¹GOLDStages of COPD defined by Spirometry are as follows: Stage 3: Severe. FEV1 30% but< 50% Stage 4: Very Severe: FEV1 <30% predicted

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1 NPA Primary Care Committee The Purpose of the Chronic Obstructive Pulmonary Disease Model Practice The 2012 PACE Chronic Obstructive Pulmonary Disease Model Practice provides relevant diagnostic and treatment recommendations to PACE primary care providers (PCPs). The Model Practice was adapted specifically for PACE from evidence-based published guidelines for older adults and offered with the belief that shared decision-making between individual PCPs and /caregivers is optimal. This Model Practice is not intended to replace the clinical judgment of the individual provider or establish a standard of care. PACE are a heterogeneous group, with differing health profiles, prognoses, preferences, and goals of care. Life epectancy and quality of life issues require an individualized contet within which to apply practice guidelines that may have been developed from and for a population of non-frail adults. We recommend that whether a PCP follows any of the summary recommendations for an individual participant will depend upon factors specific to that participant, including the participant s preferences, prognosis and life epectancy, co-morbid conditions, functional status, and goals of care. This Model Practice assumes that the goals of care for PACE can be divided into three broad categories: promoting longevity, optimizing function, and palliative care. Accordingly, the Model Practice suggests different approaches to interpreting the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the 2011 ACP/ACCP/ATS/ERS recommendations, depending on whether the goal is life-etension, function, or palliative care. The PCP will need to determine which recommendations are appropriate for each individual participant, considering the participant s preferences, life-epectancy, and the epected benefit versus burdens of specific interventions. DETERMINATION OF GRADES OF SEVERITY OF COPD Post bronchodilator FEV1/FVC < 0.70 is still required for the diagnosis of COPD. Furthermore, spirometric evaluation determining the percentage of predicted FEV1 has historically been used to determine the GOLD stage of COPD. However, FEV¹ is a poor descriptor of disease status. The 2011 GOLD recommendations continue to include spirometric determinations; however, incorporated into that determination of grade are self assessment tools of symptoms, and the history of previous eacerbations frequency. This has lead to a new classification that incorporates these added variables. Included with the Model Practice are the validated self assessment tool - the COPD Self Assessment Tool (CAT), the GOLD spirometric stage, and the grid to determine the new COPD Patient Group (ABCD)... ¹GOLDStages of COPD defined by Spirometry are as follows: Stage 1: Mild. FEV1 80% predicted Stage 2: Moderate. FEV1 50% but <80% predicted Stage 3: Severe. FEV1 30% but< 50% Stage 4: Very Severe: FEV1 <30% predicted *FUNCTIONAL DETERMINATION OF S SPIROMETRIC EXACERBATIONS CHARACTERISTICS CLASSIFICATION PER YEAR CAT A Low Risk Eacerbations, Less Symptoms GOLD <10 B Low Risk Eacerbations, More Symptoms GOLD C High Risk Eacerbations, Less Symptoms GOLD <10 D High Risk Eacerbations, More Symptoms GOLD National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed

2 NPA Primary Care Committee Recommended Intervention DIAGNOSIS A B C D Spirometry for Staging² Determine the Patient Group Arterial Blood Gas Chest X-Ray at Diagnosis TREATMENT OF CHRONIC COPD Smoking Cessation Counseling Inhaled LABA³ X Inhaled Long Acting Anticholinergic² Inhaled Long Acting Corticosteroid Combined Inhalation: LABA & Corticosteroid Short Acting Beta Agonist for Rescue Pulmonary Rehabilitation Standard Intervention Interval Evidence Category For diagnosis and periodically to assist assessment of Grade if prt functionally able to perform Upon Diagnosis, and with worsening symptoms and/or signs and symptoms of respiratory failure or R. Heart Failure. Initially if FEV1 < 50% predicted or with Respiratory Failure or R. Heart Failure Initially done to look for concurrent pulmonary disorders Smoking cessation still most effective and cost effective way to stop progression If the participant is symptomatic. Manipulation of device can be problematic for certain If participant is symptomatic. Either Initial therapy or in combination with LABA. Manipulation of DPI s can be problematic for certain. Monitor for signs and symptoms of urinary retention in men. If symptomatic. Not initial R but can be added to LABA and/or Anticholinergic therapy If Symptomatic. Not initial R but can be added to Anticholinergic R or substituted for LABA Initially and periodically, if participant able Initially and no less than annually. Initially & change in respiratory status GOLD, not ACP Longevity Functional Palliative By Whom Yes Consider No PCP GOLD Yes Yes No PCP GOLD Yes Consider No PCP Initially GOLD Yes Yes No PCP Yearly GOLD, ACP Yes Yes No PCP Daily, if able GOLD, ACP Yes Yes Yes PCP Daily, if able GOLD, ACP Yes Yes Yes PCP Daily if able GOLD,AC P Yes Yes Yes PCP Daily, if able GOLD, ACP Yes Yes Yes PCP Symptomatic relief of dyspnea Q 4-6 hr. prn GOLD, ACP Yes Yes Yes PCP Increased eercise tolerance, quality of life. Decreased hospitalizations, depression Min. of 6 weeks if able to participate GOLD,ACP Yes Yes No P.T. National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed

3 Recommended Intervention A B C D Supplemental Oygen for > 15 hours a day Supplemental Oygen for symptom management Maintenance Oral Corticosteroids** Methylanthine for those unable to used inhaled R X Roflumilast Therapy TREATMENT OF ACUTE EXACERBATION Increased use of short-acting beta agonist Antibiotics X Standard Intervention Interval Evidence Category PaO2 55 torr or SaO2 88%. O2 in these circumstance increases survival Titrate to O2 saturation 88%- 92%. Monitor for signs of CO2 narcosis. Long-term treatment with oral corticosteroids is not recommended in COPD Only Long-Acting Methylanthines are effective in COPD; toicity limits their use to those intolerant of inhalation therapy. Cannot be used with Roflumalast. Can Reduce eacerbations, but many side effects including weight loss. Use cautiously in ppt with depression. Cannot use with Methylanthines. X Alleviation of dyspnea symptoms Most effective if prt has increased dyspnea & sputum, and increased sputum purulence. Consider having at risk keep course of antibiotics at home for use at first sign of eacerbations. NPA Primary Care Committee Longevity Functional Palliative By Whom 15 hours a day GOLD, ACP Yes Yes Consider PCP Prn GOLD Yes Yes Yes PCP, RN Daily or every other day GOLD No No No _ Daily GOLD Yes Consider No PCP Daily No firm recommendation from GOLD nor ACP Consider Consider No PCP Every 2-4 hours GOLD Yes Yes Yes PCP prn GOLD Yes Yes Consider PCP Oral Corticosteroids** X In-Patient Care⁴ X Oral or IV recommended along with other therapies in the hospitalized ppt. Consider having at risk keep a R for short course of corticosteroids at home for use at first sign of eacerbations See annotation at end of document prn GOLD Yes Yes Consider PCP See Recommended criteria in GOLD GOLD Yes Yes No PCP National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed

4 Recommended Intervention Non-Invasive Positive Pressure Ventilation (NIPPV)⁴ Inpatient Invasive Ventilation⁵ OTHER A B C D X Influenza Vaccination Pneumococcal Pt/Family Education about Disease, maintenance T, and T of eacerbations CBC to eval for Polycythemia Review AD,PD concerning intubation Nutritional Counseling NIPPV ( BiPAP )⁵ Lung Volume Reduction Surgery Standard Intervention Interval Evidence Category Improves resp. acidosis. Reduces mortality, intubation and hospital LOS, severity of breathlessness If likelihood of improvement appears to eists, and in keeping with prt Present Directives Covered in PACE Preventive Care Guidelines, but important to be reiterated to COPD Covered in PACE Preventive Care Guidelines, but important to be reiterated to COPD Prompt reporting new symptoms; review action plan for Treatment of eacerbations NPA Primary Care Committee Longevity Functional Palliative By Whom In-patient Treatment GOLD Yes Consider No PCP In-Patient Treatment Yes Consider No PCP Yearly GOLD, ACP Yes Yes Yes Once in Lifetime if 65 GOLD, ACP Yes Yes Yes PCP or RN PCP or RN Every 6 months Yes Yes No RN Yearly GOLD Yes Consider Consider PCP Education as to risk/benefit of intubation to assure participant true and informed wishes are followed. Low body mass independent risk factor for increased mortality in COPD. Dietary consultation should be combined with Rehab Can lessen CO2 retention, improve dyspnea, and may improve survival at a cost of worsening quality of life. An epensive palliative surgical procedure and can only be recommended in carefully selected. Every6 months at time of Assessments Annually as directed by PACE regulations ( ) None Yes Yes Yes PCP GOLD Yes Yes Yes Dietician. Nightly GOLD Consider Consider No PCP RN MSW? - GOLD No or RARE No No PCP QUALITY INDICATORS: (May not apply to with multiple co-morbidities, and/or limited functional ability) GOLD Grade Listed in Record YES YES NO Pulmonary Rehab YES YES NO Smoking Cessation Counseling in past 6 months YES YES NO LABA or Long Acting Anticholinergic or inhaled steroid YES YES YES National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed

5 ¹Stages of COPD: Reviewed on first and last two pages of this document. Please refer to that page. NPA Primary Care Committee ²Post Bronchodilator FEV1/FVC <0.7 is necessary to make a diagnosis of COPD. Results from accurate spirometry determinations form the basis for many of the recommendations in clinical practice guidelines. It is understood that PACE may not have the physical or cognitive ability to perform accurate spirometry. The 2011 GOLD Guidelines recognize that FEV1 is a poor descriptor of disease status, and those other parameters such as self assessment scores of symptoms, and number of eacerbations which must be incorporated into a more accurate assessment of stage. ³Nebulized short-acting beta agonists and short-acting anticholinergics can be substituted for LABA and long acting anticholinergic in those who are unable to tolerate or use the long-acting forms. However, there is no evidence based studies to show that neither short acting beta agonists nor short term anticholinergics have any effect on decreasing frequency of COPD eacerbations. ⁴ Indications for Hospitalization: 1) marked increase in symptoms, resting dyspnea: 2) Severe underlying COPD: 3) Onset of physical signs (edema, cyanosis): 4) Failure to respond to initial management: 5) Significant Co morbidities: 6) Frequent eacerbations: 7) New cardiac arrhythmias: 8) Diagnostic uncertainties: 9) Older age and 10) insufficient home support. COPD Eacerbations have been successfully treated in the community as evidenced in the Hospital at Home model previously reported. ⁵ Noninvasive Positive Pressure Ventilation (NIPPV) Contraindications: 1) Respiratory Arrest: 2) Cardiovascular instability: 3) Mental Status change/uncooperative ppt.: 4) high aspiration risk: 5) Viscous or copious secretions: 6) recent gastroesophageal surgery: 7) facial trauma, fied facial defects, recent facial surgery: 8) burns: 9) morbid obesity **Maintenance Oral Steroids: While low dose oral steroids are not generally recommended, is sometime the most compliant treatment for those with COPD and dementia who are marginally living independently and can t master MDI s, DPI s, and/or nebulizers. Indications for Palliative Care: Severe COPD, disabling dyspnea at rest, lack of response to inhalers and other treatments, frequent ED visits/hospitalizations, weight loss, poor food intake, disabling fatigue. A Participant with these parameters may be a good candidate for the Palliative Pathway after discussion and informed decision-making. References: 1. Ann. Intern. Med 2011:155: Global Initiative for Chronic Obstructive Lung Disease (GOLD) Leff: Ann. Int. Medicine: 2005: 143: Essential Evidence Plus: 5. European Respiratory Journal: Sept 2009: Vol 34; No 3; p National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed

6 NPA Primary Care Committee COPD ASSESSMENT TOOL CAT TOOL (ref. 5) Symptom Symptom Total I Never Cough I have no phlegm (mucous) in my chest at all I Cough all the Time My Chest is full of Phlegm (Mucous) My Chest does not feel tight at all When I walk up a hill or one flight of stairs I am not breathless I am not limited doing any activities at home I am confident leaving my home despite my lung condition My Chest feels very tight When I walk up a hill or one flight of stairs, I am very breathless I am very limited doing activities at home I am not confident at all leaving my house because of my lung condition I sleep soundly I have lots of energy GRAND TOTAL MAXIMUM SCORE 40 I don t sleep soundly because of my lung condition I have no energy at all *FUNCTIONAL DETERMINATION OF S SPIROMETRIC EXACERBATIONS CHARACTERISTICS CLASSIFICATION PER YEAR CAT A Low Risk Eacerbations, Less Symptoms GOLD <10 B Low Risk Eacerbations, More Symptoms GOLD C High Risk Eacerbations, Less Symptoms GOLD <10 D High Risk Eacerbations, More Symptoms GOLD *Adapted from GOLD Guidelines National PACE Association This is the property of the National PACE Association and may not be used, reproduced or modified without the epressed