The British Thoracic Society (BTS), and its forerunners, have been involved with standards of care for respiratory disease for many years. In the 1950s and 60s the focus was on TB. By the 1980s the new concern was with asthma and the alarming increase in both the death rate and prevalence of that condition. In 1990 the first UK asthma guidelines were produced1 and these, with their minor updates,2,3 have gained widespread acceptance as the general standard for asthma care in both hospital and primary care.
The push to improve asthma management was undoubtedly helped by having effective treatments available. Many would believe that asthma management is significantly better for the guidelines and asthma death rates are falling despite the increased prevalence of asthma.
While all this was happening, respiratory physicians were aware that there was an even greater problem that was not being tackled – chronic obstructive pulmonary disease (COPD). The term COPD was introduced in the 1970s and encompasses bronchitis, chronic bronchitis, emphysema and the wonderful ICD9 term 'obstructive airways disease not elsewhere classified'.
The death rate from COPD is many times greater than that from asthma (see figure 1). However, perhaps partly because it was viewed as a self-inflicted condition caused by smoking and partly because there were few proven treatments for COPD, there was little interest in improving management.
|Figure 1: Death rates from COPD and asthma in England and Wales, 1990-92 (OPCS)|
In 1993, the BTS standards of care committee decided to explore the feasibility of establishing COPD guidelines, but a lack of funding for the travel and room hire expenses of meetings meant that it was a further 18 months before progress began.
There was a core group of eight doctors who met four times to construct an outline framework for the project. The group then produced fully referenced background papers that were used to inform the discussion at a consensus meeting.
Thirty people representing hospital physicians, general practice, nursing and public health/purchasing took part in the meeting which was held over two days.
Organising the meeting consumed the whole of the educational grant. The company who provided the money took no part in any of the meetings and did not see the final document until after it had been accepted for publication, thus it was a genuine educational grant.
The guideline document was therefore based on reviews of literature by the eight experts on the core group but not on systematic reviews.
Nowadays systematic reviews are expected for all guideline documents, but had this counsel of perfection existed in 1993 the COPD guidelines would never have got off the ground, as the funds needed to carry out systematic reviews were not available. When the North of England Guidelines Project looked systematically at asthma, there were few changes to the 'non-systematic' document that had been produced in 1990 and 1993.
The COPD guidelines (see chart below) which are summarised in Guidelines, have three major tenets for long-term care of COPD.
- The first is to establish the diagnosis objectively using spirometry, in an equivalent and as routine a manner as blood pressure or blood sugar readings are used in hypertension and diabetes respectively.
COPD is a disease affecting older people who often have other conditions. Confusion with heart failure, asthma, and general debility is common and leads to inappropriate prescribing which does not help the patient.
The guidelines include a table of possible reasons why patients might be referred to a specialist respiratory clinic.
All the indications revolve around either cases in which one or more of the clinical features do not 'fit' with the diagnosis of COPD (eg someone who has hardly ever smoked) or because there is a need for more sophisticated investigations than can be performed in primary care (eg measurement of blood gases before deciding on oxygen therapy long term).
- The second is to persuade the patient to stop smoking. Failure to stop smoking in a patient with established COPD will lead to a continuing accelerated loss of lung function. Stopping smoking has been shown to slow the decline in lung function. Nevertheless, many professionals appear to prefer to prescribe drugs that cannot alter the natural history of the disease rather than invest their time in anti-smoking measures which can achieve quit rates of up to 27%.
- Third, the guidelines recommend that drug treatments should be linked to severity of disease, as defined by the loss of FEV1. For bronchodilators the outcome is based on subjective symptom reporting but for inhaled steroids and for oxygen therapy objective measures are appropriate.
Non-drug therapy such as exercise, diet, pulmonary rehabilitation and lifestyle adjustments are equally as important as drugs.
|Diagnosis and management of stable COPD|
The management of the acute exacerbation should also use objective measures where possible to establish both the diagnosis and appropriate therapy. Acute COPD exacerbations make up about 10% of all acute medical admissions. With an average hospital stay of 9-10 days this represents a huge hospital workload. There are likely to be even more exacerbations, than are recorded by hospital statistics, as many of those cases seen by GPs do not reach hospital.
It is believed that many of the admissions could be managed at home if appropriate support could be provided and several projects are looking at this. Such an assertion inevitably links resource issues with medical ones.
The most severe cases must be treated in hospital and with new techniques of ventilatory support (with or without formal intermittent positive pressure ventilation), can be helped through exacerbations that would have been fatal a few years ago. Survival in this group of patients is much better than is commonly believed and they can, and often do, enjoy life for several years thereafter.
If more patients are to be managed in the community then there needs to be adequate provision for them and specialist respiratory nurses may be a way of bridging the primary-secondary care divide.
One of the central aspects of this shift to primary care is that diagnosis and treatment in both secondary and primary care become more accurate and compatible with each other. There is room for improvement in both sectors. This is a major challenge that the guidelines have to face before successful implementation will be possible.
During the time that the guidelines have been emerging, there have been several pharmaceutical companies who have developed new products that are likely to be of help in COPD and who were persuaded together with manufacturers of spirometers to come together in a consortium to promote and disseminate the guidelines in a non-product promotional manner.
This co-operation between the commercial and medical worlds has had a number of benefits. First, all physicians (respiratory and non-respiratory), all GPs and many nurses and other professionals received copies of the documents as published in Thorax as well as simplified summary charts.
Second, there has been a stimulus to audit of clinical practice in both hospital and primary care with funding from individual members of the consortium. And third, there is a dialogue about potential future activities that will improve the standard of COPD care. An indirect benefit has been that half the profits from the Thorax supplement are received by the BTS which is now reinvesting them to help produce new guidelines initiatives in areas of medicine where there is no prospect of any outside financial support.
It is hoped that the COPD guidelines will prove to be a sufficient spur to professionals in both primary and secondary sectors to look at their practice in a new light, and thus to reconsider what can and should be done for the huge number of people with COPD.
It is a disease which cannot be cured because by definition by the time of diagnosis, the damage from cigarettes is already done. However there is no doubt that these patients can be helped to cope within the limits of their impairment and that, with that help, they can and should be able to enjoy life for many years.
- Guidelines for the management of asthma. British Thoracic Society, Kings Fund, Roy. Coll. Phys. and National Asthma Campaign. Br Med J 1990; 31, 653-7
- Guidelines for the management of asthma. BTS, RCP, RCGP, BPRG, GPIAG, NAC, Kings Fund. Thorax 1993; 48; 51-24 and Br Med J 1993
- The British Guidelines on Asthma Management. 1995 review and position statement Thorax 1997:52(suppl 1):S1-21