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DATE: 07/05/20 Ef
SI ON: 0.07

TITLE: KIMBERLEY HEALTH PROTOCOL- CHRONIC DISEASE:
CHRONIC LUNG DISEASE- COPD AND BRONCHIECTASIS
REFERENCE MANUAL
This protocol refers to Adults with Chronic Lung Disease. For children, refer to
child health protocols.

1. GUIDING PRINCIPLES
 
This protocol is applicable only to eligible Aboriginal and Torres Straight Island Health
Services in remote areas of the Kimberley region of Western Australia approved under
Section 100 of the National Health Act 1953 that makes special provision for supply of
medications to patients/clients.

The protocol was designed for use in conjunction with the Kimberley Standard Drug
List (KSDL) which is a standardised list of medications available on the
Pharmaceutical Benefits Scheme and Section 100 throughout the Kimberley, including
remote area clinics.
2. PROTOCOL- Chronic lung disease:

2.1 Case Definition COPD1
• Chronic cough and/or sputum production >1 year. AND Airflow limitation that is not ful y reversible: • FEV1 / FVC < 70% predicted value post bronchodilator (15-30 minutes after two puffs of salbutamol via spacer) 1, 2 where: FEV1 = forced expiratory volume in one second and FVC = forced vital capacity. Exclude asthma: if airflow limitation is ful y or substantial y reversible fol owing bronchodilator, treat as Asthma 1. Case Definition Bronchiectasis3, 4
• Recurrent or persistent bronchial infection, cough and/or sputum (may or may not be associated airway obstruction). 2.2 Screening2,5
Every two years ask / note: 1. cough and/or sputum production for on most days for 2-3 months. 2. Recurrent chest infections( eg ≥ 3 episodes per year) 3. Unexplained shortness of breath. Spirometry for anyone answering YES to any of the above screening questions and at other times, for anyone presenting to clinic with any of the above problems at any time. This information is available in alternative formats upon request
2.3 Principles of Management
• Smoking cessation reduces the rate in decline of lung function 2
• Spirometry is essential for diagnosis of COPD1.
• PEFR (peak expiratory flow rate) is useful for monitoring COPD but should not be
used for diagnosis18. • Diagnosis of Bronchiectasis should be confirmed by High Resolution CT scan3. • Salbutamol provides symptom relief and may improve exercise function1. • Tiotropium and inhaled corticosteroid preventers improve symptom control and • Long term use of oral prednisolone is NOT recommended1 and should not be used in patients with bronchiectasis 3. • Long-term oxygen therapy (>15 hr/day) prolongs life in patients with significant • Early diagnosis and prompt treatment of exacerbations1. • Pulmonary Rehabilitation (Physiotherapy) improves symptom control and lung BASELINE ASSESSMENT
• Spirometry, before and 15 minutes after Salbutamol two puffs via spacer 1, 2, 4 for
diagnosis and to guide therapy. • BMI 1, 4: if high (eg. >25) see HEALTHY LIVING PROTOCOL, if low (eg. <20) refer • Oxygen saturation on room air4: o If O2 saturation at rest < 92% on room air, do / arrange arterial blood gas1 o Also document O2 saturation after a short walk on a level surface2. • FBE 2, 4 • ECG2, 4 • CXR 2, 4 • Echocardiogram: if PaO2 55-60 mmHg on room air, if severe disease or symptoms seem out of proportion to degree of airflow limitation1. • For people < 40 years, <10 year pack history or never/occasional smoker, very frequent chest infections- consider α1 antitrypsin deficiency or bronchiectasis1. • In these people check: o α 1 antitrypsin serum level and genotype if level reduced 1. o if CXR shows no evidence of bronchiectasis, organise high resolution CT scan of chest 1, 4. o If bronchiectasis confirmed (on CT or CXR), refer to physician for further
SEVERITY 1,4
% Predicted FEV1
Reduced activity Moderate
If FEV1 < 50%, acute episodes may impact daily life / prognosis Extremely impaired quality of life, acute episodes are now life threatening. This information is available in alternative formats upon request
The % predicted FEV1 is the variable most closely associated with prognosis1: 2.4 Therapeutic Protocol
• ENCOURAGE SMOKING CESSATION1.
• Ensure influenza and pneumococcal vaccines are up to date 9 (see Healthy
Living Guideline). • Check puffer and spacer technique 4.
DISEASE SEVERITY 8:
• Mild: Salbutamol 100mcg 2 puffs PRN via MDI/spacer as needed*.
• Moderate / Severe: As above and Tiotropium 18mcg daily* then if symptoms not
control ed ADD Fluticasone and Salmeterol (250mcg/25mcg) two puffs BD or Accuhaler (500mcg/50mcg) one puff BD*. EXACERBATIONS
If frequent exacerbations e.g. ≥ 3 exacerbations/infective episodes per year:
o With CLD of any severity and not already on Fluticasone, add Fluticasone 500mcg one puff BD* 1. ACUTE EXACERBATIONS1,7:
An acute change in the patient's baseline symptoms that may require increase or change in medications and may include: o increasing cough. o increasing purulence of sputum o increasing SOB MANAGEMENT OF ACUTE EXACERBATION OF COPD (excluding confirmed
bronchiectasis)8:
1. ANTIBIOTIC: Amoxycil in 500 mg tds for five days or, if penicil in hypersensitivity,
use doxycycline 100mg BD for five days. SEE NOTE.
2. STEROIDS: Prednisolone 50mg daily for five days (unless confirmed bronchiectasis-
steroids not recommended3).
3. SPUTUM COLLECTION for MC&S if failure of response to Amoxycil in
4. ADMISSION if history of severe CLD3.
NOTE: Use of Augmentin has not been shown to be superior in the treatment of exacerbation of COPD and is NOT RECOMMENDED. Use of Roxithromycin or Azithromycin is not recommended as first line treatment8.
MANAGEMENT OF ACUTE EXACERBATION OF CONFIRMED
BRONCHIECTASIS 8:
1. SPUTUM COLLECTION for MC&S (take prior to commencing antibiotics).
2. ANTIBIOTIC: until culture results are known, empirical Amoxycil in 500 mg tds for
two weeks or, if penicil in hypersensitivity, use doxycycline 100mg BD for two weeks.
If the patients is KNOWN to be colonised with Pseudomonas Aeruginosa, use
ciprofloxacin 750mg BD for 7 to 14 days (this does not apply to a positive culture in
the WELL patient, pseudomonas eradication therapy is usual y not indicated in the
well patient).
3. ADMISSION if history of severe CLD or significant haemoptysis3,4
4. Steroids are NOT recommended
This information is available in alternative formats upon request
CLD / ASTHMA COEXISTING:
• Patients who show significant reversibility fol owing bronchodilators, e.g. FEV1
improves significantly (>12%)10 fol owing Salbutamol, may have coexistent asthma1. • If good control is not achieved with Salbutamol and Fluticasone alone: o replace Fluticasone with Salmeterol + Fluticasone* MDI (25mcg/250mcg) two puffs bd or Accuhaler (50mcg/500mcg) one BD10. N.B. Theophyl ine: May be useful if patient unable to use inhaled medications or if first line therapy has failed to adequately control symptoms. Requires serum monitoring and caution regarding interactions with other medications8. Discuss use with physician. *See Explanatory Notes On Medications
2.5 Follow-Up
INITIALLY
• Review 2 weeks after any medication change and assess symptom control, PEFR
and inhaler technique. • If inadequate control adjust management according to therapeutic protocol. LONG TERM • Yearly Spirometry for mild to moderate CLD, 6 monthly for severe CLD2. • Mild and Moderate CLD2,4: o Review every 6 months. o Assess: § smoking status and encourage patient to quit § encourage exercise and regular activity § adequacy of symptom control (SOB, exercise tolerance, exacerbation § inhaler technique o Annual y check BMI o Annual y check FBC and oxygen saturation o Review every 2-3 months, and assess as above. o Check oxygen saturation and FBC every 6 months
Flights- if planning a flight and oxygen saturations ≤ 93% the patient should have 2L
via nasal prongs of supplementary oxygen during the flight.
2.6 Women of Child-Bearing Age
• If planning a pregnancy, ensure appropriate therapy for optimisation of lung
• Women with chronic lung disease planning pregnancy or who are pregnant should be seen by the Physician1. • No inhaled medications are contraindicated in pregnancy or breastfeeding8. • Pregnancy should be avoided in women with severe air flow obstruction. This information is available in alternative formats upon request

2.7 Refer / Discuss
PHYSICIAN1:
• Diagnostic uncertainty and exclusion of asthma
• <40 years of age.
• Confirmed bronchiectasis for further assessment.
• More than 4 exacerbations per year
• If when stable, pO2 < 60mmHg OR pCO2 > 45mmHg.
• Cor pulmonale (coexistent right heart failure)
• Suspected chronic hypoxaemia/Polycythaemia (Hb > 170g/L after excluding
• Moderate or severe disease failing to respond to therapy. • Bul ous lung disease or severe disease to assess for appropriateness for lung volume reduction surgery or lung transplantation. • BMI <18 • First time Pseudomonas Aeruginosa isolated on sputum culture if patient not previously diagnosed with Bronchiectasis, especial y if associated clubbing, large volumes of sputum or in those under 45 years of age and <10 pack year smoking history. PALLIATIVE CARE: • Severe CLD1. Contact: Kimberley Palliative Care Service- Coolibah St Kununurra
HOURS: Monday – Friday 8:00am – 4:00pm
CONTACT:pH: 91664208 fax:91664250
POSTAL ADDRESS: PO Box 239, Kununurra, WA, 6743
EMAIL: KHR.Pal [email protected]
Regional Coordinator: Sal y Thomas CN pH: 0434 181 044 email: KHR.Pal [email protected] Senior Social Worker: Sal y Eves pH:0407 840 628 Pal iative Care Clinical Nurse: Paul Schultz pH:0407 880 570 Aboriginal Health Worker: Kimika Lee pH: 0407 847 418 Administration Assistant: Sal y Parker pH:08 9194 2325 All pal iative care referrals can be made to the regional coordinator Sal y Thomas. Dr Kevin Yuen (Pal iative Care Physician) visits the region every 3rd month and does a monthly teleconference. In between the pal iative care team meets weekly and has a monthly Cancer & Pal iative Care Meeting with the Regional Director Of Nursing FOR 24 hour Palliative Care Support:
Silver Chain and WA Combined Pal iative Care Outreach Service have two contact
numbers for phone support regarding pal iative care advice (ie pain and symptom
management, family support, End Of Life (terminal phase), medication, any other
pal iative care issues that may arise).
The two numbers are manned by pal iative care physicians and pal iative clinical
nurse consultants who are available 7 days a week 24 hours a day to provide
This information is available in alternative formats upon request
current, up to date, evidence based advice and support to al ow you to continue to provide excel ent care to your pal iative care clients and families Silver Chain Pal iative Nursing Helpline:1800 420 102 WA Combined Pal iative Care Outreach Service (Medical):1300 558 655 PHYSIOTHERAPIST: • If severe CLD for pulmonary rehabilitation, home assessment and assessment of need for exercise related supplemental oxygen1. • If BMI < 18
3 ROLES AND RESPONSIBILITIES OF MULTIDISCIPLINARY TEAM MEMBERS
Physician Review1: • If when stable, the clients pO2 < 60mmHg OR pCO2 > 45mmHg. • When the client has coexistent right heart failure. • Suspected chronic hypoxaemia/Polycythaemia (Hb > 170g/L) • When the client is unable to be weaned from oral steroids after acute exacerbation. • When the client with severe CLD is planning a flight. • When there is a lack of response to therapies suggested in the protocol. • When the client has severe disease, to assess for appropriateness of referral for lung volume reduction surgery or lung transplantation. • When the client is planning a pregnancy or is already pregnant2. • Utilise interpreter services, if appropriate. Cal the Translating and Interpreter Service (TIS) on 13 14 50 • Liaison with the multidisciplinary team. Pal iative Care: • Review if requested in severe CLD1. • Liaison with Multidisciplinary team. Physiotherapist1: • When the client has severe CLD for pulmonary rehabilitation • Airway clearance techniques in patients with bronchiectasis • For home assessment • Assessment of need for exercise related supplemental oxygen. • Liaison with Multidisciplinary team. Medical Officer: • The client should be reviewed by a medical officer six monthly (unless client has been seen by a nurse practitioner). Patients with mild COPD may be reviewed annually. • If medication is being titrated, the patient should be reviewed at least every two weeks by a medical officer (or nurse practitioner). • Refer the client to the physician, pal iative care or the physiotherapist if they meet the requirements above. • Order blood or other tests at appropriate times according to the guideline, and the patient's clinical picture. Review of the results and arrange fol ow-up as per results and clinical picture. This information is available in alternative formats upon request
• Give appropriate education with regard to patient's condition, co-morbidities, other risk factors, lifestyle issues and medications. • Offer patient support with regard to the management of their condition, including self-management where appropriate, and other issues affecting lifestyle. • Commence the patient on treatment as per clinical picture and guideline. • Commence on, or update the patient's care plan in accordance with their clinical picture, and the guideline. • Engage in brief interventions, and make use of the Lifescripts as appropriate. • Utilise interpreter services, if appropriate. Cal the Translating and Interpreter Service (TIS) on 13 14 50. • Liaison with Multidisciplinary team. Remote Nurse Practitioner: • The scope of practise of the remote nurse practitioner is defined by: • The ordering of pathology, radiology and referral for routine specialist review as outlined within this guideline. • The management of ongoing care of the client whose pathology and radiology results are within normal limits, which includes the provision of a further 12 month prescription for the medications outlined within this guideline. • All clients must be reviewed by a medical officer annual y. • Specifical y relating to this chronic disease protocol: • Review the client every six months (unless the client has been seen by a medical officer) in accordance with the guidelines and their clinical picture. Patients with mild COPD may be reviewed annual y. • Refer the client to the physician, pal iative care or the physiotherapist if they meet the requirements above. • Give appropriate education with regard to their condition, co-morbidities, other risk factors, lifestyle issues and medications. • Offer patient support with regard to the management of their condition, including self-management where appropriate, and other issues affecting lifestyle. • Commence the patient on treatment as per clinical picture and guideline. • Commence on, or update the patient's care plan in accordance to their clinical picture, and the guideline. • Engage in brief interventions, and make use of the Lifescripts as appropriate. • Discuss any concerns about patient and / or treatment with medical officer, or relevant specialist. • Timely and appropriate referral of patient. • Commence on, or update the patient's care plan in accordance with their clinical picture, and the guideline. • Utilise interpreter services, if appropriate. Cal the Translating and Interpreter Service (TIS) on 13 14 50. • Liaison with Multidisciplinary team. Remote Area Nurse: • Three monthly observations / assessment. This information is available in alternative formats upon request
• Give appropriate education with regard to patient's condition, co-morbidities, other risk factors and lifestyle issues. • Offer patient support with regard to the management of their condition, including self-management where appropriate, and other issues affecting lifestyle. • The taking of bloods / urine as ordered by the medical officer or nurse practitioner. • Engage in brief interventions, and make use of the Lifescripts as appropriate. • Utilise interpreter services, if appropriate. Cal the Translating and Interpreter Service (TIS) on 13 14 50. • Liaison with Multidisciplinary team. Aboriginal Health Worker: • Three monthly observations / assessment. • Give appropriate education with regard to patient's condition, co-morbidities, other risk factors and lifestyle issues. • Offer patient support with regard to the management of their condition, including self-management where appropriate, and other issues affecting lifestyle. • The taking of bloods / urine as ordered by the medical officer or nurse practitioner. • Engage in brief interventions, and make use of the Lifescripts as appropriate. • Liaison with Multidisciplinary team. 4 EXPLANATORY NOTES ON MEDICATIONS
Although other short acting bronchodilators, long acting bronchodilators and inhaled corticosteroid medications have been shown to be equal y effective 8, Salbutamol, Fluticasone, and combination Salmeterol + Fluticasone are recommended for use in the Kimberley due to their availability on the essential list of the KSDL 11. In order to comply with PBS criteria for prescription, severe COPD requires the addition of Salmeterol to the recommended Fluticasone, as Seretide MDI 250/25 or Accuhaler 500/50. 5 REFERENCES

1. David K McKenzie, Michael Abramson, Alan J Crockett, Nicholas Glasgow, Sue Jenkins, Christine McDonald, Richard Wood-Baker, Peter A Frith on behalf of The Australian Lung Foundation. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2010 Level 1, 2 and 3b evidence, in accordance to the NHMRC guidelines 2. Queensland Health, Royal Flying Doctor Service of Australia (Queensland Section) and Apunipima Cape York Health Council, Chronic Disease Guidelines, 3rd edition, 2010. Cairns. Level 1 evidence, in accordance to the NHMRC guidelines 3. Therapeutic Guidelines. Respiratory Bronchiectasis. 2009 [cited 2011 September 1]; Available from: etg 34. Level 1 and 2 evidence, in accordance to the NHMRC guidelines 4. CARPA (2009) CARPA Standard Treatment Manual, 5th edition. Alice Springs: Central Australian Rural Practitioners Association Inc This information is available in alternative formats upon request
5. NACCHO, Evidence base to a preventive health assessment Aboriginal and Torres Strait Islander peoples in Preventive health assessment in Aboriginal and Torres Strait Islander peoples. 2005, RACGP: Melbourne. Grade D recommendation, in accordance to the NHMRC guidelines 6. Veale, A., et al. ‘Normal' lung function in rural Australian Aborigines. Aust NZ J Med 1997; 27:543–9. Level 3c evidence, in accordance to the NHMRC guidelines 7. Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management and Prevention: A guide for Health Care Professionals. Updated 2010 8. Therapeutic Guidelines. COPD. 2009 [cited 2011 August 21]; Available from: etg 34 Level 1 and 2 evidence, in accordance to the NHMRC guidelines 9. National Health and Medical Research Council. The Australian immunisation handbook. 9th ed. Canberra: NHMRC;2008 Level 1 evidence, in accordance to the NHMRC guidelines 10. Up to date. Diagnosis of Asthma in Adolescents and Adults. 2012 {cited 2012 January 27}; Available from: http://www.uptodate.com 11. Kimberley Aboriginal Medical Services Council and WA Country Health Service (WACHS) Kimberley. Kimberley Standard Drug List. 6th ed. 2010. 12. Commonwealth Consolidated Acts. National Health Act 1953 - Sect 100 [Internet]. 2010 [cited 2011 August 3]. Available from: http://www.austli .edu.au/au/legis/cth/consol_act/nha1953147/s100.html This information is available in alternative formats upon request

Source: http://kamsc.org.au/resources/downloads/referencing/cld_referencing.pdf