COPD QRG Chronic Care

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Introduction

Prevention & awareness

Identification & diagnosis

Chronic care

Acute care

Self care

End-of-Life care

Asthma

Implementing the strategy

Chronic Care Further Resources

COPD National Strategy Slide Kit (members only)

Consultation on a strategy for COPD (Feb 2010)

PCRS-UK COPD National Strategy Resources

PCRJ COPD National Strategy Supplement

PCRS-UK Guidance on the Diagnosis and Management of COPD

GOLD COPD Guidance

NICE COPD Guidance

Conditions of Use

Back to Quick Reference Guide

COPD National Strategy Quick Reference Guide
Chronic Care

Recommendation 12: Chronic disease management approaches should be adopted in health and social care for all people diagnosed with COPD, irrespective of severity or symptoms.

Recommendation 13: All people with COPD should receive evidence-based treatment using a structured medicines management approach. A step-up approach to smoking cessation intervention as part of preventive management strategies should be taken.

Recommendation 14: All people with COPD and hypoxaemia should be clinically assessed for long-term oxygen therapy and reviewed at regular intervals, and existing home oxygen registers should be reviewed.

Recommendation 15: All people with COPD should be advised to undertake moderate exercise according to their condition. People with functional impairment should be referred for quality assured pulmonary rehabilitation.

Chronic care model in COPD

Provision of a comprehensive system to support clinical management
Promotion of self management and adoption of healthy lifestyle
Evidence-based support for decision making. e.g Map of Medicine
Use of clinical guidelines. e.g NICE COPD Guideline

Local Clinical Networks will bring together primary and secondary health care professionals, managers and patients to commission, provide and support COPD services in a locality. COPD Clinical leads at Strategic Health Authority level will support implementation.

Regular review

Patients on the COPD register should have a regular clinical review appropriate to the severity of the disease which should encompass:

Assessment of the impact of the disease based on multidimensional indices airflow limitation, exacerbation frequency, MRC dyspnoea score. Patient reported outcome measures such as the Clinical COPD Questionnaire and COPD Assessment Test may aid assessment of the impact of disease on patients’ quality of life
Review pharmacological and non pharmacological interventions
Identify co-morbid conditions
Promote self management education
Consider the need for specialist respiratory referral

Evidence-based treatment

The NICE guidance for the management of COPD has recently been updated
The PCRS_algorithm provides a primary care summary of the guidance
Map of Medicine is a pathway-based aid to decision making

Specific interventions that should be available for people with COPD

Smoking cessation services: There should be equitable access to smoking cessation pharmacotherapy and stepped smoking cessation interventions
Psychological support: Look for anxiety and depression, and offer a range of interventions including cognitive behavioural therapy and pharmacological treatments
Long-term oxygen therapy (LTOT): Oxygen saturations should be routinely checked in primary care and patients with saturations ≤ 92% referred for specialist assessment. Patients on LTOT should be regularly reviewed
Pulmonary rehabilitation: Exercise is a vital part of COPD treatment and should be provided according to severity. For example:
- Patients with MRC dyspnoea score 1 or 2 could be encouraged to increase physical fitness by taking at least 150 minutes exercise per week
- Patients with MRC dyspnoea score 3, 4 or 5 should be referred for pulmonary rehabilitation. A 6-12 week course, which may be delivered by a multidisciplinary team in the community, can improve exercise tolerance, quality of life, activities of daily living and reduce healthcare utilisation

Further resources

Author: Dr Hilary Pinnock, University of Edinburgh, and Whitstable Medical Practice, Kent | Editor: Dr Mark Levy, Kingsbury, London

This COPD National Strategy Quick Reference Guide is provided to you by the Primary Care Respiratory Society UK (PCRS-UK)
and is an interpretation of the document Consultation on a Strategy for Chronic Obstructive Pulmonary Disease (COPD) in England (February 2010) written by the Department of Health.
This Quick Reference Guide has been supported by an educational grant from Allen & Hanburys,
the specialist respiratory division of GlaxoSmithKline, AstraZeneca UK Ltd and Boehringer Ingelheim Ltd/Pfizer Ltd.
The views expressed in the materials are not necessarily those of either the Department of Health, the sponsors or the Primary Care Respiratory Society UK (PCRS-UK). © PCRS-UK

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