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Background

information

Chronic Obstructive Pulmonary Disease (COPD) - Suspected Medicine > Thoracic medicine > Chronic Obstructive Pulmonary Disease (COPD)

Information resources for patients and carers

Resources for providers

Updates to this care map

Hauora Māori Pasifika

COPD Suspected

Conduct medicines

review

Provide Stop Smoking Go to Stop Smoking

Support Support

Spirometry and Other

Investigations

Interpretation of

Results

Obstructive Restrictive Normal

Asthma Diagnosis COPD Diagnosis

Confirmed

Go to COPD - Stable

Management

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1. Background Information

Scope:

• early detection, assessment and diagnosis of chronic obstructive pulmonary disease (COPD) in adults

Out of scope:

• children and adolescents

• management in primary and secondary care, and criteria for specialist referral

• principles of palliative care in COPD

• management of acute exacerbation of COPD

Definition:

• COPD is characterised by airflow obstruction [1,2,3]:

• forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio less than 0.7 [3,10]

• airflow obstruction is usually progressive, not fully reversible [1,2,3,4], and does not change over several months [1,3]

• airflow limitation is usually associated with an abnormal inflammatory response of the lungs to noxious particles or gases [2]

• COPD is the preferred term for patients with airflow obstruction who were previously defined as having [1,3]:

• chronic bronchitis

• emphysema

Incidence and prevalence [6-7]:

• according to the World Health Organisation, COPD afflicts some 50 million people around the world, and is the fourth leading

killer – causing nearly 3 million deaths every year

• COPD has a substantial impact on the health of New Zealanders. Although often undiagnosed, it affects an estimated 15 % of

the adult population over the age of 45 years (at least 200 000 New Zealanders)

• the prevalence of COPD in New Zealand adults (aged 45+) is approximately 5.5%

• there was no significant difference in the prevalence in males (4.8%; 3.5 – 6.1) and females (6%; 4.8 – 7.3)

• the incidence of COPD increased with age for both genders

• there was no significant difference across the deprivation quintiles

• more than 85 % of the burden of COPD arises from tobacco smoking, with contributions from cannabis use and dust exposure

in the workplace

Prognosis [7]:

• COPD is the 4th leading cause of death after cancer, heart disease and stroke

• COPD is ranked 2nd in men and 5th in women with regards to its health impact

• COPD is an irreversible disease but is almost entirely preventable by avoiding exposure to tobacco smoke. Over 15% of all

smokers are likely to become affected

Common co-morbidities include [3]:

• lung cancer − COPD increases the risk for lung cancer

• cardiovascular disease

• metabolic syndrome

• osteoporosis

• depression

• skeletal muscle dysfunction

Risk factors [1-3]:

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• smoking

• occupational exposure

• increasing age

• deprived communities

• genetic risk of homozygous alpha1-antitrypsin deficiency − accounts for less than 1% of cases

• environmental factors, e.g. air pollution

2. Information resources for patients and carers

Support Groups:

Breathe Easy Support Groups are established in Horowhenua, Manawatu and Tararua:

• the groups are for adults with lung conditions such as Asthma, Chronic Bronchitis and Emphysema

• there is no charge to join the groups which offer the opportunity to:

• meet others with a common interest in managing their lung condition

• learn and participate in some gentle exercises

• go on social outings

• listen to key speakers

• receive advice on diet for patients with chronic obstructive pulmonary disease (COPD) who are either under weight or over

weight

• Tararua Breathe Easy Support Group

• Manawatu Breathe Easy Support Group

• Horowhenua Breathe Easy Support Group

Pulmonary Rehabilitation [2,3]:

Pulmonary rehabilitation should be offered to all appropriate patients with COPD, including those who have had a recent

hospitalisation for an acute exacerbation].

Pulmonary rehabilitation aims to:

• reduce symptoms

• improve quality of life (QoL)

• increase physical and emotional participation in everyday activities

• provide dietary advice for patients with COPD who are either under weight or over weight

• better breathing service pamphlets:

• Tararua

• Manawatu

• Horowhenua

Resources for patients:

• The Asthma Foundation website provides comprehensive information for anyone wanting current information to help manage a

respiratory condition

• patient support - Lung Foundation Australia

• Ministry of Health

• patient resources on inhalers

• What is a spacer?

• Oxygen Therapy at Home

• Peak Flow

• Health Navigator NZ contains information on a wide range of health topics including COPD and Asthma

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Patient information [2,3]:

• specific information packages should be developed for patients with chronic obstructive pulmonary disease (COPD):

• packages should take into account the different needs of patients at different stages of their disease

• do not use programmes designed for asthma

• patients with moderate to severe COPD should be made aware of non-invasive ventilation (NIV) as a possible treatment if

admitted to hospital:

• benefits and limitations should be explained in case it is necessary in the future

• all patients should be advised about reducing risk factors

• patients should be provided with the following patient education:

• information about the nature of COPD

• instructions on how to use inhalers and other treatments

• recognition and treatment of exacerbations

• strategies for minimising dyspnoea

• patients with stage IV COPD should be provided with additional patient education, i.e:

• information about complications

• information about oxygen treatment

• advance directives and end of life decisions

Self-management:

• patient should be advised to contact their GP for review as soon as possible after self administering medicines as per "Personal

Action Plan and Self Assessment Form"

Te Ara Whānau Ora Brochure:

• Te Ara Whānau Ora Brochure

3. Resources for providers

Assessment tools:

• COPD Assessment Test (CAT)

• CAT Score

• Assessment of COPD - GOLD 2013 Guidelines

• Modified Medical Research Council (mMRC) dyspnoea scale

• Personal Action Plan and Self Assessment Form

• HAD score

Service provider information/referral forms:

• Tararua Breathe Easy Support Group

• Manawatu Breathe Easy Support Group

• Horowhenua Breathe Easy Support Group

• UCOL U-Kinetics Pulmonary Exercise Programme

• referral form for consideration of Pulmonary Rehabilitation / UCOL U-Kinetics Pulmonary Exercise Programme

• CPHO referral Form

• CPHO dietitian referral criteria

• Massey Psychology Service Brochure

• Massey Psychology Service Referral Form

• Massey Self Distress Rating Form

• Allied Health referral form

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• Respiratory Services Referral Form for Respiratory Function Tests

Information/resources:

• Graph of Lung Function Age (Thatcher and Peto natural history of lung function decline graph)

• pharmacological treatment of COPD

• medicines optimisation and review

• Asthma versus COPD

• bpac publication - COPD: A practical guide for Primary Care Nurses (April 2005)

• bpac publication - The Nutritional Management of Unintentional Weight Loss in People with COPD

• Lung Foundation Australia - resources

• Australian and New Zealand Guidelines for the management of COPD

• non-invasive ventilation (NIV)

• National Community Specifications Oxygen Therapy Services

• MidCentral Health Clinical Guidelines Oxygen Therapy

• Arohanui Hospice website

• NZ Formulary

Advance Care Planning:

• table highlighting differences between advance care plans, advance directives and EPOA

• Advance Care Planning: A guide for the New Zealand health care workforce, is available

• advance care planning - how to have the conversation

4. Updates to this care map

Date of publication: March 2016.

Please see the care map’s Provenance for additional information on references, accreditations from national clinical bodies,

contributors, publication schedule, and the editorial methodology.

5. Hauora Māori

Māori are a diverse people and whilst there is no single Māori identity, it is vital practitioners offer culturally appropriate care when

working with Māori Whānau. It is important for practitioners to have a baseline understanding of the issues surrounding Māori

health.

This knowledge can be actualised by (not in any order of priority):

• acknowledging Te Whare Tapa Wha (Māorimodel of health) when working with Māori Whānau

• asking Māori clients if they would like their Whānau or significant others to be involved in assessment and treatment

• asking Māori clients about any particular cultural beliefs they or their Whānau have that might impact on assessment and

treatment of the particular health issue (Cultural issues)

• consider the importance of Whānaungatanga (making meaningful connections) with their Māori client / Whānau

• knowledge of Whānau Ora, Te Ara Whānau Ora and referring to Whānau Ora Navigators where appropriate

• having a historical overview of legislation that has impacted on Māori well-being

For further information:

• Hauora Māori

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6. Pasifika

Pacific Cultural Guidelines (Central PHO) 6MB file

Our Pasifika community:

• is a diverse and dynamic population:

• more than 22 nations represented in New Zealand

• each with their own unique culture, language, history, and health status

• share many similarities which we have shared with you here in order to help you work with Pasifika patients more effectively

The main Pacific nations in New Zealand are:

• Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu

Acknowledging The FonoFale Model (pasifika model of health) when working with Pasifika peoples and families.

Acknowledging general pacific guidelines when working with Pasifika peoples and families:

• Cultural protocols and greetings

• Building relationships with your pasifika patients

• Involving family support, involving religion, during assessments and in the hospital

• Home visits

• Contact information

Pasifika Health Service - Better Health for Pasifika Communities:

• the Pasifika Health Service is a service provided free of charge for:

• all Pasifika people living in Manawatu, Horowhenua, Tararua and Otaki who have long term conditions

• all Pasifika mothers and children aged 0-5 years

• an appointment can be made by the patient, doctor or nurse

• the Pasifika Health Service contact details are:

• Palmerston North Office - 06 354 9107

• Horowhenua Office - 06 367 6433

• Better Health for Pasifika Communities brochure

Additional resources:

• Ala Mo'ui - Pathways to Pacific Health and Wellbeing 2014-2018

• Primary care for pacific people: a pacific health systems approach

• Tupu Ola Moui: The Pacific Health Chart Book 2004

• Pacific Health resources

• Central PHO Pasifika Health Service

7. COPD Suspected

Consider Chronic Obstructive Pulmonary Disease (COPD) in patients with [8]:

• dyspnoea

• chronic cough

• sputum production

• smoking history

• and/or a history of exposure to risk factors for the disease e.g:

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• smoking

• occupational exposure

• increasing age

• deprived communities

• genetic risk of homozygous alpha1-antitrypsin deficiency − accounts for less than 1% of cases

• environmental factors, e.g. air pollution

Use the Modified Medical Research Council (mMRC) dyspnoea scale to assess functional impact of breathlessness [1,2,3]:

During the early stages of COPD the patient may have no or minimal symptoms [3]; airflow limitation, however, may be present in

the absence of symptoms [3].

Clinical presentation of COPD includes [3,8]:

• persistent and progressive dyspnoea

• wheeze

• cough - maybe intermittent and unproductive

• sputum production

Systemic features of COPD include [2,3]:

• cachexia − loss of fat free mass

• skeletal muscle wasting

• osteoporosis

• depression

• increased risk of cardiovascular disease (CVD)

Additional features of severe COPD include [2]:

• weight loss

• anorexia

• cough syncope

• rib fractures caused by coughing spells

• pedal oedema − symptom of cor pulmonale

• increasing panic / depression and anxiety

8. Conduct medicines review

Conduct medicines optimisation and review

9. Provide Stop Smoking Support

The most critical intervention is smoking cessation. All patients with chronic obstructive pulmonary disease (COPD) should be

encouraged to stop smoking, and offered help to do so at every opportunity [3].

Telling smokers their lung age has been shown to significantly improve the likelihood of them quitting smoking [16].

Graph of Lung Function Age (Thatcher and Peto natural history of lung function decline graph).

‘ABC’ is a memory aid for health care workers to understand the key steps to helping people who smoke:

• A. Ask all people about their smoking status and document this

• B. Provide Brief advice to stop smoking to all people who smoke, regardless of their desire or motivation to quit

• C. Make an offer of, and referto or provide, evidence based Cessation treatment

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For further information on smoking cessation services see the Stop Smoking Support pathway.

10. Spirometry and Other Investigations

Demonstrating airflow obstruction is critical in supporting the diagnosis of chronic obstructive pulmonary disease (COPD) [2,3]:

• post-bronchodilator FEV1/FVC (forced expiratory volume in 1 second/forced vital capacity) ratio of less than 0.7 confirms the

presence of airflow limitation

• severity of airflow limitation is measured by post-bronchodilator FEV1

• NB: caution is required in the elderly. A number of published guidelines define airflow obstruction as a fixed ratio of FEV1/

FVC<0.7 rather than the lower limit of normal (LLN). However, this results in over-diagnosis of COPD in the older age group

• spirometry is the only accurate method of measuring airflow obstruction in COPD

• peak expiratory flow (PEF) measurement may underestimate the severity of obstruction

Referrals:

Referrals for spirometry may be sent by fax/posted to Respiratory Clinic at MidCentral Health on 06 350 8647. Requests are

prioritised by physiologists with input as required from Respiratory Specialists into urgent (e.g. pre-op assessment, suspected

cancer) and semi-urgent (e.g. diagnostic assessment).

Spirometry is performed by a Respiratory Technician / physiologist at the Respiratory Laboratory, Palmerston North Hospital.

Enquiries regarding referrals can be made on 06 350 8616. Spirometry is interpreted by respiratory specialists with the results

returned to the referrer within one week of the completed spirometry.

For diagnostic spirometry it is important that it is done by trained staff using validated equipment that is calibrated and

checked regularly.

General practice based community spirometry clinics are currently available in Dannevirke and Horowhenua, and there are plans to

expand the spirometry clinic service to other General Practice centres.

Respiratory Services Referral Form for Respiratory Function Tests - or use Medtech outbox doc.

Other investigations:

The following investigations should be completed as part of the diagnosis and assessment of COPD:

• chest X-ray (CXR):

• signs suggestive of COPD include [1,2]:

• hyperinflation

• flat hemi-diaphragm

• reduced peripheral vascular markings

• bullae

• CXR may exclude other pathologies [1,2,9]:

• lung cancer which may have precipitated the presentation

• causes of a chronic cough e.g:

• bronchial carcinoma

• tuberculosis

• bronchiectasis

• interstitial lung disease

• NB: CXR cannot diagnose mild emphysema; should be repeated if new symptoms develop because there is an increased

incidence of lung cancer in these patients [10]

• consider the following:

• haematology:

• full blood count (FBC) to identify [3]:

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• anaemia [1,3] causing breathlessness [1]

• eosinophilia, eg. may suspect asthma [1]

• polycythaemia [2,3] which may indicate chronic hypoxia [1,5]:

• polycythaemia cannot be assumed to be secondary without measurement of arterial blood gas tensions [10]

venesection may be considered if the packed cell volume is more than 50% [9]

• body mass index (BMI):

• should be performed on initial diagnostic evaluation [3]

• PHO dietitian referral criteria for underweight patients:

• BMI <18.5kg/m2 with unintentional weight loss of 5% in one month

• PHO dietitian and PAE referral criteria for overweight patients:

• BMI >25kg/m2

11. Interpretation of Results

Interpretation of results should be after post bronchodilator spirometry. Chronic obstructive pulmonary disease (COPD) is an

irreversible airway disease [1,2,3,4]:

• normal spirometry does not exclude COPD

• interpretation is undertaken by Respiratory Specialist at MCH

• for diagnostic spirometry it is important that it is done by trained staff using validated equipment that is calibrated and checked

regularly

Measures included in Spirometry results [14]:

• Forced Vital Capacity (FVC): volume of air exhaled after full inspiration. If low, suggests restrictive pattern

• Forced Expiratory Volume in One Second (FEV1): volume of air exhaled in first one second of expiration. Important for

determining severity of COPD

• FEV1 / FEV ratio: ratio of vital capacity exhaled in one second, expressed as percentage. Used to detect airways obstruction

• % Predicted: uses the normal values for age, sex, and height

For diagnostic spirometry it is important that it is done by trained staff using validated equipment that is calibrated and

checked regularly.

12. Obstructive

If the FEV1/FVC ratio is less than 0.7 or less than the lower limit of normal (included with the test report), an obstructive defect is

present. Determine the severity of the obstructive defect by looking at the FEV1 as a percent predicted.

Suggestive features of Asthma versus COPD .

The following clinical features help to differentiate chronic obstructive pulmonary disease (COPD) from asthma [1,3]:

• smoker or ex-smoker:

• nearly always present in COPD >10 pack years

• possible in asthma

• symptoms under age 35 years:

• rare in COPD

• often in asthma

• chronic productive cough:

• common in COPD

• uncommon in asthma

• breathlessness:

• persistent and progressive in COPD

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• variable in asthma

• night time waking with breathlessness and/or wheeze:

• uncommon in COPD

• common in asthma

• significant diurnal or day-to-day variability of symptoms:

• uncommon in COPD

• common in asthma

• allergy:

• uncommon COPD

• common asthma

• family history:

• uncommon COPD

• common asthma

13. Restrictive

Common causes of a restrictive spirometric pattern [14]:

• parenchymal lung disease: pulmonary fibrosis / interstitial lung disease

• neuro-muscular disease

• morbid obesity

• pleural disorders

• miscellaneous including heart failure and pneumonia

Testing for restrictive spirometric pattern:

• if the FEV1/FVC ratio is greater than 0.7 or greater than the lower limit of normal (LLN), then spirometry is either normal or a

restrictive defect may be present

• when the FVC is above the LLN, a restrictive pattern is excluded

• when the FVC is below the LLN, a restrictive pattern is suggested. Full lung function testing may be appropriate, depending on

the clinical situation. Restrictive patterns seen on spirometric testing are correct only 50% of the time

14. Normal

Consider the following differential diagnosis:

• congestive cardiac failure [1,2,3] − symptoms include:

• breathlessness when lying flat

• history of ischaemic heart disease

• fine lung crackles [1]

Also consider:

• asthma

• bronchiectasis [1,2,3]:

• copious sputum, frequent chest infection, history of childhood pneumonia, coarse lung crackles [1]

• carcinoma of the bronchus [3]:

• haemoptysis, weight loss, hoarseness [1]

• pneumonia [3]

• pneumothorax [3]

• interstitial lung disease − dry cough, fine crackles [1]

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• recurrent pulmonary embolism [10]

• tuberculosis [2]

• obstructive sleep apnoea [1]

• upper airway obstruction [3]

NB: Some of these conditions may coexist with chronic obstructive pulmonary disease (COPD) [1].

Normal spirometry does not exclude asthma or COPD - 10% of patients with asthma will have normal spirometry.

15. Asthma Diagnosis

Table illustrating suggestive features of Asthma versus COPD

Asthma is a reversible airways disease.

16. COPD Diagnosis Confirmed

Confirmation of the presence of airflow obstruction requires post bronchodilator spirometry.

Diagnosis is also based on clinical judgement [3]:

• signs and symptoms:

• exertional breathlessness

• chronic cough

• regular sputum production

• wheeze

• smoking exposure

If you have confirmed COPD diagnosis commence treatment.

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Chronic Obstructive Pulmonary Disease (COPD)

Provenance Certificate

Overview | Editorial methodology | References | Contributors | Disclaimers

Overview

This document describes the provenance of MidCentral District Health Board’s Chronic Obstructive Pulmonary Disease (COPD) Pathway. This pathway is regularly updated to include new, quality-assessed evidence, and practice-based knowledge from expert clinicians. Please see the Editorial Methodology section of this document for further information.

This localised pathway was last updated in March 2016.

For information on changes in the last update, see the information point entitled ‘Updates to this care map’ on each page of the pathway.

One feature of the “Better, Sooner, More Convenient” (BSMC) Business Case, accepted by the Ministry of Health in 2010, was the development of 33 collaborative clinical pathways (CCP).

The purpose of implementing the CCP Programme in our DHB is to:

• Help meet the Better Sooner More Convenient Business Case aspirational targets, particularly the following:

o Reduce presentations to the Emergency Department (ED) by 30%

o Reduce avoidable hospital admissions to Medical Wards and Assessment Treatment and Rehabilitation for over-65-year-olds by 20%

o Reduce poly-pharmacy in the over-65-year-olds by 10%

• Implement a tool to assist in planning and development of health services across the district, using evidence-based clinical pathways.

• Provide front line clinicians and other key stakeholders with a rapidly accessible check of best practice;

• Enhance partnership processes between primary and secondary health care services across the DHB.

To cite this pathway, use the following format:

Map of Medicine. Medicine. MidCentral District View. Palmerston North: Map of Medicine; 2014 (Issue 1).

Editorial methodology

This care map was based on high-quality information and known Best Practice guidelines from New

Zealand and around the world including Map of medicine editorial methodology. It has been checked by

individuals with front- line clinical experience (see Contributors section of this document).

Map of Medicine pathways are constantly updated in response to new evidence. Continuous evidence

searching means that pathways can be updated rapidly in response to any change in the information

landscape. Indexed and grey literature is monitored for new evidence, and feedback is collected from users

year-round. The information is triaged so that important changes to the information landscape are

incorporated into the pathways through the quarterly publication cycle.

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References

This care map has been developed according to the Map of Medicine editorial methodology. The content of this care map is based on high-quality guidelines and practice-based knowledge provided by contributors with front- line clinical experience.

This localised version of the evidence-based, practice-informed care map has been peer-reviewed by stakeholder groups and the CCP Programme Clinical Lead.

1 Clinical Knowledge Summaries (CKS). Chronic obstructive pulmonary disease. July 2013. Newcastle upon Tyne: CKS; 2013. Available from: http://cks.nice.org.uk/chronic-obstructive-pulmonary-disease

2

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Barcelona: GOLD; 2013. Available from: http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf

3

National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre; 2010. Available from: http://www.nice.org.uk/nicemedia/live/13029/49425/49425.pd

4 Bott J, Blumenthal, Buxton M et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax 2009; 64: i1-i51. Available from: http://thorax.bmj.com/content/64/Suppl_1/i1.full

5 Contributors representing the Royal College of Physicians; 2011.

6 Practice-informed recommendation. London; 2011.

7 O'Driscoll BR, Howard LS, Davison et al. Guidelines for emergency oxygen use in adult patients. Thorax 2008; 63: vi1-68. Available from: http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Emergency%20oxygen%20guideline/THX-63-Suppl_6.pdf

8 Diagnosis and management of COPD in Māori and Pacific peoples. Best Practice Journal, 2012. BPJ: 43 – COPD in Maori and Pacific people. Available from: http://www.bpac.org.nz/BPJ/2012/April/copd.aspx

9

British Thoracic Society (BTS). Clinical component for the home oxygen service in England and Wales. London: BTS; 2006. Available from: http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Home%20Oxygen%20Service/clinical%20adultoxygenjan06.pdf

10

Department of Health (DH). Medical Directorate. Respiratory Team. An outcomes strategy for COPD and asthma: NHS companion document. London: DH; 2012. Available from: https://www.gov.uk/government/publications/an-outcomesstrategy-for-copd-and- asthma-nhs-companion-document

11 The Asthma Foundation. COPD in New Zealand. 2012. Available from: www.asthmafoundation.org.nz

12 Auckland District Health Board. Pacifika health needs assessment. 2012. Available from: http://www.adhb.govt.nz/healthneeds/Pacific%20health.htm

13 Ministry of Health. A portrait of Health: Key results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health; 2008

14

Bolton CE, Bevan-Smith EF, Blakey JD et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68 Suppl 2: ii1-ii30. Available from: http://www.britthoracic.org.uk/Portals/0/Guidelines/Pul%20Rehabilitation/Pulmonary_rehab_2013/pulmonary_rehab_final.pdf

15

Nannini LJ, Poole P, Milan SJ et al. Combined corticosteroid and long-acting beta2-agonist in one inhaler versus inhaled corticosteroids alone for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2013; CD006826. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23990350

16 Jones R, Price D, Chavannes N et al. GOLD COPD categories are not fit for purpose in primary care. The Lancet 2013; 1: e17. Available from: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(13)70015-8/fulltext

17 Contributors representing the Royal College of Physicians; 2012.

18 National Institute for Health and Clinical Excellence (NICE). Generalised anxiety disorder and panic disorder (with

or without agoraphobia) in adults. Clinical guideline 113. London: NICE; 2011.

19 National Institute for Health and Clinical Excellence (NICE). Depression: The treatment and management of depression in adults. Clinical guideline 90. London: NICE; 2009.

20 Curtis, J.R. Palliative and end-of-life care for patients with severe COPD. Eur Respir J 2008; 32: 796–803.

21 Conversation with Arohanui Hospice Palliative Care Team

22 Advance Care Planning: A guide for the New Zealand health care workforce. MOH: Wellington 2011

23 Ford ES, Li C et al. Associations between antioxidants and all-cause mortality among US adults with obstructive lung

function. Br J Nutr. 2014 Nov 28; 112(10): 1662-73.

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24

Virtamo J, Taylor R et al. Effects of α-tocopherol and β-carotene supplementation on cancer incidence and mortality: 18 year post intervention follow-up of the Alpa-Tocopherol, Beta-Carotene Cancer Prevention Study. International Journal of Cancer: 135, 178- 185 (2014).

25 Cortes-Jofre, M and Rueda J.R. et al. Drugs for Preventing Lung Cacner in Healthy People. Cochrane Database Syst Rev. 2012.http://www.ncbi.nlm.nih.gov/pubmed/23076895

26 Rautalahti M, Virtamo J et al. The effect of alpha-tocopherol and beta-carotene supplementations on COPD symptoms. Am J Journal Respir Crit Care Med. 1997 Nov; 156 (5): 1447-52.

27 The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of Vitamin E and Beta Carotene on the Incidence of Lung Cancer and other Cancers in Male Smokers. The New England Journal of Medicine. 1994. Volume 330.

Contributors MidCentral DHB’s Collaborative Clinical Pathway editors and facilitators worked with clinical stakeholders such as front-line clinicians and pharmacists to gather practice-based knowledge for its care maps.

The following individuals contributed to the update of this care map:

• Dr Aldoph Nanguzgambo, Respiratory Physician, MidCentral Health (Secondary Care Clinical Lead)

• Dr Michael Short, General Practitioner, Kauri Health Group (Primary Care Clinical Lead)

• Karen Lombard, Pharmacist, CPHO

• Marina Lambert, Nurse Practitioner Respiratory Services, MCH

• Lindy Campbell, Community Respiratory Physiotherapist ,CPHO

• Sarah Dixon, Respiratory Physiotherapist, MCH

• Lupe Kelekolio, Community Clinical Nurse: Long Term Conditions, CPHO

• Jess Robb, Project Director, Collaborative Clinical Pathways (Facilitator)

• Alaina Glue, Project Assistant, Collaborative Clinical Pathways (Editor)

The following individuals have contributed to the original development of this care map:

• Dr Aldoph Nanguzgambo, Respiratory Physician, MidCentral Health (Secondary Care Clinical

Lead)

• Dr Michael Short, General Practitioner, Kauri Health Group (Primary Care Clinical Lead)

• Karen Lombard, Pharmacist, CPHO

• Julia Hince, Practice Nurse, Kauri Health Group

• Marina Lambert, Nurse Practitioner Respiratory Services, MCH

• Lindy Campbell, Community Respiratory Physiotherapist ,CPHO

• Sarah Dixon , Expert Respiratory Physiotherapist, MCH

• Lupe Kelekolio, Community Clinical Nurse: Long Term Conditions, CPHO

• Alaina Glue, Project Assistant, Collaborative Clinical Pathways (Editor)

• Leanne Bell - Clinical Nurse Specialist Acute Care Team, Health Care Development, MDHB

• Linda Dubbeldam, Senior Clinical Advisor, CPHO (Facilitator)

• Dr Greig Russell – Medical Director, Central PHO

• Denise White - Clinical Nurse Specialist (Lead) Community MidCentral Health

• Dr. Delamy Keall – General Practitioner, Tararua Health Group

• Kirsty Dunlop, Clinical Networks Project Manager

Other contributors:

• Fay Selby Law – Kaiarahi, Te Ohu Auahi Mutunga

• Suzanne Aitken – Community Dietician, CPHO

• Dr Alistair Watson – Respiratory Physician, MCH

• Jan Dewar - Nurse Director Medicine, Elder Health, Rehabilitation, District Nursing, MCH

• Kylie Bradley – Community Nurse, Tararua Health Group

• Sonja Dreyer – Senior Lecturer UCOL Kinetics

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) - SUSPECTED April 2018 Page 15 of 15

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• Kim Fry, Director of Allied Health, MidCentral Health and Whanganui DHB

• Angela Verhoeven, Project Leader, CPHO

• Syed Zaman, Consultant Physician and RMO Director, MCH

• Aimee McGregor, CNS Respiratory, MCH

• Sharon Hancock, CNS Respiratory, MCH

• Susan Alexander – CNS Respiratory, MCH

• Victoria Perry, NP Respiratory, MCH

Disclaimers

Clinical Board Central PHO, MidCentral DHB

It is not the function of the Clinical Board Central PHO, MidCentral DHB to substitute for the role of the

clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map

of Medicine are therefore urged to use their own professional judgement to ensure that the patient

receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of

the information on this online clinical knowledge resource, we cannot guarantee its correctness and

completeness. The information on the Map of Medicine is subject to change and we cannot guarantee

that it is up-to-date.