Primary care and palliative careBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7560.188 (Published 20 July 2006) Cite this as: BMJ 2006;333:188
- Daryl Freeman, clinical research fellow,
- David Price, professor
- department of general practice and primary care, University of Aberdeen, Foresterhill Health Centre, Aberdeen.
Over the past decade, interest in diagnosing and managing COPD in primary care has grown in recognition of its increasing burden on patients, families, health services, and society. Guidelines from bodies such as the British Thoracic Society, National Institute for Health and Clinical Excellence, Global Initiative for Chronic Obstructive Lung Disease, and International Primary Care Airways Group have also increased awareness of COPD among primary care doctors.
COPD is a cause of great misery to many patients and their carers. Decreasing lung function—with symptoms such as breathlessness, cough, wheeze, fluid retention, and fatigue—results in a downward spiral of reduced activity, social isolation, loss of independence, depression, and increased contact with health and social care providers. However, considerable help can and should be provided in primary care. Recently, the inclusion of COPD management in the UK general practice “new contract” has provided incentives for better care.
Patients with COPD typically present late, often with respiratory tract infections that have not previously been linked with COPD or with breathlessness misdiagnosed as asthma. Studies suggest that, among cigarette smokers older than 40 years, about 20% of those without a respiratory diagnosis and at least a quarter of those with a diagnosis of asthma actually have COPD. By the time most have COPD diagnosed, at least 50% of their lung function will have been lost.
Thus, a priority in primary care should be earlier detection and correct diagnosis. The use of simple questionnaires may allow easier detection of patients who need spirometry, avoiding the need for mass spirometry screening programmes.
This is the 11th in a series of 12 articles
Diagnosis and assessment
The diagnosis of COPD is established by detection of airflow obstruction in conjunction with typical symptoms and a history of smoking. Spirometry must be performed by adequately trained staff using a vitalograph that is properly maintained and calibrated. Similarly, results should be interpreted by individuals with sufficient expertise. Some primary care teams may find either performing or interpreting spirometry difficult, and help should be readily available in undertaking these tasks.
The severity of COPD should be assessed not only in terms of impairment in lung function but as an overall assessment of the patient. This should include symptoms (particularly breathlessness according to the MRC dyspnoea score), frequency of exacerbations, extent of disability, health status, evidence of depression and anxiety, and body mass index.
Secondary care referral
The decision to refer to secondary care will depend on the individual general practitioner's experience and confidence in managing COPD and on the facilities available. If diagnostic uncertainty exists, however, consider referral to a specialist to help confirm or refute the diagnosis. Other potential reasons for specialist referral include
Severe airflow obstruction
Marked functional impairment
Rapidly declining lung function
Assessment of suitability of domiciliary oxygen in hypoxic patients
Young age or family history of α1 antitrypsin deficiency
Persistent symptoms despite apparently adequate therapy
Frequent exacerbations and infections
Haemoptysis or suspected lung cancer
Signs suggestive of cor pulmonale
Assessment for specialist treatment such as nebulisers, pulmonary rehabilitation, domiciliary non-invasive ventilation, lung volume reduction surgery, lung transplantation, or bullectomy.
Management of stable disease
Once the diagnosis of COPD has been established, ensure that patients are given sufficient information about the disorder and that their inhaler technique is assessed at every available opportunity. The detailed management of patients with stable COPD should involve both non-pharmacological and pharmacological measures as outlined in earlier articles. Pulmonary rehabilitation is not universally available, although in some regions it is extending beyond secondary care to community settings. This development may be especially attractive to patients with milder disease and those in rural communities where travelling to a secondary care centre every week for several months is impractical.
Management of exacerbations
Most exacerbations can and should be managed by the patient or the primary care team. The decision to admit a patient to hospital depends on a combination of physical and social criteria, which may vary according to the facilities available to the clinician making the decision. Patients may find a self management plan useful. This normally gives advice on how to recognise and respond to an exacerbation. Its content will probably vary according to the patient population (and indeed individual patients) but should include
How to recognise an exacerbation
What treatment to take and for how long (antibiotics, oral corticosteroids, and increase in bronchodilators)
Who to contact in an emergency (including out of hours services, or the nearest emergency room facility) and how to recognise the need to do so
Advice to see their doctor or respiratory nurse for review once they have improved.
The need to review patients with COPD will depend on the individual patient, the severity and stability of the disease, the extent of social support, and any recent changes in treatment. However, all patients should be reviewed four to six weeks after a change in treatment or after an exacerbation (this should include measurement of spirometry, a review of treatment, and discussion of patients' understanding of their disease). In general, those with mild to moderate disease should be reviewed annually, while those with severe disease at least every six months. The review process may be assisted by the use of standardised templates for primary care computer systems such as that endorsed by the General Practice Airways Group (www.gpiag.org/news/copd_template1.php).
Palliative care is defined as “an approach that improves quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Patients with end stage COPD need structured palliative care at least as much as patients with malignant disease, and this should ideally be delivered by a multidisciplinary team working in synchrony. In some cases referral to a specialist palliative care team with access to hospice beds and home nursing services may be required. However, primary care input is vital as the individual patient's general practice will probably have looked after the patient for many years and be familiar with his or her family and social background. Knowing when to discuss prognosis is often difficult, as patients vary widely in the length of time between diagnosis and pre-terminal events. However, most patients generally find open discussion about end of life issues worth while and prefer to be involved in decision making.
The most disturbing symptom for patients with end stage COPD is usually overwhelming dyspnoea, which often induces anxiety and frank fear. General principles for management of distressing breathlessness revolve around reassuring patients and care givers, suggesting distraction techniques, devising coping strategies, adapting daily activities, and ensuring patients have realistic expectations of their capabilities. Some patients find that a moving stream of cool air produced by a bedside or hand held fan also helps to relieve breathlessness, but oxygen should be considered if patients are hypoxic. Patients should, of course, receive bronchodilators. For patients with end stage disease who continue to have distressing breathlessness despite maximal treatment, there should be a low threshold to starting opiates and benzodiazepines. However, palliation of symptoms should neither postpone nor hasten death.
Patients at the pre-terminal stage who are too weak to expectorate may experience accumulations of upper airway secretions. These can produce a “death rattle” that may be distressing to both patient and family. In hospital, oropharyngeal suctioning may be useful, and if this fails a subcutaneous infusion or boluses of hyoscine hydrobromide can be given (0.6-2.4 mg/24 hours).
The ABC of chronic obstructive pulmonary disease is edited by Graeme P Currie, specialist registrar in the Respiratory Unit, Aberdeen Royal Infirmary, Aberdeen. The series will be published as a book by Blackwell Publishing in autumn 2006.
Competing interests DF has received travel grants to national and international conferences, reimbursement for lecturing and speaking at educational meetings, and funding for clinical staff from GlaxoSmithKline, Boehringer Ingelheim, Schering Plough, Altana, and AstraZeneca. DP has received honorariums for speaking at sponsored meetings or attending advisory boards and research funding from 3M, Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Pfizer, Schering Plough, and Viatris. GPC has received funding for attending international conferences and honorariums for giving talks from pharmaceutical companies GlaxoSmithKline, Pfizer, and AstraZeneca.
The questionnaires for evaluating risk and differential diagnosis of COPD were adapted from Price et al. Chest 2006;129: 1531-9.
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