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Chronic Obstructive Pulmonary Disease (COPD) Care Pathway Overview

The COPD pathway has been refreshed to support the diagnosis, referral and optimal management of COPD in adults with addition of myCOPD application details increasing the offering for patients referred to Pulmonary rehabilitation.

Please click the relevant flowchart box to be taken directly to textual information.

Red Flags
  • Haemoptysis                                 
  • Weight loss
  • Acute breathlessness
  • Crushing central chest pain at rest or on exertion
  • Very low less than 90% SpO2
  • Finger clubbing and/or abnormality on chest x-ray
Consider Arranging Urgent Admission via Emergency Department (ED)
Presentation

Over 35 years

Smokers or ex-smokers

 

Have any or a combination of the following symptoms

  • Breathlessness on exertion
  • Chronic cough
  • Regular sputum production
  • Frequent winter bronchitis or chest infections
  • wheeze
Differential Diagnosis

Pulmonary:                                                                       

  • Asthma                                                                            
  • Bronchiectasis                                                                 
  • Sarcoidosis
  • Tuberculosis
  • Lung cancer
  • Interstitial pulmonary fibrosis
  • Pleural disease

 

Extrapulmonary:

  • Congestive cardiac failure
  • 'Gastro-oesophageal Reflux'
  • Drug induced: ACEi, Methotrexate
Initial Primary Care Assessment

There is no single diagnostic test for COPD and on examination various signs may be present.  The diagnosis is based on a combination of history (substantial smoking history or exposure to other noxious compound, persistent progressive symptoms, recurrent ‘winter bronchitis), the presence of symptoms (some of: exertional breathlessness, cough, regular sputum production, wheeze), the confirmation of airflow obstruction by spirometry testing, and the absence of any reasonable other diagnosis.

Obstruction demonstrated on spirometry testing with a history and symptoms consistent with COPD confirms the diagnosis. If there is diagnostic doubt negative reversibility testing rules out asthma as a differential diagnosis.

Initial Primary Care Management

If you suspect COPD the following should be performed:

Diagnosing COPD Checklist:

  • Chest x-ray
  • Full blood count
  • Pulse oximetry
  • Spirometry with reversibility if patient well enough to perform- otherwise postpone until patient is well.

 

Provide Patient Information Leaflets, signpost to Online Resources and Community Resources.

Annual Review

The following should be completed on an annual basis, NICE guidance suggests that those most vulnerable and at risk of deterioration should be seen more frequently.

Check the diagnosis of COPD was based on an accurate history and confirmed by post bronchodilator quality assured spirometry demonstrating a FVC/FEV1 or RVC/FEV1 ratio (whichever is less) ratio of less than 0.7. Subsequent spirometry testing will also demonstrate reduced ratio results of less than 0.7. FEV1 is likely to be less than 80% of predicted, diagnosis can be made if FEV1 is greater than 80% predicted if the person has symptoms.

The COPD Assessment Test (CAT Score), MRC score or Clinical COPD Questionnaire (CCQ) are validated questionnaires used to measure the symptom burden in COPD. When using these tools it is also useful to look at the weighting of where the patient is scoring - is it cough and sputum or is it breathlessness for example, and the subsequent scoring over time to look for a rise or fall in the score indicating a change in condition, as well as the total score at the time of completion.

GOLD also uses symptoms scoring (mMRC or CAT) as one of the factors to calculate treatment in the ABCD algorithm. This is also necessary for risk stratification using tools such as the DOSE index.

Patients with predominant symptoms of cough with tenacious sputum may benefit from education on sputum clearance techniques as this will ease breathlessness and fatigue. Referral to a respiratory physiotherapist may be necessary or access to written information may be enough.

Introduction of an oral mucolytic, such as carbacysteine, may be beneficial – review after a six week trial but stop if no useful effect noticed.

Ask about the action of inhaled medication – does it help with breathlessness? If there is no benefit consider stopping it. Check the patient understands what to expect as an effect or side effect from prescribed medication.  Discuss the prescribed regimen and adherence with it. Consider the number of prescriptions issued against the prescribed regimen – is it correct?

Check no other medication is worsening breathlessness – beta blockers for example

Always check inhaler technique and correct or fine tune errors. All health care professionals consulting with COPD patients should take the opportunity to check inhaler technique.

Dry powder inhalers need fast deep inhalations from the start of the inhalation whilst aerosol inhalers require a slow gentle inspiration. Aim to use the same type of device for all inhaled medications. If unable to use the device change to an appropriate device that the person is able to use after instruction.

The only effective device is one a patient can and will use.

See the Right Breathe website for further information.

A record of oxygen saturation at rest when not undergoing an exacerbation is extremely valuable in assessing the severity of exacerbation. If saturation is below 92% a referral for oxygen assessment should be considered.

Oxygen is not a treatment for breathlessness but is to prevent organ damage due to hypoxia. It should only be prescribed following assessment by a specialist (this might be a specialist nurse). Long term oxygen therapy, once prescribed, needs to be used, as prescribed, for at least 15 hours a day.

FEV1 should be measured annually during a period of stability (when the person has been stable for at least 6 weeks). Accelerated decline in lung function or a change in the spirometric pattern, for example from an obstructive to restrictive pattern, needs further investigation.

A microspirometer can be used during the annual review to measure the FEV1 but if the result is found to be outside of the expected parameters in any way the person must be referred for full diagnostic spirometry by a qualified health care professional as well as any further investigations considered necessary eg chest x-ray. Microspirometry can also be used for case finding or screening but must never be used for diagnosis.

All people with COPD need to be encouraged to remain active to avoid the spiral of decline associated with COPD. Daily activities such as gardening and shopping maintain fitness but exercise in addition to this is beneficial. Being slightly short of breath associated with activity is not harmful but patients need to be reassured of this and have medication optimised to allow activity.

Those who qualify for pulmonary rehabilitation should be encouraged to take up the opportunity to attend and be referred.

Tobacco dependence needs to be discussed by every clinician at each consultation in a structured way.

Use the NICE recommended MECC (Making Every Contact Count) Very Brief Advice consultation style to discuss smoking.A MECC brief intervention involves a conversation, with negotiation and encouragement, and may lead to referral for other interventions, or more intensive support. 

  • Ask – is the person a smoker? If so what do they smoke and how much?
  • Advise – if the patient is ready to change, explain that the best way to quit is using pharmacotherapy – NRT or Varenicline – and the support of a trained advisor to support them through a quit attempt
  • Act – give the details of how to contact Healthy Lifestyles Gloucestershire for support through a quit attempt for a smoke free future.

See the Smoking Cessation section for further information.

Height and weight should be measured annually

Loss of height can be associated with osteoporosis from steroid use (oral or inhaled) and should be monitored and investigated.

(Unintentional) Loss of weight may suggest the patient has lost muscle mass and/or be at risk of malnutrition– monitoring weight more frequently that annually may be necessary and ideally a malnutrition risk score should be calculated using ‘MUST’. Advice should be given to improve nutrition by following GCCG ‘Food First’ guidance which includes information specific to COPD.

Obesity will worsen breathlessness so appropriate dietary advice should be considered also using a MECC approach.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) uses number of exacerbations as one of the factors to calculate treatment in the ABCD algorithm. This is also necessary for risk stratification using tools such as the DOSE index.

See the Global Initiative for Chronic Obstructive Lung Disease COPD Diagnosis Management and Prevention of Chronic Obstructive Pulmonary Disease (2018 report) for further information.

People with COPD often have up to 5 comorbidities and frequently will suffer depression and/or anxiety. If unaddressed this will impact on breathlessness, adherence with medication, ability to cope at home and access to unscheduled care. Discuss this and address or refer on appropriately. See the Depression / Anxiety Pathways for further information.

The cornerstone of good patient care is supported self-management based around education and shared decision making. Help the patient complete a Gloucestershire self-management plan based around the annual review. If appropriate issue a rescue pack of antibiotics and oral steroids to keep at home.

Please use this COPD self-management plan.

Actively encourage your patients to have their annual flu vaccination. Preventing infection helps reduce exacerbation of COPD. Protecting patients against influenza annually will reduce rates of influenza related exacerbation, as will a one off pneumococcal vaccination offer protection against some strains of pneumonia.

Many COPD patients will live well at home without help but many rely on help and support of family or carers. Unpaid family carers take the burden of care especially when patients become unwell or decline and if the carer is a spouse they may be elderly themselves. They may not know what support is available so referral to the Community Wellbeing Service (Social Prescribing) or Citizen’s Advice may be helpful.

Please see the Carers (Adult and Parent) and Carers (Children and Young People) pages for further information.

Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD)

Smoking cessation is a vital part in the management of COPD and must be discussed at every opportunity. Quit attempts are four times more likely to be successful when supported by appropriate pharmacotherapy and behavioural support.

Refer or direct the patient to the Healthy Lifestyles Gloucestershire service support (self-referral is available via the website). 

See the Smoking Cessation page for further information.

Please see the Clinician Education section for VBA Smoking cessation training for Health Care Professionals.

Promote Self-care

Signopost/refer to:

Please follow this link for the weight management pathway, referral and services in Gloucestershire.

Please follow this link for Gloucestershire Exercise on Referral schemes and referral guidance.  


Healthy Lifestyles Gloucestershire

Healthy Lifestyles Gloucestershire is an integrated service which provides people with lifestyle support through one single point of access for:

  • Smoking cessation
  • Weight management
  • Alcohol reduction
  • Physical activity support

Healthy Lifestyles Gloucestershire can also provide support on multiple pathways at the same time, for example, weight management and increasing physical activity.

Healthy Lifestyle Coaches don’t write diet plans or exercise programmes, instead it works with patients to collaboratively identify small changes that can be made in lifestyle and provides motivational support to achieve their lifestyle goals.

Please follow this link for further information and referral guidance.

Patients can also self-refer by calling 0800 122 3788 or visiting: hlsglos.org/referral-form

Pulmonary Rehabilitation is delivered in sites throughout the county by physiotherapists, occupational therapists and nurses.  It is a course that offers respiratory patients group sessions that include activity and education about their respiratory disease and improves the patient’s confidence and ability to self-manage.  It is an intensive course of two 2 hourly sessions over seven weeks and is highly recommended upon hospital discharge.   Please send referrals to: glos-care.glosrespiratoryteam@nhs.net  & refer to the criteria checklist on the Referral Form.

Please follow this link to local support groups, information on the Live Better to Feel Better (previously Experts Patients Programme) and Key Local Organisations.

Please follow this link for information on the Gloucestershire Stop Smoking Service, including referral and patient information leaflets.

Even if the patient is referred to the Healthy Lifestyles service please continue to support the patient.

Gloucestershire's Community Wellbeing (Social Prescribing) Hubs offer primary care health professionals a structured way of linking identified patients with support in their community. The aim is to encourage patients to access organisations and community groups, which can support patient’s wellbeing. These opportunities may include arts, creativity, physical activity, learning new skills, volunteering, mutual aid, befriending and self-help, as well as support with other matters such as employment, benefits, housing, debt, legal advice, or parenting problems. The co-ordinators use a strength based approach and offer one to one support as well as signposting.

Please follow this link for further information.

Prescribing Guidelines

The aim of treatment for people with COPD is to improve current control and prevent future risk (by preventing exacerbations and slowing disease progression). The Gloucestershire formulary guidelines follow national prescribing recommendations.

Additional GCCG Optimising the use of Inhaled Corticosteroids in COPD Guidance

The use of inhaled corticosteroids in patients with COPD should be considered for people who are GOLD category D. Some people may have been prescribed inhaled corticosteroids as part of their treatment regimen following older guidelines which may no longer be considered appropriate so consideration may be given to prescribing such therapy. A treatment algorithm has been developed for safe reduction to removal of inhaled corticosteroid.

Other relevant respiratory prescribing links can be found in the respiratory section of our joint formulary.

Supporting COPD self-management

Self-management plans are a tool around which patients can be engaged and motivated in their own care and encouraged to take responsibility for their health, giving them the information and education to do so.

Shared decision-making and patient-centred care need to be embedded in everyday practice — become routine — so that rather than consult, clinicians take a more coaching, motivational interviewing approach towards people with long-term conditions, such as COPD and supported to manage in the longer term. Supporting self-management is not a substitute for care from doctors and nurses, but a ‘hallmark of good care’.

Please use this COPD self-management plan.

Managing an exacerbation of COPD

An acute exacerbation of chronic obstructive pulmonary disease (COPD) is described as a sustained worsening of symptoms that is beyond normal day-to-day variation, and is acute in onset. This is a significant event that may result in worsening prognosis. Acute exacerbations of COPD may be due to bacterial or viral infection, or poor air quality.

Consider whether other diagnoses need to be excluded, including:

  • Pulmonary embolus
  • Pneumonia
  • Pneumothorax
  • Acute cardiac events

Consider whether other diagnoses need to be excluded, such as pulmonary embolus, pneumonia, pneumothorax and acute cardiac events. Once the diagnosis is established a clinical assessment of severity is required to determine management.

Does this patient need admitting to hospital? If so telephone Single Point of Clinical Access (SPCA) to discuss the best option for your patient

Most exacerbations can be managed at home, but consider the following when assessing the severity of your patient’s condition and whether or not they need hospitalisation:

  • Marked breathlessness
  • SaO2 92% or below (unless this is normal for the person)
  • ↓ level of consciousness, confusion
  • ↑ respiratory rate
  • Pursed lip breathing
  • New onset cyanosis
  • High fever
  • Chest pain
  • General condition
  • Co-morbidities especially cardiac conditions, diabetes mellitus, anxiety and depression
  • Receiving home oxygen (If saturations are the same as baseline and patient is well established on oxygen it is safe to treat at home)
  • Social circumstance i.e. lives alone

Exacerbations may precipitate Cor Pulmonale and Respiratory Failure, leading to:

  • Fluid retention
  • Cyanosis and SaO2 < 90%
  • Acute confusion

 

1. Give maximal dose of inhaled bronchodilators through the most effective delivery system, eg inhaler or nebuliser.

2. Give oral Prednisolone 30mgs stat and then daily for 5 days (unless contraindicated).

3. Give antibiotics if sputum has recently become purulent.

 

Table 1 Antibiotic treatment for adults aged 18 years and over - Taken from NICE Guidance NG11

Antibiotic 1,2

Dosage and course length

First-choice oral antibiotics (empirical treatment or guided by most recent sputum culture and susceptibilities)

Amoxicillin

500 mg three times a day for 5 days (see BNF for dosage in severe infections)

Doxycycline

200 mg on first day, then 100 mg once a day for 5‑day course in total (see BNF for dosage in severe infections)

Clarithromycin

500 mg twice a day for 5 days (see BNF for dosage in severe infections)

Second-choice oral antibiotics (no improvement in symptoms on first choice taken for at least 2 to 3 days; guided by susceptibilities when available)

Use alternative first choice (from a different class)

as above

Alternative choice oral antibiotics (if person at higher risk of treatment failure 3 ; guided by susceptibilities when available)

Co-amoxiclav

500/125 mg three times a day for 5 days

Levofloxacin4

500 mg once a day for 5 days

Co-trimoxazole5

960 mg twice a day for 5 days

First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available) 6

Amoxicillin

500 mg three times a day (see BNF for dosage in severe infections)

Co-amoxiclav

1.2 g three times a day

Clarithromycin

500 mg twice a day

Co-trimoxazole5

960 mg twice a day (see BNF for dosage in severe infections)

Piperacillin with tazobactam

4.5 g three times a day (see BNF for dosage in severe infections)

Second-choice intravenous antibiotic

Consult local microbiologist; guided by susceptibilities

1 See the British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and administering intravenous antibiotics.

2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.

3 People who may be at a higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher risk of developing complications.

4 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).

5 Co-trimoxazole should only be considered for use in acute exacerbations of COPD when there is bacteriological evidence of sensitivity and good reason to prefer this combination to a single antibiotic (BNF, October 2018).

6 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

If the patient has been admitted to hospital a discharge care bundle should be completed. It includes:

  • Smoking cessation advice and referral if appropriate
  • Medication review
  • Inhaler technique check and instruction
  • Referral to Pulmonary Rehabilitation
  • Introduction to supported self-management including issue of self-management plan and issue of rescue pack if appropriate
  • Booked follow up appointment

A follow up appointment, either face to face or telephone should be arranged on initiation of rescue medication.

The consultation should cover:

  • Review of event and providing patient education as needed
  • Revision of the self-management plan for subsequent exacerbations including who, when and how to contact
  • Providing optimal maintenance therapy including drugs, oxygen and onward referral (e.g. pulmonary rehabilitation) as appropriate
Within licensed indications, oseltamivir is recommended for at risk patients who present with influenza-like illness within 48 hours of the onset of symptoms. (Zanamivir should be avoided because of the risk of bronchospasm.)
Vulnerable Patients

COPD is a multi-system disease, which has been linked to premature physiological ageing.

Recognised co-morbidities include increased:

  • Risk of cardiovascular events
  • Osteoporosis
  • Loss of muscle mass and function
  • Impaired quality of life.

All patients with COPD should be aware of the risk of acute deterioration with their condition. Advanced care planning is something that can be discussed at any stage and further information can be found here.

The county hospices offer services that serve people with COPD and breathlessness well and can be accessed even before palliation is a consideration. Management of breathlessness is a component of hospice care, for example.

Those with worsening COPD symptoms may be approaching end stage disease and have a unique set of care needs relating to their breathlessness.

Treatment and management goals should shift and to focus more on holistic care and controlling breathlessness. Goals of care should be reviewed regularly ensuring the involvement of patients and carers in discussion around the options for management. If it is appropriate a shift in focus towards comfort measures including the introduction of opioids for relief of breathlessness is supported.

Hospice

Referral

Assessment

Day Hospice Programme

Services

Great Oaks

Referral Form on Website, patient can self-refer but will contact GP with permission

Weekly MDT to assess referrals then nurse assesses at home to tailor offering

1 day a week for 12 weeks then reviewed

 

Day Hospice, Outpatients, outreach, Hospice at Home, bereavement support groups, complimentary therapy

Longfield

Referral form from health care professional or self-referral by attending ‘Welcome to Longfield’ session Thursday 9.30-12.30

One to one assessment

A 12 week programme

Patient Information leaflet available here.

Day therapy, counselling, Fatigue and Breathlessness Groups, Arts for Health, complementary therapies, carer and family support, hospice at home. Bereavement support.

Sue Ryder

Via website or email from health or social care professional

Nurse assessment at day hospice

12 weeks day hospice, can be reduced to 6 weeks.

Patient Information leaflet available here.

Staff nurses, advanced nurse practitioners, occupational therapists, physiotherapists, complementary therapists, creative art workers, family support, a chaplain, volunteer supporters

When to Refer/Services

Gloucestershire Respiratory Service (GRS)

GRS is an integrated specialist respiratory service delivered by nurses, physiotherapists, occupational therapists, clinical support workers and administrators in the acute sites (GHFT) and the community (GCS). 

The acute team operates primarily to support ward-staff with patients requiring specialist respiratory input and facilitates and supports early discharge of patient admitted with exacerbation of their respiratory disease.

The community respiratory team provides clinic appointments (or home-visits for house-bound patients) to optimise the management and quality of life of patients with chronic respiratory disease including COPD, asthma, bronchiectasis and interstitial lung disease.

  • Adults with a confirmed respiratory condition (listed above), (or suspected diagnosis following an acute admission.)  
  • Registered with a Gloucestershire GP
  • Oxygen assessment (SA02 ≤ 92%); confirmed respiratory diagnosis and  non-respiratory conditions
  • Pulmonary Rehabilitation for patients with an MRC ≥ 3 secondary to their respiratory condition.
  • Pulmonary Rehabilitation for patients with Interstitial Lung Disease, no minimum MRC

Please follow this link to the referral form.
 

Pathways of care:

Working with the acute clinicians to provide seamless care and support for patients with an exacerbation requiring admission, to enable an early discharge and prevent re-admission where possible.

Symptom management and medicines optimisation can be offered to those more complex patients who require support beyond the primary care setting. Patients may be seen in clinics across the county, or in the home if they are deemed house-bound.

Pulmonary Rehabilitation is delivered in sites throughout the county by physiotherapists, occupational therapists and nurses.  It is a course that offers respiratory patients group sessions that include activity and education about their respiratory disease and improves the patient’s confidence and ability to self-manage.  It is an intensive course of two 2 hourly sessions over seven weeks and is highly recommended upon hospital discharge.   Please send referrals to: glos-care.glosrespiratoryteam@nhs.net  & refer to the criteria checklist on the Referral Form.

As of August 2018, myCOPD has been adopted and offered by the PR teams to appropriate patients referred to PR alongside the normal PR offer of education and classes.

myCOPD is an integrated online platform incorporating education,  self-management, symptom reporting and a PR System.

Patients will be offered access to myCOPD at the referral triage stage so that people can start their learning and interactive PR whilst waiting for their class to begin. myCOPD can then be accessed alongside PR to enhance and improve their PR experience.

If individuals feel they are unable to attend for PR, myCOPD due to the time commitment required patients still may be able to use myCOPD to improve their health and wellbeing.

What do I need to do as a GP?

Continue to refer to the PR Team as appropriate. The referral form is available here the team will offer myCOPD to individuals at the point of triage.

If individuals do not meet the specific criteria for PR but you think they would benefit (e.g. newly diagnosed or milder disease) myCOPD is available for private purchase for a lifetime cost of £20. Feel free to signpost this as an NHS approved platform to patients you feel may benefit from it.

More information about myCOPD application can be found here.

HOAS (see below) offers specialist review for those people who are receiving home oxygen therapy or who may meet the criteria for assessment.  The team offer clinics around the county usually in community hospitals and home visits may be offered to those who are house bound. Please note we do not accept referrals for those who are still smoking.

In cases where a patient has been prescribed oxygen via a HOOF A, the prescriber MUST complete an IHORM/HOCF for risk mitigation and patient consent.  The HOOFA (prescription) can be found on the Air Liquide website https://www.airliquidehomehealth.co.uk/hcp/ and the IHORM/HOCF is now available here to upload to your clinical system.  All patients prescribed oxygen under a HOOF A must also be referred to the HOAS team via the referral form.

GPs are now only able to prescribe an urgent concentrator (which will come with a backup cylinder) for patients who are considered end of life. To prescribe an urgent concentrator please contact Air Liquide on 0808 202 2229. 

Respiratory ‘Hot Advice’ - GHNHSFT

Respiratory consultants at GHNHSFT offer an enhanced and responsive acute service to support people with acute respiratory illnesses who are threatening hospital admission. 

The respiratory “Hot Consultant” is available from 8.30am - 5.30pm, Monday to Friday and can be reached by telephoning 07384 834430  

Where appropriate, the consultant may offer your patient a clinic review in ambulatory care at GRH within 48 (working) hours.

Alternatively you may be signposted to Rapid Response (Urgent Care) via SPCA on 0300 421 0300.  To discuss your patient with the team prior to referral you can call 0300 421 6900

For routine advice and guidance from a respiratory medicine consultant, you can refer via e-RS with a response by the end of the next working day.

  • For less urgent requests for advice and guidance, the ERS system is available, with a response by the end of the next working day

 

Respiratory Medicine Services – GHNHSFT

The majority of COPD can be managed in primary care or with the support of the Gloucestershire Respiratory Service in the community. If in doubt please use the respiratory advice and guidance service on e-RS.

Reason

Purpose

There is diagnostic uncertainty

Confirm diagnosis and optimise therapy

Suspected severe COPD

Confirm diagnosis and optimise therapy

The patient requests a second opinion

Confirm diagnosis and optimise therapy

Onset of cor pulmonale

Confirm diagnosis and optimise therapy

Bullous lung disease

Identify candidates for surgery

A rapid decline in FEV1

Encourage early intervention

Assessment for lung transplantation

Identify candidates for surgery

Dysfunctional breathing

Confirm diagnosis, optimise pharmacotherapy and access other therapists

Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency

Identify alpha-1 antitrypsin deficiency, consider therapy and screen family

Uncertain diagnosis

Make a diagnosis

Symptoms disproportionate to lung function deficit

Look for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation

Frequent infections

Exclude bronchiectasis

Haemoptysis

Suspected end –stage disease

Exclude carcinoma of the bronchus

Optimisation of symptoms control and advanced care planning involvement of palliative care

Record Keeping and Audit/Quality Improvement

Accurate systematic READ coding of all care is vital for the audit process and therefore improvements in patient care once full PDSA audit cycles have been completed. Quality improvement is more than data collection. Data needs to be studied, improvement planned and implemented and results monitored. The cycle then needs to be repeated making small adjustments to achieve the desired improvement.

Not all changes result in improvement first time around. This is not to be viewed as failure – just the need for adjustment.  

Please click here for the Read Code Specification to support the COPD Winter Reviews 2016/17.

Please follow the resource link below for nationally recommended read codes.

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