COPD Assessment and Action Plan

The assessment of COPD requires a multifactorial approach. Spirometry is required for diagnosis and is useful for assessment of severity of airway obstruction. However after having established a spirometric diagnosis, management decisions should be individualized and guided by the severity of symptoms and disability, as measured by the MRC scale.
  • Canadian Thoracic Society COPD Guidelines - 2008 update
  • Global initiative for chronic Obstuctive Lung Disease - 2017

    • What is COPD?
    Who should be screened?
    Goals of Care
    Non-pharmacotherapy
    Pharmacotherapy
    Who should get home O2?
    End of life care




    Patient name Date:
    Patients age: Sex:

    Spirometry results (post bronchodilator).   Cannot diagnosis COPD without spirometry.

    FEV1/FVC as ratio (post bronchodilator). Must be < 0.70 for diagnosis of COPD

    FEV1 as a percentage of predicted (post bronchodilator), predictor of survival, consider oxygen if < 40. NOT used as guide to bronchodilator Rx.
    Modified British Medical Research Council Questionnaire:   mMRC Grade 4 suggests < 3 yr survival
     

    Grade 0: I only get breathless with strenuous exercise

    Grade 1: I get shortness of breath when hurrying on the level or walking up a slight hill

    Grade 2: I walk slower than people of the same age on the level because of breathlessness OR.....
                    I have to stop for breath when walking at own pace on the level

    Grade 3: I stop for breath after walking about 100 m or after a few minutes on the level

    Grade 4: I am too breathless to leave the house or I am breathless when dressing or undressing
    COPD Assessment Test (CAT) Score - use for GOLD ABCD algorithm

    CAT Score (significant if ≥ 10)

    CAT date (consider repeating if results stale ).
    Exacerbations in PAST YEAR - use for GOLD ABCD algorithm Yes             No

    More than 2 per year without hospitalization, or any COPD-related hospitalization (may need ICS, check eosinophils)

    		          
    Smoking history: (increased risk after 5 pack-years) Pack year       Current per day

    What is your smoking history? (active smokers have higher risk of exacerbation)    		            
    Comorbidity symptoms:

    Ankle swelling, findings of right heart failure/cor pulmonale

    Weight loss/lean body mass (increased likelihood of exacerbation)
     

    GOLD Grade

    		 mMRC CAT Exacerbations per Year
    A 0 - 1 < 10 0 - 1 in community, but no hospitalization
    B ≥ 2 ≥ 10 0 - 1 in community, but no hospitalization
    C 0 - 1 < 10 ≥ 2 in community, or ≥ 1 leading to hospitalization
    D ≥ 2 ≥ 10 ≥ 2 in community, or ≥ 1 leading to hospitalization

    Legend: Advisable Suggested Consider
    Pharmacotherapy:

    Short-acting bronchodilator (B2 agonist and/or muscarinic agent) e.g QID PRN

    		SABA/SAMA: Ventolin, Ventodisk, Bricanyl, Atrovent, Combivent
    Long-acting muscarinic agent (preferred first agent) OR LAMA: Spiriva, SeeBri, Tudorza, Incruse  
    Long-acting B2 agonist OR LABA: Serevent, Oxeze, Foradil, OnBrez, Striverdi
    Long-acting B2 agonist/muscarinic agent combo OR Combo LABA/LAMA: Ultibro, Anoro, Duaklir, Inspiolto
    Long-acting B2 agonist/inhaled corticosteroid combo (never use ICS alone) Combo LABA/ICS: Advair, Symbicort, Breo, Zenhale
    PDE-I (Phosphodiesterase inhibitor) Theophylline (Theodur BID PO)
    PDE-4 Inhibitor (especially if FEV1 <50 + pt has chronic bronchitis) Daxas (Roflumilast) 500 mcg qd (q2d to reduce GI upset)
    Daily antibiotics, long-term (especially former smokers) Zithromax 250 mg qd - MWF

    Follow up:

    Dependent on severity of illness, frequency of exacerbations and hospitalisations. There is no consensus regarding repeat pulmonary function testing, imaging or frequency of visits.

    Other strategies:
    Consider smoking cessation (QuitNow)     Check if referral made
    Encourage annual influenza vaccination
    Check pneumococcal vaccination status        
    Check inhaler technique; use YouTube resources; ask Pharmacist to teach; https://www.lung.ca/lung-health/get-help/how-use-your-inhaler
    Consider nebulizers
    Consider pulmonary rehabilitation          (Especiallly within 2 weeks of exacerbation)
    Create a personalized COPD Action Plan (Patient self management education - see below)
    Consider home O2 assessment               HOP Criteria  
    Consider ACP               


    COPD Action Plan
    ()


    Physician:


    You have been diagnosed with COPD (chronic obstructive pulmonary disease)
    COPD has 2 states:
    1. You are stable. You are not short of breath, can do daily activities, can cough up mucus easily, sleep well,
        and are able to exercise. Or.....
    2. You are having a flare up.

    How to tell if you are having a flare up
    A flare up may occur after you get a cold, get run down, are exposed to air pollution, or during very hot/cold weather
    weather. There are 3 things that define a flare up:
    1. Increased and persisting shortness of breath from your usual level. (Consider using just Prednisone to manage symptoms)
    2. Worsening of usual cough. (Probably require both antibiotics AND Prednisone)
    3. Change in usual sputum: colour change from white to yellow, green, or rust; increase in amount of sputum.
        You may also have fever, fatigue or low energy; feel a change in mood; or have chest x-ray changes noted prior to a
        flare-up.

    If 2 or more of these symptoms persist for 24 hours or more, do the following:
    Take your rescue inhaler 2-4 puffs as needed (up to 4-6 times per day) for shortness of breath.
    Call for an appointment with your family doctor for a check up and medication review.
    Use prescribed ANTIBIOTIC for a COPD flare up:
          Take
    Use prescribed Prednisone for a COPD flare up. Take
    Call for a more urgent appointment if you feel worse or if you do not feel better after 48 hours of treatment.
    Other:

    If you are extremely breathless, anxious, fearful, drowsy or having chest pain, call 911 for an ambulance to take you to the nearest Emergency Department!

    Physician Signature:



    Patient Signature: (optional)


    Goals of COPD management

    1) Prevention of disease progression (smoking cessation is the key)
    2) Decrease of frequency and severity of exacerbations
    3) Decrease symptoms, including breathlessness
    4) Improve exercise tolerance and daily activities
    5) Recognize and treat flareups early
    6) Prevent hospitalizations and emergency visits
    7) Decrease premature death

    COPD Maintenance Medication Record

    Take the following maintenance medications as prescribed to help maintain control of your COPD symptoms.


    MEDICATION PRESCRIBED Type of medication

    COPD Flare-up Medication Record

    Please fill in the medication used, and the start and finish dates.


    MEDICATION PRESCRIBED Start Date Finish Date
       
       
       
       
       
       

    Patient Resources

    Smoking Cessation:
  • Quit Now (www.quitnow.ca)

    • Subject:

      Rx for EXACERBATIONS:

      First Line:
    Doxycycline 100 mg bid 10 days
    SeptraDS 1 bid 10 days
    Ceftin 500 mg bid 10 days
    Biaxin 500 mg bid 10 days

      Second Line or Complicated COPD:
    Clavulin 500 mg tid 10 days
    Levaquin 500 mg od 10 days
    Avelox 400 mg od 10 days
    Suprax 400 mg od 10 days
    Combo Biaxin + Suprax 10 days

      Complicated COPD:
        - FEV1 < 50% predicted
        - > 3 exacerbations per yr
        - on Home Oxygen
        - existing GERD
        - Ischemic Heart Disease
        - chronic oral steroid use
        - recent Abx use in past 3 months
        - previous pneumonia
        - low BMI
        - advancing age
        - current smoker

      Prednisone:
    Prednisone 50 mg for 5-7 days
    Prednisone 40 mg for 5-7 days
    Prednisone 30 mg for 5-7 days
    Prednisone 20 mg for 5-7 days

     


      Rx for MAINTENANCE:

      SAMA:
    Ipratropium
    Ipratropium/Salbutamol

      SABA:
    Salbutamol
    Terbutaline

      LAMA:
    Tiotropium
    Glycopyrronium
    Aclidinium
    Umeclidinium

      LABA:
    Formoterol
    Salmeterol
    Indacaterol
    Olodaterol

      LABA/ICS:
    Salmeterol/Fluticasone
    Formoterol/Budesonide
    Vilanterol/Fluticasone
    Formoterol/Mometasone

      LABA/LAMA:
    Aclidinium/Formoterol
    Indacaterol/Glycopyrronium
    Olodaterol/Tiotropium
    Vilanterol/Umeclidinium

      LABA/LAMA/ICS:
    Fluticasone/Umeclidinium/Vilanterol
    Budesonide/Glycopyrronium/Formoterol

      ICS:
    Fluticasone
    Budesonide

      Oral Meds:
    Theophylline
    Roflumilast
    Azithromycin