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NICE guidelines for chronic obstructive pulmonary disease - a review.

VOL: 100, ISSUE: 24, PAGE NO: 48

Christine Fehrenbach, RGN, is senior respiratory nurse, Portsmouth Hospitals NHS Trust, vice chairperson, British Thoracic Society COPD Consortium, and regional trainer, National Respiratory Training Centre

Most nurses who care for adult patients will care for people with COPD. It is hoped the new guidelines for the management of COPD from the National Institute for Clinical Excellence (NICE, 2004) will help to improve the management of this condition.

Most nurses who care for adult patients will care for people with COPD. It is hoped the new guidelines for the management of COPD from the National Institute for Clinical Excellence (NICE, 2004) will help to improve the management of this condition.

The guidelines include management strategies already in widespread use but there are also new recommendations that are not currently happening in practice. Respiratory nurse specialists will find them invaluable for creating evidence-based care packages.

This article will discuss the seven key priorities identified by the new guidelines, which are: diagnosis; smoking cessation; inhaled therapy; pulmonary rehabilitation; exacerbations; non-invasive ventilation; and multidisciplinary working.

Diagnosis
COPD, which encompasses chronic bronchitis and emphysema, remains a neglected disease area and is still significantly underdiagnosed. A survey conducted by MORI for the British Thoracic Society's COPD Consortium found that one in five smokers has a persistent cough yet half of them do not realise that it could be an early warning sign of lung disease. Other signs include breathlessness on mild exertion, persistent production of phlegm, and a frequent cough.

Spirometry Spirometry (a lung function test) remains essential for the diagnosis of COPD. Spirometry should be considered for someone over 35 years of age with symptoms of COPD who is a smoker or ex-smoker.

Spirometry results will indicate COPD if the FEV1 <80 per cent predicted and the FEV1/FVC ratio <0.7 per cent. Practice nurses must perform spirometry in line with the new General Medical Services (GMS) contract's Quality and Outcomes Framework. The classification of severity is based on the severity of the percentage of the predicted FEV1 (Box 1).

The patient's assessment should also include:

- The assessment of disability using the Medical Research Council (MRC) dyspnoea scale (Table 1) (Fletcher et al, 1959);

- The frequency of exacerbations;

- Other prognostic factors including body mass index, oxygen saturation, and the presence of cor pulmonale.

Smoking cessation
All patients with COPD should be encouraged to stop smoking and should be offered bupropion or nicotine replacement therapy combined with a support programme. The patient's readiness to quit should be assessed every six months to allow the smoker to regain motivation.

Inhaled therapy
Most patients, whatever their age, can learn how to use an inhaler unless they have significant cognitive impairment. It is usually beneficial to use hand-held devices with a spacer (this removes the need for coordination between the actuation of a pressurised metered-dose inhaler and the inhalation). If a patient cannot use a particular inhaler, try another.

Inhaler technique should be taught before the device is issued and the technique should be checked regularly. Nebulised therapy should be considered only when breathlessness becomes disabling and distressing despite maximal therapy with inhalers.

Bronchodilators Bronchodilators are by far the most widely used treatments and the introduction of long-acting drugs has marked a significant advance. Although the disease is characterised by a substantially irreversible airflow obstruction, bronchodilators are effective at reducing breathlessness and improving exercise capacity. They also have an effect on hyperinflation of the lungs.

Response to treatment should be measured in terms of subjective symptomatic control following a therapeutic trial. Both short and long-acting beta2-agonist and anticholinergic inhaled drugs are effective.

Inhaled corticosteroids Our understanding of the role of inhaled corticosteroids in the management of COPD has become clearer. They do not reduce the rate of decline in lung function but may reduce exacerbations and the rate of decline in health status in moderate and severe disease (Burge et al, 2000; Pauwels et al, 1999; Vestbo et al, 1999).

Inhaled steroids should be used with all patients who have COPD whose FEV1 is less than 50 per cent of the predicted value and who have experienced two or more exacerbations in the previous 12 months.

The guidelines suggest that the side-effects of high dose inhaled corticosteroids (for example, osteoporosis or cataract) need to be considered. Long-term use of oral steroids is not recommended.

Pulmonary rehabilitation
A typical rehabilitation programme includes gentle physical exercise carefully tailored to each individual, and advice on lung health and how to cope with breathlessness. These components are delivered in a friendly, supportive atmosphere.

The aim is to enable people to become as active as possible and enjoy life. The guidelines suggest pulmonary rehabilitation should be offered to all patients who consider themselves disabled by COPD. However, pulmonary rehabilitation is not yet available everywhere. This inequality was highlighted by the British Lung Foundation and the British Thoracic Society (2003) and presents a challenge to all clinical areas to meet this need.

Exacerbations
Repeated exacerbations of COPD result in an accelerated decline in lung function and a reduced health status. The guidelines recommend:

- Influenza and pneumococcal vaccination;

- Self-management plans;

- The early use of oral steroids and antibiotics.

The development of 'hospital-at-home' services is advocated. These schemes provide a cost-effective answer to utilising hospital beds (Skwarska et al, 2000) and are preferred by some patients.

The treatment of an exacerbation in hospital remains unchanged but there are excellent recommendations for use of oxygen, especially during transportation of patients. Advice is given on the monitoring of peak expiratory flow (PEF), which is considered unnecessary during hospital admission. The guidelines also cover discharge planning.

Non-invasive ventilation
Ventilatory support for patients with hypercapnic respiratory failure should be provided by all hospitals with departments in respiratory medicine. When patients are started on NIV there should be a clear plan covering what to do in the event of deterioration, and ceilings of therapy should be agreed. With the advent of this intervention the topic of end-of-life decisions will become a common feature of consultations in primary and secondary care.

Multidisciplinary working
Patients should be managed by teams of health professionals including physiotherapists, dietitians, occupational therapists, social workers, and palliative care providers. Respiratory nurse specialists are recommended for the assessment and management of COPD. This should be considered when creating business plans for new positions. Education packages should take account of the different needs of patients at the various stages of the disease. Asthma education packages are not suitable for patients with COPD.

Additional areas of change
Mucolytic therapy Despite its widespread use in Europe, mucolytic therapy (drugs used to facilitate expectoration by reducing sputum viscosity) has not been used in the UK and until last year mucolytic drugs were 'blacklisted' in the NHS. There is good evidence for the efficacy of this therapy in reducing exacerbations and improving symptoms in patients with chronic bronchitis. It should be tried in patients with a chronic productive cough for one month and continued if there is a clear clinical benefit.

Oxygen therapy The guidelines advocate appropriate use of oxygen therapy, ambulatory oxygen, and short-burst oxygen therapy. Measurement of arterial oxygen saturation with an oximeter is now recommended at routine follow-up visits. Oximetry is also of value in assessing the severity of COPD.

Palliative care This has a role for patients dying from non-cancer conditions including COPD. The prognosis for some patients can be poor. The guidelines suggest these patients benefit from the services of multidisciplinary palliative care teams including admission to hospices. Opiates can be used for the palliation of breathlessness.

Diet and depression The guidelines acknowledge that both these areas are important and make recommendations. Patients should be assessed for anxiety and depression and treated if necessary. Nutritional status should be assessed using body mass index and treatment considered for patients who fall outside of the normal range.

Conclusion
COPD is an important disease that affects many people and is often undiagnosed. The guidelines provide evidence to support management strategies. Nurses should obtain the guidelines wherever they practise, and health commissioners will be expected to respond and implement the guidance (Box 3). Following it will lead to better care for all patients with COPD.

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