Chronic Obstructive Pulmonary Disease
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with Chronic Obstructive Pulmonary Disease (COPD). It addresses issues that may occur in RACF, particularly optimising function of residents with a pre-existing diagnosis of COPD, management of acute exacerbations, and end of life care.
It covers:
About Chronic Obstructive Pulmonary Disease (COPD); Assessment; Management; Maintenance Medication; Acute Exacerbations; End stage COPD; and Sources of Information Reference Cards:
Modified Medical Research Council Dyspnoea Scale
Modified Borg Dyspnoea Scale
Visual Analog Dyspnoea Scale
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and Advance Care Plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease is a significant health problem in Australia, ranked as the third leading cause of death [1]. COPD is responsible for significantly more morbidity and mortality than other airway disease in adults aged over 60 years [2]. The disease affects 52 million adults worldwide. The increasing death rate from COPD is a significant burden on western health care resources. For older adults requiring hospitalisation, the mortality rate is 11%, with a six month mortality rate of 33% and one year mortality rate of 43% [3]. In Australia COPD caused over 5000 deaths in 2003 [4].
Chronic Obstructive Pulmonary Disease is a general term used to describe respiratory tract conditions that have the same disease process. The term broadly covers the diagnoses of emphysema, chronic bronchitis and some chronic forms of asthma. The major clinical feature common to diseases classified as COPD is the trapping of air in the lungs [5].
The disease generally has a slow progression and is characterised by irreversible damage and gradually worsening respiratory function due to chronic inflammation and obstruction of the airways [2, 3, 6-9]. The progression of COPD leads to decreased quality of life, decreased ability to perform activities of daily living (ADLs) and, in the end stages, significant risk of respiratory failure [6, 7].
Assessment
The aim of assessment is to determine the diagnosis and severity of Chronic Obstructive Pulmonary Disease (COPD).
The diagnosis is usually made by the GP based on clinical assessment, chest X-ray and spirometry. Some residents may be referred to a respiratory specialist for further pulmonary function tests and advice [7, 9]. Other investigations to aid management include pulse oximetry, arterial blood gases and FBE.
Diagnosis of COPD rests on the demonstration of airflow limitation, which is not fully reversible. If airflow limitation is fully or substantially reversible, the patient should be treated as for asthma [9]. (See the Clinical Information Sheet on Respiratory: Asthma.)
Residents with COPD should be reassessed regularly, at least annually for mild-moderate COPD and 6 monthly for severe COPD.
Signs and symptoms
Signs and symptoms of COPD include [2, 6-8, 10]:
Dyspnoea with or without accompanying wheeze; Shortness of breath; Cough with or without sputum production; Decreased endurance; Hypoxaemia; Pursed-lips breathing; Hypercapnia (high levels of CO2); Decreased FEV1 (forced expiratory volume in 1 sec); and Respiratory acidosis.
In order to make an early diagnosis, it is recommended that residents who are smokers or ex-smokers be assessed for COPD if they suffer episodic shortness of breath, have a persistent cough, or experience frequent respiratory tract infections [4, 6-10, 12].
COPD and asthma have similar presentations, and they commonly occur together. Table One represents differences in symptoms.
Table One: Symptoms of COPD and Asthma [7]
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Symptoms
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COPD
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Asthma
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Smoker or ex-smoker
Symptoms under age 35
Chronic productive cough
Breathlessness
Night-time waking with breathlessness and/or wheeze
Diurnal or day-to-day variability in symptoms
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Nearly all
Rare
Common
Persistent and progressive
Uncommon
Uncommon
|
Possibly
Common
Uncommon
Variable
Common
Common
|
Investigations
Spirometry
Diagnosis of COPD is made by measurement of airflow obstruction using spirometry [5, 6, 8, 9]. Spirometry measures lung function, as the volume of air expired in 1 second (FEV1) and the total volume of air expired as fast as possible (FVC). Results are compared to the resident’s previous values, or to predicted values for his or her age range [13]. Following a baseline spirometry reading, spirometry is usually conducted pre and post administration of a bronchodilator to detect partial reversible airway obstruction such as asthma.
COPD is diagnosed when FEV1 is <80% of the predicted value for a person’s age, and the FEV1:FVC ratio is less than 70% [2, 4, 6-8, 10, 14]. Severity of COPD is classified as moderate at 50-80% predicted FEV1, severe at 30-49% and very severe at <30% predicted FEV1 [7-10]. Asthma is differentiated from COPD by the response of at least 12% improvement in the patient’s FEV1 within 15 minutes of administration of a short-acting beta2-agonist [6, 8, 9].
Chest X-ray
A chest X-ray may be normal or show signs of hyperinflation, flattened diaphragm, or large, dilated airspaces that bulge from beneath the pleura known as bullae [8]. Chest X-ray is recommended to check for differential diagnoses such as lung cancer [9], and those described in Table Two. In older adults, findings on chest X-ray change the diagnosis and management plan in approximately 16-21% of cases [3, 8, 10].
Pulse oximetry
Pulse oximetry is used to monitor oxygen saturation in residents with COPD, particularly during oxygen therapy to titrate oxygen levels to maximise oxygen saturation, whilst minimising the risk of hypercapnia. Residents with oxygen saturations of less than 80% on air require arterial blood gases and management in an acute care facility is required [8].
Arterial blood gases
For patients with severe COPD (FEV1 <40% predicted) or signs and symptoms of respiratory or heart failure arterial blood gas measurement may be performed by arterial puncture [7, 8, 10]. This usually requires transfer to an acute care facility with the appropriate equipment. The Advance Care Plan and goals of care should be considered before initiating aggressive assessment and management.
Differential diagnosis
Table Two shows features of COPD and differential diagnoses. Asthma is the major differential diagnosis. Diagnosis of COPD rests on the demonstration of airflow limitation, which is not fully reversible. If airflow limitation is fully or substantially reversible, the patient should be treated as for asthma [9]. (See the Clinical Information Sheet Respiratory: Asthma.) Where there is doubt, a trial course of corticosteroids may be initiated to determine response (more rapid in asthma) [4, 6, 9, 14].
Table Two: Features of COPD and differential diagnoses [7, 8, 10]
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Onset and Progression
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History
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Signs & symptoms
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Investigations
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Clinical outcome
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COPD
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Onset in mid-life.
Progression usually slow.
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Long smoking history.
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Dyspnoea during exercise.
Little daily variation in signs and symptoms.
Fine crackles and wheeze on auscultation.
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Pulmonary function tests indicate irreversible airflow restrictions
Chest X-ray may be normal or show hyperinflation flattened diaphragm, or bullae.
|
Largely irreversible.
|
|
Asthma
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Onset early in life (often childhood).
Daily variations in progression.
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Family history of
Allergies.
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Fine crackles and wheeze on auscultation.
Daily variation in signs/symptoms.
Often signs/symptoms present at night or early morning.
Often have accompanying allergies, rhinitis and or eczema.
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Pulmonary function tests indicate reversible airflow restrictions.
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Largely reversible.
|
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Cardiac Failure
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Mid-late life onset with varied progression.
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Fine basal crackles on auscultation.
Little daily variation in signs and symptoms.
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Chest X-ray shows dilated heart, pulmonary oedema.
Pulmonary function tests indicate volume restriction rather than airflow limitation.
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Largely reversible.
|
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Bronchiectasis
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|
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Large volumes of purulent sputum often with associated respiratory infection.
Little daily variation in signs and symptoms.
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Coarse crackles on auscultation.
Chest x-ray bronchial dilation and wall thickening.
|
|
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Tuberculosis
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Onset at all ages.
Progression varied but usually slow.
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Local prevalence of tuberculosis or travel to an area where TB is prevalent.
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Cough, often associated with blood droplets.
Fatigue.
Night sweats.
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Chest X-ray shows lung infiltrate or nodular lesions.
Microbiology confirms diagnosis.
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Reversible.
|
|
Obliterative Bronchiolitis
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Onset in younger ages.
Progression usually slow.
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Pulmonary surgery.
History of rheumatoid arthritis is common.
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Large volumes of purulent sputum often with associated respiratory infection.
Little daily variation in signs and symptoms.
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Coarse crackles on auscultation.
Chest X-ray bronchial dilation and wall thickening.
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Largely irreversible.
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COPD and depression
The long-term debilitating effects of COPD and anxiety related to chronic breathlessness significantly increase the risk of depression [9]. Residents diagnosed with COPD who have oxygen saturations of less than 92%, severe dyspnoea, and/or have been admitted to hospital for management of an acute exacerbation should routinely be screened for anxiety and depression [7].
Classifying severity of COPD
Generally FEV1 is used as the primary indicator of severity and as a guide for ongoing management of COPD [7-10]. Table Three outlines the severity classifications used for COPD.
Table Three: COPD severity classifications [7-10]
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Severity
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FEV1
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Typical signs/symptoms
|
|
Mild
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80% predicted or greater
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Little or no dyspnoea.
Cough with or without sputum.
|
|
Moderate
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50–80% predicted
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Breathlessness.
Wheeze with moderate exertion.
Cough with or without sputum.
Variable abnormal signs.
Reduction in breath sounds.
Possible hypoxemia.
|
|
Severe
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30–49% predicted
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Dyspnoea with any exertion.
Prominent cough and wheeze.
Cyanosis.
Peripheral oedema.
Hypoxemia and hypercapnia are common.
|
|
Very severe
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< 30% predicted
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Dyspnoea at rest.
Prominent cough and wheeze.
Cyanosis, possibly centrally.
Peripheral oedema.
Hypoxemia and hypercapnia are common.
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Severity or level of stable COPD can also be assessed using the Modified Medical Research Council (MRC) Dyspnoea Scale provided in the Reference Cards. Although this scale is not the most appropriate to assess responses to interventions, the modified MRC Dyspnoea Scale provides a useful baseline assessment of the resident and a change of one level or more on the scale is clinically significant [11].
Management
Goals in managing a resident with COPD are to [2]:
Improve quality of life; Increase physical endurance; Maintain optimal ventilation; Reduce anxiety; Manage co morbidities; Decrease unnecessary hospitalisations and use of medical resources; and Maintain comfort in the end stages through respiratory failure.
Residents with COPD should have a management plan developed by the general practitioner with residential care staff, the resident and/or his or her representative, and be reviewed at least annually [7, 8].
The management plan is based on clinical assessment including [5, 7]:
Smoking and nutritional status Adequacy of symptom control – breathlessness, exercise tolerance, exacerbation frequency Effects of medication Inhaler technique Presence of complications – cor pulmonale Co morbidities - cardiac failure, depression, anxiety, Measurements of FEV1 and FVC, BMI, oxygen saturation Need for long term oxygen therapy; Need for referral (specialist, physiotherapy, occupational therapy, dietitian), and Resident’s preferences for care
The following information should be documented in the resident’s management plan to [9, 12]:
Usual severity of COPD and baseline signs and symptoms; Frequency and presenting pattern of exacerbations; Non-pharmacological strategies; Medication for maintenance therapy and exacerbations; How to identify and respond to exacerbations, and Advance Care Plan
Medications
Medication reduces signs and symptoms and minimises exacerbations, but they do not reverse existing damage or prevent the eventual decrease in lung function [4, 10].
Medication prescribed for COPD is generally taken by inhalation using an appropriate medication delivery device e.g. puffer, nebuliser. Residents with poor inhaler technique can use a spacer with a metered dose inhaler to improve lung deposition. Avoid using a nebuliser for stable COPD unless it has been shown to be better for the individual [9].
Further information about prescribing medications in a form most appropriate to the resident, and techniques for using various delivery devices, is outlined in the Clinical Information Sheet Respiratory: Inhalation Medication Delivery Devices.
Long-term medication generally includes all, or a combination of [6-10, 15]:
Short-acting inhaled bronchodilators (beta2 agonists, anticholinergics); Long-acting inhaled bronchodilators; Inhaled corticosteroids; Long-term oxygen therapy; Immunisation (influenza and pneumococcal).
Prophylactic antibiotic therapy has not been shown to reduce acute exacerbations or decrease signs and symptoms in residents with stable COPD and therefore is not recommended in long term management [7].
Antitussives and Mucolytics
Antitussives (cough suppressants) are generally not recommended in the management of COPD, as cough has a protective effect on the airways [8, 10].
Use of mucolytic agents (products that break down mucous), such as bromhexine or acetylcysteine, have been shown to slightly reduce the number and duration of acute exacerbations for some residents who have frequent exacerbations [9, 16].
Short-acting Bronchodilators
Short-acting Bronchodilators are the first-line therapy for residents with COPD. Either short-acting beta2-agonists e.g. Salbutamol, Terbutaline or short-acting anticholinergics e.g. Ipratropium may be used [7-9, 14]. Medications may initially be prescribed on an as-needed basis, increased to regular timed doses as the resident’s symptoms progress [14].
Ipratropium bromide is the inhaled reliever medication used most often in COPD, particularly for older adults [13, 17, 18]. Due to fewer systemic side effects this medication is recommended as the reliever medication of choice for older adults with concurrent cardiovascular disease who are taking beta-adrenergic blocking agents [19]. Ipratropium is as effective as inhaled beta2-antagonists in maintenance therapy of COPD.
Long-acting Bronchodilators
Long-acting inhaled bronchodilators are used in residents for whom the improvement in lung function is insufficient despite the use of short-acting bronchodilators, or those who have at least 2 exacerbations per year. Either long-acting beta2-agonists e.g. Formoterol, Salmeterol or long-acting anticholinergics e.g.Tiotropium may be prescribed [4, 7, 9, 14]. Because Tiotropium has a longer duration of action than Ipratropium it may be administered only once per day. Its efficacy is slightly better than Ipratropium in maintenance therapy of COPD. Anticholinergic adverse effects, e.g. dry mouth, occur more often than with the short-acting ipratropium [4, 14, 20].
Inhaled corticosteroids
Regular systemic corticosteroids e.g. prednisolone have been shown to have minimal effect on lung function in most residents with COPD [9, 10]. However, inhaled corticosteroids - preventive medications that help control inflammation in the airways e.g. fluticasone, budesonide, beclomethasone are useful in severe and very severe COPD, (FEV1 < 50% predicted), [4, 6-10, 14, 15] or for residents experiencing more than two acute exacerbations in a year [7].
The most common side effects from inhaled corticosteroids are oral candidiasis and throat hoarseness. Residents should be encouraged to use a spacer for administering corticosteroids and to rinse the mouth well after each dose [14, 19, 21-24].
Residents on larger doses of inhaled corticosteroids or those who take systemic corticosteroids, are at risk of osteoporosis as these medications cause a decrease in bone mineralisation. The lowest possible dose to achieve a therapeutic effect should be used. Calcium and vitamin D supplements and regular screening for osteoporosis (annually for residents on doses equivalent to greater than 5mg prednisolone daily) are recommended for individuals at risk [5, 9, 19, 21]. A falls risk assessment should be conducted for residents at risk of osteoporosis to minimise the risk of injury and fractures.
Further information on assessment and management of resident falls is provided in the Clinical Information Sheet Resident Falls.
Theophylline
Theophylline has an anti-inflammatory effect as well as a being a bronchodilator. Toxicity is common as it has a very narrow therapeutic range and many drug interactions. Therefore it is generally recommended only for severe respiratory disease and is not recommended for use in older adults unless absolutely necessary [19, 21, 23]. Slow-release preparations of Theophylline may be considered for residents who do not respond to short-acting and/or long-acting bronchodilators, or for those who are unable to take inhaled medications [14]. Dosage is based on therapeutic response and trough plasma concentrations [5].
Oxygen Therapy
Long term oxygen therapy (LTOT) may be considered when the resident has severe hypoxia [1, 8, 9], including those who have [6-8]:
Because oxygen therapy may cause respiratory depression from hypercapnia (high level of carbon dioxide in the blood), residents with COPD should be carefully assessed before LTOT is initiated [7]. The goal of oxygen therapy should be to maintain oxygen concentration levels at approximately 90% when the resident is at rest. This saturation level maximises oxygen supply whilst minimising the risk of worsening hypercapnia [3, 6]. Oxygen should be administered for at least 15 hours per day, preferably up to 20 hours per day [7, 9].
Further information on oxygen delivery can be found in the Clinical Information Sheet Respiratory: Inhalation Medication Delivery Devices.
Non-pharmacological Strategies
Management strategies to improve the resident’s quality of life include resident and family education, relaxation techniques, cognitive behavioural therapy, counselling and antidepressant medication [7, 9].
Smoking cessation
Smoking is one of the primary causes of COPD and contributes to both disease progression and increase in exacerbations. Health care workers should encourage and promote the resident to cease smoking as this is one of the few unequivocally effective interventions, even in late stage disease [4, 6, 7, 9, 11] . Smoking cessation can reduce the frequency of acute exacerbations by up to one third, even in long term smokers [6]. Comprehensive information about smoking cessation programs, counselling and support groups for those wishing to stop can be obtained from organisations such as Quit Victoria (see contact information below) and it is highly recommended that the GP refer residents who smoke to support services.
Immunisation
Patients with COPD are at increased risk of invasive pneumococcal infection. It is recommended that elderly people with respiratory disease be immunised against pneumonia and influenza [6-9, 19, 21, 23, 24]. Influenza vaccination halves the risk of exacerbations, hospitalisation and death from respiratory disease and all causes [7, 9].
Nutrition
Maintaining an acceptable body mass index (BMI) contributes to improved lung function, decreased incidence of respiratory infection and increased life expectancy [25]. Nutritional intake may be effected by physical activity level, medications, dyspnoea and concurrent diagnoses such as depression [26].
Nutritional interventions recommended for residents with COPD include [7, 11, 25, 26]:
Nutritional screening as part of the diagnostic process; Referral to a dietician for those residents who have a BMI outside the recommended range of 20-25 or who have a serum albumin less than 3.5g/dl; A diet consisting of a higher fat intake, as this is associated with decreased production of carbon dioxide, and Maintenance of adequate hydration, as this contributes to thinning of pulmonary secretions.
Residents with body weight less than 90% of their ideal weight have a higher risk of mortality and morbidity. Nutritional strategies recommended for underweight residents with COPD include [25, 26]:
Small frequent meals; Appropriate enteral or parenteral nutritional supplements as recommended by a dietician, and Medication review, e.g. consider alternate therapies where medication causes anorexia and/or nausea.
Nutritional strategies for overweight or obese residents include [26]:
Medication review, e.g. consider alternate therapies if medication causes increased appetite, and Referral to a dietician for a weight loss regime that maintains an appropriate vitamin, protein and fat intake.
Physiotherapy
Regular exercise programs can reduce symptoms of dyspnea, anxiety and depression; and increase exercise capacity and quality of life [8, 9, 14]. Physiotherapy interventions that are beneficial for residents with COPD include:
Anxiolytics/benzodiazepines may be used to manage anxiety, distress and fear of dying. The least sedating medications are recommended to allow the resident to complete his or her end of life planning [11]. The following regime is recommended as appropriate in managing endstage anxiety:
Regular assessment of ability to perform activities of daily living (ADLs) [7, 14]; Breathing exercises and pulmonary muscle training [2, 11, 14]; Secretion-clearing strategies [2, 7, 11, 14]; and Energy conserving techniques [11, 14].
The Australian Lung Foundation and the Australian Physiotherapy Association have developed the Pulmonary Rehabilitation Kit, available at the website http://www.pulmonaryrehab.com.au/welcome.asp This toolkit has been developed to help health professionals establish evidence-based pulmonary rehabilitation programs throughout Australia [14].
Relaxation
Relaxation techniques are effective to reduce fear and anxiety during an exacerbation, however, there is no evidence that they improve respiratory function [11, 14].
Acute Exacerbations
An acute exacerbation is an episode of worsening signs and symptoms, often with accompanying respiratory tract infection. A person diagnosed with COPD has on average 2-3 acute episodes annually, or more often if he or she remains an active smoker [3].
Early identification and prompt treatment of an exacerbation can reduce severity, prevent complications such as respiratory infection, and reduce hospital admissions [9, 11].
Residents diagnosed with COPD who report worsening dyspnoea, should be thoroughly assessed to determine severity, and monitored for respiratory failure [9, 11]. Assess increased severity of symptoms, cyanosis and peripheral oedema, change in mental state and ADLs, and exacerbation of co morbidities [9, 11].
Treatment is aimed at reducing airflow limitation and inflammation, sputum production and purulence, hypoxia and acidosis. The action plan for acute exacerbation may include commencement of bronchodilators, antibiotics, systemic steroids and/or supplemental oxygen while awaiting medical review [9, 11]. The decision to treat at the RACF, or transfer to hospital for acute care, will be based on assessment and the resident’s preference.
Assessment
Commonly reported symptoms are worsening breathless, cough, increased sputum, change in sputum colour, and reduced ability to perform daily activities. Assess for [3, 8, 9, 11]:
Worsening dyspnoea and/or chest tightness; New or worsening cyanosis or peripheral oedema; Altered mental state; Fatigue or inability to perform daily activities; Increased sputum production or purulent sputum; Fever; Increased respiratory rate (>25 breaths/min); Increased heart rate (>110 beats/min), and Worsening hypoxaemia and hypercapnia.
Severity of dyspnoea
The experience of dyspnoea is subjective. Evidence suggests that either a visual analog scale or numeric scale are most effective in assessing the severity of a resident’s dyspnoea during an acute exacerbation. These tools can also be used to determine the resident’s response to therapy [11, 27]. The Borg Scale – a numeric scale that assesses severity of acute dyspnoea, and a Visual Analog Dyspnoea Scale are provided in the Reference Cards. Both scales are reliable indicators of severity of dyspnoea, however, the visual analog scale is more sensitive to changes in the resident’s experience of dyspnoea [27].
Pulse oximetry
Level One evidence supports pulse oximetry to monitor oxygen saturation levels in residents with COPD, particularly during oxygen therapy to maintain oxygen saturations levels at 90-92%. This saturation level maximises oxygen supply whilst minimising the risk of worsening hypercapnia [3, 6, 7]. Residents with oxygen saturations of less than 80% on air require arterial blood gases and management in an acute care facility [8].
Arterial blood gases
During an exacerbation of COPD, blood gas measures can monitor risk of respiratory failure and/or if mechanical ventilation is required [1, 3, 6, 7, 10, 11]. Residents will generally require transfer to an acute care facility to have arterial blood gases performed, and those with a pH is less than 7.32 require ongoing management in an acute care facility due to the high risk of acute respiratory failure [8]. The decision to pursue this level of assessment and intervention, therefore, should be discussed with the resident and his or her representatives. See information on End-Stage COPD below.
Medication
It is recommended that the documented action plan for an acute exacerbation, include PRN medication orders and a supply of emergency medications [7, 13].
An acute exacerbation of COPD is generally managed with [1-3, 10, 11, 13]:
Increase in dose and frequency of inhaled bronchodilators; Systemic corticosteroids; Oxygen therapy, and/or Antibiotics for concurrent infection.
Bronchodilators
Bronchodilators can increase airflow by 15-29% within 2 hours. Although administration via a metered dose inhaler with spacer is as effective as use of a nebuliser, the latter may be easier for the resident to use during an acute exacerbation [3, 8, 9].
Salbutamol, a short-acting bronchodilator, is the preferred medication unless contraindicated, in an acute exacerbation, as its effect is rapid. Inhaled salbutamol can be administered in continual serial doses until the resident’s symptoms are relieved. If the resident develops side effects e.g. tachycardia and/or tremor, ipratropium bromide may be added to the resident’s medication regime to allow for use of lower doses of salbutamol [1, 7, 8, 10, 16].
|
Commence with continuous salbutamol.
Decrease to intermittent salbutamol when the resident’s signs improve.
Add ipratropium if no response, or to decrease use of salbutamol [1, 7, 8, 10, 16].
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Corticosteroids
Systemic corticosteroids reduce severity and shorten recovery time. They are generally prescribed for 7-14 days in the event of an acute exacerbation, especially when symptoms interfere with daily activities [1, 3, 4, 7-9, 13]. If the resident is on a regular corticosteroid regime, the dose may be increased. Unless the resident is on a regular dose of corticosteroid, tapering the dose is not required [1].
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Prednisolone 30-50mg daily for 5-14 days [1, 3, 7, 8].
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Oxygen therapy
Oxygen therapy should be used with care during an acute COPD exacerbation due to the risk of hypercapnia. The use of pulse oximetry to measure oxygen saturations during oxygen therapy, therefore, is essential.
Residents with an oxygen saturation level of 80-90% on air should receive oxygen therapy. The rate should be titrated to maintain oxygen saturation levels at 90-92%. This saturation level maximises oxygen supply, whilst minimising the risk of worsening hypercapnia [3, 6, 7].
Residents with an oxygen saturation of less than 80% on air should have arterial blood gases performed [8].
Details on oxygen delivery are provided in the Clinical Information Sheet Respiratory: Inhalation Medication Delivery Devices.
Antibiotics
Bacterial infection contributes to the severity of an exacerbation of COPD. Broad spectrum oral antibiotics, e.g. amoxycillin or doxycycline should be prescribed for 5-10 days in the presence of purulent sputum with increased sputum volume and/or increased dyspnea [1, 3, 4, 8, 13]. A macrolide antibiotic, e.g. erythromycin, roxithromycin, cephalosporin or amoxycillin plus clavulanic acid, may be prescribed if there is no response to first line antibiotic therapy, only if Haemophilus influenzae has been excluded [13]. If pneumonia is suspected, investigate and treat as for community acquired pneumonia (see Clinical Information Sheet Respiratory: Pneumonia).
Procedure for Managing Acute Exacerbation of COPD
Reassure the resident and remain calm. Remain with the resident and alert assistance [11]. Assess the resident’s respiratory status including [11]:
level to which resident is currently experiencing dyspnoea; the resident’s usual level of dyspnoea; vital signs; pulse oximetry; movement of chest wall and use of accessory muscles ; ability to complete a verbal sentence; presence of cough ; presence and characteristics of sputum; chest auscultation; presence of peripheral oedema. Administer inhaled bronchodilators [3, 11] according to the resident’s medication orders. If the resident has no medication orders contact the resident’s GP immediately. Administer oxygen therapy [3, 6, 7, 11]. Do pulse oximetry and adjust the oxygen flow accordingly to maintain oxygen saturations levels at 90-92%. This saturation level maximises oxygen supply whilst minimising the risk of worsening hypercapnia [3, 6, 7]. Administer systemic corticosteroids [3, 11] according to the resident’s medication orders. If the resident has no medication orders contact the resident’s GP to perform an assessment of the resident. Corticosteroids are usually administered for 5-10 days [3]. Monitor the resident’s progress every 15 minutes until the resident’s condition is stable. If the resident is experiencing pain or discomfort administer analgesia as prescribed [11]. Consult the resident’s Advance Care Plan before calling emergency ambulance services. Document the episode in the resident’s progress notes according to the facility policy. Inform the resident’s GP immediately to request a review of the resident’s condition. Inform other care workers according to facility policy, and the resident’s representative according to their personal preferences. Maintain the resident’s ongoing medication regime as prescribed. If the exacerbation is accompanied by respiratory tract infection the resident should commence oral antibiotics[3].
Transfer to acute care
Indications for transfer of a resident experiencing an exacerbation of COPD to an acute care facility include [8]:
Rapid increase in severity of symptoms; A history of severe exacerbations requiring mechanical ventilation; Co-morbidities that increase risk of death, e.g. pneumonia, cardiac failure; Failure to respond to treatment; Increase in dyspnoea and/or hypoxia despite oxygen therapy; Decrease in alertness, and/or decrease in ability to perform basic ADLs due to dyspnoea Measure arterial blood gases (check for hypercapnia or Ph of less than 7.32), and New signs, especially cyanosis or peripheral oedema.
Before arranging for transfer to an acute care facility, refer to the resident’s Advance Care Plan and consult with their GP and relatives/representatives [28].
End stage COPD
It is important for the general practitioner to provide education and discuss preferences for End-of-Life care with the resident and/or his or her representatives. Discussions should include the level of intervention the resident prefers, and whether or not the resident wishes to be admitted to an acute care facility for management during an acute exacerbation [8, 11, 28].
The major decision to be made is the level of medical intervention they desire when they are no longer able to breathe on their own. Appropriate education and support should be provided to assist the resident in deciding whether s/he wishes:
Advance Care Plans should be regularly reviewed, particularly where the resident experiences frequent exacerbations. The Clinical Information Sheet on Advance Care Planning provides more information.
The likely outcome of palliative care rather than mechanical ventilation is eventual unconsciousness and a quick death [28]. The Clinical Information Sheet on End-of-Life Care provides more information about palliative care in COPD and other chronic diseases.
Sources of Information
Where to go for more information
Quit Victoria
Quit Victoria provides support and information for people wishing to quit smoking. There are a variety of free resources available including a Quit pack with educational material, Quit courses operating in the community and telephone counselling. Support groups such as Quit Victoria provide motivation and encouragement, and all smokers should be encouraged to seek assistance in cessation.
Quitline: 137848
Website: http://www.quit.org.au/
The Australian Lung Foundation
The Australian Lung Foundation provides information, support and counselling for people diagnosed with COPD, their families and their carers. The Foundation is involved in the development and review of national COPD guidelines and provide numerous tools relating to the assessment and management of COPD on its website at
http://www.lungnet.com.au/home/contact.html
Contact: Mon-Fri 9am-5pm for all enquiries: 1800 654 301 (within Australia)
LungNet
LungNet is a co-ordinating network of support groups for COPD and other respiratory diseases. The organisation, established by The Australian Lung Foundation, connects those requiring support with the most appropriate local services. LungNet also provide a quarterly newsletter.
Contact during business hours: 1800 654 301
Further reading
In addition to the references, the following articles are recommended:
The Australian Lung Foundation and Thoracic Society of Australia and New Zealand’s COPD-X website at http://www.copdx.org.au/ provides a comprehensive resource for information about COPD including a variety of proforma management plans and checklists. An online pulmonary rehabilitation toolkit, an initiative of The Australian Lung Foundation and the Australian Physiotherapy Association, is available at the website http://www.pulmonaryrehab.com.au This toolkit has been developed to help health professionals establish evidence-based pulmonary rehabilitation programs throughout Australia. LungNet Quarterly newsletter – available by registering your interest at the LungNet website - http://www.lungnet.org.au/pat_support/whats_lungnet-pat_support.html
References
Harvey, P., Murphy, M., Dornom, D., Berlowitz, D., Lim, W., Jackson, B., Implementing evidence based guidelines: inpatient management of Chronic Obstructive Pulmonary Disease. International Medicine Journal, 2005. 35(3): p. 151-. Karavatas, S., The Integration of the Guide to Phyiscal Therapy Practice in the Management of the Geriatric Patient with Chronic Obstructive Pulmonary Disease. Topics in Geriatric Rehabilitation, 2005. 21(2): p. 127-132. Stoller, J., Acute Eaxacerbations of Chronic Obstructive Pulmonary Disease. The New England Jounrla of Medicine, 2002. 346(13): p. 988-994. McKenzie, D. et al, Managing COPD and preventing progression. National Prescibing Service News, 2006. 45. eTG, Therapeutic Guidelines: COPD, in http://www.tg.com.au (accessed April 2006), eTG. 2005 Guidelines and Protocols Advisory Committee, Chronic Obstructive Pulmonary Disease (including patient guide). 2005, British Columbia Medical Association, (BCMA)
British Columbia Health Services, (BCHS): British Columbia. National Institute for Clinical Excellence, (NICE), Management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2004, National Institute for Clinical Excellence, (NICE): London. p. 54. Institute for Clinical Systems Improvement, (ICSI), Chronic obstructive pulmonary disease. 2005, Institute for Clinical Systems Improvement (ICSI): Bloomington (MN). p. 66. Australian Lung Foundation, (ALF),Thoracic Society of Australia and New Zealand, (TSANZ), The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006. 2006, Australian Lung Foundation, (ALF). p. 66. Global Initiative for Chronic Obstructive Lung Disease, (GOLD) , World Health Organization, (WHO), National Heart, Lung and Blood Institute, (NHLBI), Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2005, Global Initiative for Chronic Obstructive Lung
Disease, World Health Organization, National Heart, Lung and Blood Institute: Bethesda (MD). p. 115. Registered Nurses Association of Ontario, (RNAO), Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). 2005, Registered Nurses Association of Ontario, (RNAO): Toronto. p. 136. National Asthma Council Australia, (NACS), Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. McKenzie, D., COPD: interventions for better outcomes. Prescibing Practice Review, 2006. 33. Australian Lung Foundation, (ALF),Australian Physiotherapy Association, (APA), Pulmonary Rehabilitation Kit. 2006, Australian Lung Foundation, (ALF)
Australian Physiotherapy Association, (APA). Poole, PJ ,Black, PN, Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease (Review). The Cochrane Library, 2006(2). American Medical Directors Association, (AMDA), COPD management in the long-term care setting. 2003, American Medical Directors Association: Columbia (MD). p. 32. Scottish Intercollegiate Guidelines Network , (SIGN),British Thoracic Society, (BTS), British guidelines on the management of asthma. 2003, London: SIGN and BTS. Asthma Victoria, (AV), Nebulisers, in http://www.asthma.org.au/informationsheets/nebulise.doc (accessed March 2004), Victoria, Asthma. 2000 National Institutes of Health (National Heart Lung and Blood Institutes), Considerations for Diagnosing and Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services. Bochner, F, ed. Australian Medicines Handbook 2004. 2004, Hyde Park Press: Richmond, SA. Australia, National Asthma Council, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. Asthma Australia, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia. National Institutes of Health (National Heart Lung and Blood Institutes), Practical guide for the diagnosis and management of asthma. 1997, New York: U.S. Department of Health and Human Services. Scottish Intercollegiate Guidelines Network and British Thoracic Society, British guidelines on the management of asthma. 2003, London: SIGN and BTS. Harmon-Weiss, S., Chronic obstructive pulmonary disease. Nutrition management for older adults. 2002, Nutrition Screening Initiative (NSI): Washington (DC). p. 11. Nutrition Screening Initiative, (NSI), A physician’s guide to nutrition in chronic disease management for older adults. 2002, Nutrition Screening Initiative, (NSI): Washington. p. 4. Meek, P.,Lareau, S., Critical outcomes in pulmonary rehabilitation: Assessment
and evaluation of dyspnea and fatigue. Journal of Rehabilitation Research and Development, 2003. 40(5): p. 13-24. Hébert, P., O’Connor, A., Aaron, S., Wilson, K., Dales, R., Fiset, V., Viola, R., McKim, D., The Use of Intubation and Mechanical Ventilation for Severe Chronic Obstructive Pulmonary Disease (COPD): A Decision aid for patients. 2004, Ottowa: University of Ottowa. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on the management of COPD provided in this Clinical Information Sheet is based on Level I evidence produced by expert opinions in the field, particularly the 2006 Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006 produced by The Australian Lung Foundation (ALF) and Thoracic Society of Australia and New Zealand, (TSANZ). Supporting evidence is based on additional Level I evidence, including guidelines produced by National Institute of Clinical Excellence (NICE) in the UK and the Scottish Intercollegiate Guidelines Network (SIGN).
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Harvey, P., Murphy, M., Dornom, D., Berlowitz, D., Lim, W., Jackson, B., Implementing evidence based guidelines: inpatient management of Chronic Obstructive Pulmonary Disease. International Medicine Journal, 2005. 35(3): p. 151-. |
2005 |
Level III evidence |
2. |
Karavatas, S., The Integration of the Guide to Phyiscal Therapy Practice in the Management of the Geriatric Patient with Chronic Obstructive Pulmonary Disease. Topics in Geriatric Rehabilitation, 2005. 21(2): p. 127-132. |
2005 |
Level IV C evidence |
3. |
Stoller, J., Acute Eaxacerbations of Chronic Obstructive Pulmonary Disease. The New England Jounrla of Medicine, 2002. 346(13): p. 988-994. |
2002 |
Level IV C evidence |
4. |
McKenzie, D. et al, Managing COPD and preventing progression. National Prescibing Service News, 2006. 45. |
2006 |
Level IV C evidence |
5. |
eTG, Therapeutic Guidelines: COPD, in http://www.tg.com.au (accessed April 2006), eTG. 2005 |
2006 |
Level IV C evidence |
6. |
Guidelines and Protocols Advisory Committee, Chronic Obstructive Pulmonary Disease (including patient guide). 2005, British Columbia Medical Association, (BCMA)British Columbia Health Services, (BCHS): British Columbia. |
2005 |
Level I evidence |
7. |
National Institute for Clinical Excellence, (NICE), Management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2004, National Institute for Clinical Excellence, (NICE): London. p. 54. |
2004 |
Level I evidence |
8. |
Institute for Clinical Systems Improvement, (ICSI), Chronic obstructive pulmonary disease. 2005, Institute for Clinical Systems Improvement (ICSI): Bloomington (MN). p. 66. |
2005 |
Level I evidence |
9. |
Australian Lung Foundation, (ALF),Thoracic Society of Australia and New Zealand, (TSANZ), The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006. 2006, Australian Lung Foundation, (ALF). p. 66. |
2006 |
Level I evidence |
10. |
Global Initiative for Chronic Obstructive Lung Disease, (GOLD) , World Health Organization, (WHO), National Heart, Lung and Blood Institute, (NHLBI), Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2005, Global Initiative for Chronic Obstructive LungDisease, World Health Organization, National Heart, Lung and Blood Institute: Bethesda (MD). p. 115. |
2005 |
Level I evidence |
11. |
Registered Nurses Association of Ontario, (RNAO), Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). 2005, Registered Nurses Association of Ontario, (RNAO): Toronto. p. 136. |
2005 |
Level I evidence |
12. |
National Asthma Council Australia, (NACS), Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. |
2002 |
Level IV C evidence |
13. |
McKenzie, D., COPD: interventions for better outcomes. Prescibing Practice Review, 2006. 33. |
2006 |
Level I evidence |
14. |
Australian Lung Foundation, (ALF),Australian Physiotherapy Association, (APA), Pulmonary Rehabilitation Kit. 2006, Australian Lung Foundation, (ALF) Australian Physiotherapy Association, (APA). |
2006 |
Level IV C evidence |
15. |
Poole, PJ ,Black, PN, Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease (Review). The Cochrane Library, 2006(2). |
2006 |
Level I evidence |
16. |
American Medical Directors Association, (AMDA), COPD management in the long-term care setting. 2003, American Medical Directors Association: Columbia (MD). p. 32. |
2003 |
Level I evidence |
17. |
Scottish Intercollegiate Guidelines Network , (SIGN),British Thoracic Society, (BTS), British guidelines on the management of asthma. 2003, London: SIGN and BTS. |
2003 |
Level I evidence |
18. |
Asthma Victoria, (AV), Nebulisers, in http://www.asthma.org.au/informationsheets/nebulise.doc (accessed March 2004), Victoria, Asthma. 2000 |
2004 |
Level IV C evidence |
19. |
National Institutes of Health (National Heart Lung and Blood Institutes), Considerations for Diagnosing and Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services. |
1996 |
Level IV C evidence |
20. |
Bochner, F, ed. Australian Medicines Handbook 2004. 2004, Hyde Park Press: Richmond, SA. |
2004 |
Level IV C evidence |
21. |
Australia, National Asthma Council, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. |
2002 |
Level I evidence |
22. |
Asthma Australia, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia. |
2003 |
Level IV C evidence |
23. |
National Institutes of Health (National Heart Lung and Blood Institutes), Practical guide for the diagnosis and management of asthma. 1997, New York: U.S. Department of Health and Human Services. |
1997 |
Level IV C evidence |
24. |
Scottish Intercollegiate Guidelines Network and British Thoracic Society, British guidelines on the management of asthma. 2003, London: SIGN and BTS. |
2003 |
Level I evidence |
25. |
Harmon-Weiss, S., Chronic obstructive pulmonary disease. Nutrition management for older adults. 2002, Nutrition Screening Initiative (NSI): Washington (DC). p. 11. |
2002 |
Level IV C evidence |
26. |
Nutrition Screening Initiative, (NSI), A physician’s guide to nutrition in chronic disease management for older adults. 2002, Nutrition Screening Initiative, (NSI): Washington. p. 4. |
2002 |
Level IV C evidence |
27. |
Meek, P.,Lareau, S., Critical outcomes in pulmonary rehabilitation: Assessmentand evaluation of dyspnea and fatigue. Journal of Rehabilitation Research and Development, 2003. 40(5): p. 13-24. |
2003 |
Level IV B evidence |
28. |
Hébert, P., O’Connor, A., Aaron, S., Wilson, K., Dales, R., Fiset, V., Viola, R., McKim, D., The Use of Intubation and Mechanical Ventilation for Severe Chronic Obstructive Pulmonary Disease (COPD): A Decision aid for patients. 2004, Ottowa: University of Ottowa. |
2004 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [29] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for COPD
The following reference cards are designed to be used in conjunction with the COPD Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Modified Medical Research Council Dyspnoea Scale
Modified Borg Scale
Visual Analog Dyspnoea Scale
Downloads and Printing
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