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OUTPATIENT MANAGEMENT OF COPD
ASPECT OF CARE MONITOR RECOMMENDATIONS
Screening
It is important to obtain a thorough history to screen
for risk factors especially cigarette smoking,
occupational exposure, and outdoor/indoor pollution.
The most important risk factor for COPD is cigarette
smoking.
At initial assessment and periodically determine risk
factors and causes of exacerbations. Initiate and
monitor cigarette and smoking cessation
Diagnosis
Symptoms:
Chronic cough throughout the day
Any pattern of sputum production
Dyspnea that is progressive, persistent, worse on
exercise, worse during respiratory infections
Repeated episodes of acute bronchitis
History of exposure to tobacco smoke , occupational
dusts and chemicals
Smoke from home cooking and heating fuel
The diagnosis should be confirmed by spirometry if
patient has symptoms.
At initial assessment and annually. According to the
GOLD standards, spirometry can be used to monitor
disease progression but to be reliable the intervals
between measurements must be at least 12 months
apart.
Additional tests for the assessment of a patient with
Stages II-IV: Bronchodilator Reversibility Testing,
CXR, ABG
Classification by Severity:
Stage 0: At Risk
Chronic cough and sputum production
Lung function is normal
Avoidance of risk factors
Annual Influenza Vaccine
Stage 1 Mild COPD
FEV
1
>=80% FEV
1
/FVC<70%
Mild airflow limitation, and usually, but not always,
chronic cough and sputum production.
Short Acting Bronchodilator when needed
Albuterol, terbutaline, metaproterenol,
ipratropium (Tier 1)
Proventil HFA, Ventolin HFA, Atrovent HFA
(Tier 2)
Stage 2 Moderate COPD
FEV
1
/FVC < 70%
50%<=FEV
1
<80% predicted
Worsening airflow limitation, and usually the
progression of symptoms, with shortness of breath,
developing on exertion.
Continue short acting Bronchodilators as needed
Add treatment with one or more long acting
bronchodilators
Servent, Spiriva (Tier 2)
Pulmonary Rehabilitation
Stage 3 Severe COPD
FEV
1
/FVC < 70%
30%<=FEV
1
<50% predicted
Further worsening of airflow limitation, increased
shortness of breath, and repeated exacerbations which
have an impact on patients’ quality of life.
Short and long acting bronchodilators
Pulmonary Rehabilitation
Inhaled Glucocorticosteroids if repeated exacerbations
Asmanex, Flovent HFA, Pulmicort (Tier 2)
Combo w/ long-acting bronchodilator: Advair
(Tier 2)
Stage 4 Very Severe COPD
FEV
1
/FVC < 70%
FEV
1
<30% predicted or FEV
1
<50% predicted plus
chronic respiratory failure
Severe airflow limitation, quality of life is very
appreciably impaired, and exacerbations may be life
threatening
Add long term care oxygen
Initiate oxygen therapy for patients with Stage IV:
Very Severe COPD if:
1. PaO
2
is < or = 55mm Hg or SaO
2
is < or = 88%
with or without hypercapnia or 2. PaO
2
is between
55mm Hg and 60 mm Hg or SaO
2
is 89%, if there is
evidence of pulmonary hypertension, peripheral
edema, suggesting CHF or polycythemia
Patient Education/Prevention of Complications
Patient education is an effective way to accomplish
smoking cessation, improve knowledge of disease
and associated signs and symptoms, and improve
responses to acute exacerbations.
How to assess severity of an exacerbation:
PaO
2
< 60mmHg and/or SaO
2
< 90% with or without
PaCO
2
>50mmHg when breathing room air indicates
respiratory failure
PaO
2
< 50 and PaCO
2
>70 and pH<7.30 suggest a life
threatening episode that needs close monitoring or
critical management:
Smoking cessation (all stages COPD)
Yearly Influenza vaccination (all stages COPD)
Pneumococcal Vaccine:
One dose for persons under 65 who have chronic
disorders of the pulmonary systems.
One dose for unvaccinated persons age 65 and older.
One dose revaccination for persons age 65 and older
if they received the vaccine greater than or equal to 5
years previously and were less than 65 years at time
of primary vaccination.
Increase bronchodilator therapy
Consider antibiotic therapy for bacterial infection
Consider corticosteroids if no improvement in
symptoms; Administer O
2
as needed;, Increase social
support; Improve exercise tolerance
Indications for Hospital Admissions:
Insufficient home support; newly occurring
arrhythmias; significant co-morbidities; onset of new
physical signs (cyanosis, peripheral edema); failure of
exacerbation to respond to initial medical treatment;
severe background COPD; marked increase in
intensity of symptoms such as development of resting
dyspnea
This table of suggested guidelines has been developed from the American Diabetes Association: 2007 Standards of Medical Care in Diabetes: Diabetes Care 29: S4-S42, 2006.
It is intended to
provide guidance to practitioners to reduce risks associated with diabetes, increase awareness of diabetes, and to optimize disease management. It contains guidelines only and should never supersede
clinical judgment. The practitioner in conjunction with the patient should decide whether these or other recommended services should be performed more or less frequently. Clinical judgment and
discussion should be documented in the medical record **Utilization Management Committee will review Guidelines for new scientific evidence or national standard changes prior to distribution to
Providers annually.
