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Step 2 Examination


• Vital signs: blood pressure, pulse (rate and rhythm), respiratory rate (RR), temperature, oxygen saturation • Observe breathing pattern (use of accessory muscles) • Auscultate chest and assess airways patency • Check peripheral oedema and assess jugular venous pressure • BMI, waist circumference • Peak expiratory flow (PEF) % predicted (for age, sex and height) • Expired carbon monoxide (ppm), if available


Step 3


Tier 1 investigations for presentation of chronic breathlessness


The minimum tests required for all patients presenting with chronic breathlessness:


Initial consultations • FBC, ECG if irregular pulse, TFT • U&E, albumin:creatinine ratio, NT-ProBNP, LFT, spirometry, chest X-ray (if not done within past six months) • Breathlessness score – MRC scale • Initiate peak flow diary if FEV1 or PEF are less than expected to assess whether airways obstruction is variable • Screening for anxiety and depression if appropriate


Medication for COPD


If you are referring somebody for pulmonary rehabilitation, ensure they are optimally bronchodilated so they can get more out of their sessions. Check your local guideline to see what device choices and products are available.


Mild COPD Minor symptoms, mild air flow limitation, ≤1 exacerbations per year, FEV1 ≥80% predicted. Offer a SABA as required. Do not limit salbutamol prescriptions as you would for asthma patients, as people may use this regularly. If they are using regularly and benefit then consider starting a LABA, but check that this is COPD and not asthma.


Moderate COPD Moderate air flow limitation, ≤1 exacerbations per year, FEV1 50-79% predicted with increasing severity. Offer LAMA or LABA. Continue SABA as required.


Severe COPD Higher risk of exacerbation, ≥2 exacerbations per year, or FEV1 <50% predicted. After every flare-up or addition or change of therapy, consider other diagnoses, such as lung cancer. Be aware of potential of developing side-effects (including non-fatal pneumonia) in people with COPD treated with inhaled steroid and be prepared to discuss this with patients.


Oxygen


Long-term oxygen therapy can only be initiated by a specialist. You should refer any new patient with persistently low pulse oximetry (<92%), those who desaturate on activity to <90% and patients currently on oxygen who haven’t had a review by a specialist in the past year. Oxygen therapy for hypoxic patients with COPD prolongs life when used appropriately. Patients with distressing breathlessness in the final years


of life need to see a breathlessness support specialist – usually from your palliative care team – to discuss optimisation, prognostication, advance planning and breathlessness mastery skills.


Download a PDF in a larger format. Go to pulsetoday.co.uk/ refreshers


Pulse February 2016 67


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