actuation inhaler CFC free
Inhale one to two puffs twice a day.
Supply 1 120 dose inhaler.
Volumatic spacer: for use with Clenil or Flixotide
Volumatic
Use to aid inhalation.
Supply 1 spacer.
Budesonide CFC-free MDI: 400mcg twice a day
Budesonide 200micrograms/dose inhaler CFC free
Inhale two puffs twice a day.
Supply 1 120 dose inhaler.
NebuChamber spacer device: for use with Pulmicort
NebuChamber with child mask
Use to aid inhalation.
Supply 1 spacer.
Corticosteroid & long-acting beta2-agonist: combination inh
Age from 16 years onwards
Seretide 500 Accuhaler: one puff twice a day
Seretide 500 Accuhaler
Inhale the contents of one blister twice a day.
Supply 1 60 dose inhaler.
Symbicort 400/12 Turbohaler: one puff twice a day
Symbicort 400/12 Turbohaler
Inhale one puff twice a day.
Supply 1 60 dose inhaler.
Aminophylline and theophylline preparations
Age from 16 years onwards
Aminophylline: Phyllocontin Continus m/r tablets
Phyllocontin Continus 225mg tablets
Take one tablet twice a day for 1 week, then take two tablets twice a day.
Supply 98 tablets.
Theophylline MR: Nuelin SA m/r tablets 175mg twice a day
Nuelin SA 175mg tablets
Take one tablet twice a day.
Supply 60 tablets.
Theophylline MR: Nuelin SA m/r tablets 350mg twice a day
Nuelin SA 175mg tablets
Take two tablets twice a day.
Supply 120 tablets.
Nuelin SA m/r tablets: 500mg twice a day
Nuelin SA 250 tablets
Take two tablets twice a day.
Supply 120 tablets.
Theophylline MR: Slo-Phyllin m/r capsules 250mg twice a day
Slo-Phyllin 250mg capsules
Take one capsule twice a day.
Supply 56 capsules.
Theophylline MR: Slo-Phyllin m/r capsules 500mg twice a day
Slo-Phyllin 250mg capsules
Take two capsules twice a day.
Supply 112 capsules.
Theophylline MR: Uniphyllin Continus m/r tablets 200mg twice a day
Uniphyllin Continus 200mg tablets
Take one tablet twice a day.
Supply 56 tablets.
Theophylline MR: Uniphyllin Continus m/r tablets 300mg twice a day
Uniphyllin Continus 300mg tablets
Take one tablet twice a day.
Supply 56 tablets.
Theophylline: Uniphyllin Continus m/r tablets 400mg twice a day
Uniphyllin Continus 400mg tablets
Take one tablet twice a day.
Supply 56 tablets.
Mucolytic therapy: starting doses
Age from 16 years onwards
Start carbocisteine: 750mg three times a day
Carbocisteine 375mg capsules
Take two capsules three times a day.
Supply 180 capsules.
Start mecysteine: 800mg/day for 2 days, then 600mg/day
Mecysteine 100mg gastro-resistant tablets
Take two tablets four times a day for 2 days, then take two tablets three times a day.
Supply 184 tablets.