Some changes in the management of chronic obstructive pulmonary disease (COPD) are expected in the new National Institute for Clinical Excellence (NICE) guidelines due for publication soon, endorsed by the British Thoracic Society (BTS).
Respiratory Nurse Consultant, Leicestershire, and Part Time Clinical Fellow, University of Aberdeen
COPD is a chronic, progressive disease of airway obstruction, predominantly caused by smoking, with breathlessness a hallmark symptom. In the past it was largely neglected, with nurses and doctors feeling they could do little to help patients. However, a new philosophy has emerged and new therapies are now known to help reduce symptoms, improve exercise capacity and increase quality of life.
Around 900,000 people in the UK are diagnosed with COPD, though another 450,000 are thought to be misdiagnosed with asthma (which can lead to inappropriate treatment) or left undiagnosed. The total annual cost of COPD to the NHS is estimated at over £980 million a year. Around half of this is due to inpatient hospitalisation resulting from exacerbations of symptoms. Costs to general practice are also high.
Improvements in management of COPD will not only benefit a huge number of people, but the NHS as well. The National Collaborating Centre for Chronic Conditions, which is producing the new evidence-based guidelines for NICE, is looking at several key areas where recommendations are likely to have a large impact on COPD management.
In light of the underdiagnosis and misdiagnois of COPD, new guidelines should highlight the possibility of a diagnosis of COPD in smokers or ex-smokers with breathlessness, cough, sputum, wheeze or winter bronchitis.
While spirometry is still essential for confirming the diagnosis of COPD, it might not be so useful for differentiating COPD from asthma. The last UK COPD guidelines, published in 1997, reflected routine use of spirometric reversibility testing using bronchodilators or corticosteroids to differentiate the two conditions. But this test is falling out of favour because of inconsistencies and its inability to predict long-term responses. Differentiation from asthma can usually be made on a good history and clinical grounds, assessing response to treatment if necessary.
Treatments are discussed in Box 1.
When the last BTS guidelines were produced, pulmonary rehabilitation for COPD was in its infancy, but the benefits of this ‘holistic’ approach is now well documented. While the new recommendations are likely to advocate pulmonary rehabilitation, such services are still sparse in many areas and any nurses running these facilities may find themselves inundated with requests for their service.
Smoking cessation remains one of the most important factors of COPD management and would almost certainly remain a priority in the new guidelines. Those involved with COPD patients should remember to harness opportunities for stopping smoking. Most trusts run free clinics and nicotine replacement products are now available on prescription.
The COPD guidelines from NICE are long awaited. They will be compulsory reading for all nurses involved with the treatment of COPD.
The guidelines will be published on the NICE website (www.nice.org.uk) and in Thorax.
The BTS COPD Consortium will be publishing some practical pointers, which will summarise key issues and will also be worthwhile reading.