North carolina department of correction

HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None To assure that DOP inmates with Pulmonary Diseases are receiving high quality Primary Care for their condition. All DOP Primary Care Providers and Chronic Disease Nurses are to follow these guidelines when treating inmates with this chronic disease. Deviations from these guidelines are permissible only on a case by case basis. When deviations are made they must be clearly documented in the medical record along with a clear explanation of the rationale for the deviation. PROCEDURE
PULMONARY DISEASE
(Document care on Pulmonary Flow Chart, DC-815.) Initial evaluation: May be done by Chronic Disease Nurse (CDN) at the first housing assignment after
processing. It should be completed within 30 days of arrival at the first housing assignment. If good control
should see MD/PA within 60 days of the initial evaluation by CDN, if new diagnoses or partial/poor control
must see MD/PA within 15 – 30 days.
A. Vital Signs: Blood pressure and pulse standing and lying, resp. rate, height and weight without shoes, and
B. History of Present Illness: Any current symptoms or side effects, compliance with medication.
Pulmonary ROS – Ask if they are having any chest pain, SOB, edema, cough, sputum production, or exercise intolerance. Also ask about symptoms of anxiety/depression. These conditions are often present in patients with moderate to severe disease, particularly COPD. C. Pulmonary History: When first diagnosed, previous medications and/or treatments, any previous
problems with medications, any surgery or hospitalizations. Is there any personal history of asthma, chronic bronchitis, emphysema, COPD, pneumonia, TB or other chronic pulmonary infections, collapsed lung, lung cancer, asbestosis, brown/black lung? What is their immunization status (i.e. influenza and Pneumovax). D. Medications: Complete list of all prescription and OTC medications (ask specifically about aspirin,
Goody’s Powders, NSAIDS) and herbal remedies they have been taking in the past 6 months. E. Social History: Smoking, alcohol use, illicit drug use, exercise (how much and how often). Occupational
history, specifically ask about any work in mining, cotton mills, ship building, or with asbestos. F. Family History: Ask if there is any history of asthma, chronic bronchitis, emphysema, and COPD.
G. Physical Exam: Cardiovascular and pulmonary exam plus general if not done within the past 60 days, plus
any other areas of concern identified from history. H. Assessment:
1. Good Control:
a. ASTHMA = no or minimal SOB, use of rescue inhaler < 2 days of the week, no or minimal
b. COPD/CHRONIC BRONCHITIS/EMPHYSEMA = stable symptoms over the past 3 months.
2. Partial control:
a. ASTHMA = using rescue inhaler 3 – 5 days a week, but no serious attacks requiring ER/hospital
b. COPD/CHRONIC BRONCHITIS/EMPHYSEMA = mild to moderate worsening of symptoms,
but no serious attacks requiring ER/hospital visits in the past three months. 3. Inadequate Control = if the above are not met.
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None I. PFT: If diagnosis or level of control is uncertain and results will help determine correct therapy.
J. Peak flow: Do three attempts, encourage maximum effort and record the best result
K. Labs: BMP, Hepatic, and Lipid panels; dip stick urinalysis if not done in the past 6 months, have reviewed
L. Educate: Usually it is best to discuss no more then one or two issues at a single visit and/or arrange for
separate individual or group educational sessions (Listed in the order of importance)
1. Smoking cessation
2. Proper use of inhalers
a. Stress the need to take preventative inhalers (inhaled steroid, long acting beta agonist,
anticholinergics, etc. when ordered by MD) on a regular basis.
b. Make sick call request if having to use rescue inhalers > 2 days a week for more then 3 weeks in
c. Review proper MDI and/or spacer technique.
4. Exercise:
a. Goal: 30 – 60 Minutes of aerobic exercise 5 – 7 times a week.
b. If not doing regularly start with 10 – 15 minutes and increase by 1 minute everyday or every other
c. Speed: As fast as they can walk without chest pain or severe SOB. Not so fast that they cannot
5. Avoidance of aspirin/NSAIDS
M. Assessment/Plan:
1. Asthma: Definition is based on pretreatment symptoms. (See table I for Diagnosis, see Table II for
2. COPD/Chronic
Bronchitis/Emphysema
a. Definitions (See Table III for Stages of COPD)
1) COPD: The presence of airway obstruction (FEV1/FVC < 70% after bronchodilation) due to
chronic bronchitis or emphysema, which is usually progressive and may be partially
reversible. Suggestive Features:
a) Mid-life onset
b) 10 – 20 or more pack year history of smoking
c) Slowly progressive symptoms
d) DOE which often progresses to dyspnea at rest
2) Chronic Bronchitis: The presence of chronic productive cough for 3 mouths in each of two
successive years where other causes of chronic cough have been excluded. 3) Emphysema: The presence of abnormal permanently enlarged airspaces distal to the terminal
b. Therapy (See Table III also)
1) Stage 0: At risk
a) STOP SMOKING
b) Influenza and pneumococcal vaccines
c) Exercise
d) Patient Education
2) Stage I: FEV1/FVC < 70%, FEV1 > 80%, ADD:
a) Beta2-agonist MDI: 1 – 2 puffs every 2 – 4 hours not to exceed 12 puffs per day
b) No evidence that these drugs alter the long term course of COPD, but they will often help
symptoms even if there is no reversible component seen on PFT. 3) Stage II: FEV1/FVC < 70% & FEV1 = 50 – 80% Consider adding one or more of the
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None a) Ipratropium with or without Beta2-agonist MDI: 2 – 4 puffs 4 times a day either PRN
b) Salmeterol: 50 – 100 ug BID or
c) Tiotropium: 1 cap INH qd
4) Stage III: FEV1/FVC < 70% & FEV1 = 30 – 50%
a) Inhaled steroids: consider if the patient has repeated exacerbations
b) Oral steroids: Should be avoided in the long term management of COPD
c) Dietary Therapy: Consider ordering a dietary consultation for patients who have a BMI
5) Stage IV: FEV1/FVC < 70% & FEV1 < 30% or FEV1 < 50% with chronic respiratory failure
a) Oxygen: In the appropriate patient this can both improve the quality and quantity of life
b) pO2 and O2 Saturation (sO2) should be measured via ABG obtained after 30 minutes
c) If resting pO2 & sO2 do not meet criteria and patient is having severe dyspnea with
exercise or sleep, consider measuring pO2 or sO2 during these times
d) Indications for oxygen therapy:
1) pO2 < 55 or sO2 < 88%
2) In presence of EKG evidence of “P” pulmonale, hematocrit > 55%, or CHF. pO2 =
55 – 59 or sO2 < 89%
3) If patient meets criteria at night or with exercise oxygen should be prescribed for
e) Dosage
1) O2 flow rate adjusted so that resting pO2 > 60 or sO2 > 90%
3. Anxiety/Depression: If the patient has symptoms which are poorly controlled and/or not currently
being followed by Mental Health, refer patient to Mental Health for evaluation and/or treatment. N. Convert medications to formulary: If patient enters the system on non-formulary medications convert
them to those available on formulary. Consult Central Pharmacy if you need assistance in making the conversion. Non-formulary requests will generally not be approved unless patient has been tried on the formulary agent first, even if current control is good. O. Immunize
1. Pneumovax: Administer if never received in the past. (If over 65 administer if not received since 65th
2. Flu: Administer if appropriate time of year. If not, put on reminder list for vaccine.
P. Referral: If being seen by Chronic Disease Nurse, refer to or discuss with MD/PA any patient who is
having new or worsening symptoms, decrease in physical activity levels, or has a new abnormality or worsening on labs/studies. Q. PULHEAT/Acuity level: PULHEAT AND ACUITY LEVEL ARE TO BE REEVALUATED AT EVERY
FOLLOW UP VISIT. Review their current rating and update as indicated. See PULHEAT guidelines for
asthma or COPD for guidance. If being seen by Chronic Disease Nurse and she/he feels that there is a need
for change in PULHEAT, she/he should review with MD/PA.
2. Follow up evaluations:
A. Frequency: Minimum frequency of visits may be more frequent if clinical situation indicates a need for
more frequent visits:
1. Good control: See above for criteria.
a. Chronic Disease Nurse – every 3 – 6 months
b. MD/PA – every 6 - 12 months
2. Partial control: See above for criteria.
a. Chronic Disease Nurse – every 2 – 3 month
b. MD/PA
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None 3. Inadequate control: See above for criteria.
a. Chronic Disease Nurse – every 1 – 2 month
b. MD/PA – every 1 – 2 months
B. Vital signs: Check sitting BP (also check standing BP if there are any complaints of dizziness or
C. Interval history: Ask about the following:
1. Compliance with medications/ medication side effects
2. Level of physical activity: Ask if there has been any decrease since last visit
3. SOB: How often, how severe (rate on a 1 – 10 scale), duration, what level of activity brings it on
4. MDI use: Ask how many days of the week are they using their rescue inhaler
D. Pulmonary review of systems: Ask if they are having any chest pain, SOB, edema, cough, sputum
production, or exercise intolerance. Self monitored Peak Flows. E. Other problems – Ask if they are having any other problems/symptoms
F. Health habits – Ask about smoking, exercise, diet compliance
G. Review MDI technique: Re-educate if indicated
H. Labs/studies:
1. Peak flow – Every visit
2. BMP – annually if on steroids
3. Hepatic panel – annually if on medications
4. Dip stick urinalysis – annually
5. PFT – as indicated by clinical situation
6. Oxygen saturation – annually in stage II or III COPD
I. Assessment/Plan:
1. Evaluate control – use criteria listed above under Initial Evaluation
2. Evaluate for anxiety/depression – are there new symptoms or loss of adequate control of previously
J. Education: Review risk factors that have not previously been discussed and/or ones that are on going.
K. Referral: If being seen by Chronic Disease Nurse, refer to or discuss with MD/PA any patient who is
having new or worsening symptoms, decrease in physical activity levels, or has a new abnormality or worsening on labs/studies L. PULHEAT/Acuity level: PULHEAT AND ACUITY LEVEL ARE TO BE REEVALUATED AT EVERY
FOLLOW UP VISIT. Review their current rating and update as indicated. See PULHEAT guidelines for
asthma or COPD for guidance. If being seen by Chronic Disease Nurse and she/he feels that there is a need
for change in PULHEAT, she/he should review with MD/PA
10/25/07
__________________________________________________
SOR: Deputy Medical Director
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None Table I. Clinical Features Before Treatment1
CLASS
SYMPTOMS2
NIGHTTIME
LUNG
SYMPTOMS
FUNCTION
• Symptoms < 2 times a
• < 2 times a month
• FEV1 or PEF > 80% predicted
Intermittent
• PEF variability < 20%
• No symptoms &
normal PEF between
attacks
• Attacks last few hours
to a few days
• Symptoms > 2 times a
• > 2 times a month
• FEV1/PEF > 80% predicted
Persistent
• PEF variability 20 – 30%
• Attacks may affect
activity
Moderate
• Daily symptoms
• > 1 time a week
• FEV1/PEF 61 – 79% predicted
Persistent
• Daily use of inhaled
• PEF variability > 30%
short-acting b2 agonist
• Attacks affect activity
• Continual symptoms
• Frequent
• FEV1/PEF < 60% predicted
Persistent
• Limited physical
• PEF variability > 30%
activity
• Frequent attacks
1. The presence of one of the features of severity is sufficient to place a patient in that category. An individual should be assigned to the most severe grade in which any feature occurs. 2. Patients at any level of severity can have mild, moderate, or severe exacerbations. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None Table II. Stepwise Approach to Drug Therapy in Asthma
CLASS
DAILY
QUICK
EDUCATION
MEDICATIONS 6
RELIEF 3
• None needed
• Short-acting inhaled • Basic facts about asthma
Intermittent
B2-agonist
• Inhaler/spacer technique
• Short bursts of PO
• Role of medications
prednisone if needed •
Environmental controls
• Inhaled low dose
• Same as above
• Same as above
Persistent
corticosteroids
III. Moderate
• Inhaled medium dose
• Same as above
• Same as above
Persistent
corticosteroids
• Self monitoring (peak flow)
• If needed add long acting
• Develop action plan based on
B2 agonist
peak flow readings
IV. Severe
• Inhaled high dose
• Same as above
• Same as step III
Persistent
corticosteroids AND
• Refer for individual
• Leukotriene modifier
education counseling
and/or long acting B2
agonist AND
• If needed PO prednisone5
1. Step down: Review treatment every 2 to 6 months. If well controlled consider a gradual stepwise reduction in
treatment to the lowest level of medications that will control symptoms and maintain lung function. 2. Step up: If control is not adequate or maintained, first review patient medicine technique, compliance, and/or
environmental controls. Then if still not controlled consider a step up in therapy. 3. Alternative therapy for quick relief: Nebulizer with albuterol +/- ipratropium maybe be consider as an
alternative to MDI particularly in severe attacks or in patients with poor MDI technique. Also Combivent MDI may also be more effective then albuterol alone and maybe considered when albuterol alone is in effective. 4. Burst prednisone: For severe exacerbations and those not improving with bronchodilators alone try a short
burst of oral prednisone. Give 40 – 60 mgs per day for 7 to 14 days +/- a short taper. (Some recent studies have shown that tapers may not be needed for short bursts in asthma). 5. Long term prednisone: Start with 1 mg/kg/day up to 60 mgs then when controlled taper to lowest dose
6. Alternatives: Though not usually considered as first line drugs (generally first line drugs should be tried before
these agents) in some selected patients, theophylline or long acting oral B2 agonists maybe be helpful as add-ons or in replacement of the above. These drugs can be especially useful in controlling night time symptoms. HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None Table III. Stages of COPD with Treatment
Characteristics
Treatment
0: At risk
I: Mild COPD
• Short-acting bronchodilator if needed II: Moderate COPD
• Consider dietary evaluation if over or III: Severe COPD
IV: Very Severe COPD
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
Page 8 of 9
EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None Table IV: Management of acute exacerbations of COPD
Patient with Known Chronic COPD with two or more of the following cardinal symptoms: 1. Dyspnea or increase in baseline dyspnea
2. Increase in sputum volume
3. Sputum purulence
Plus/minus one or more of the following: Cough, malaise, insomnia, sleepiness, fatigue, depression, confusion, decrease in exercise Evaluate suitability for outpatient management
Factor Unit/infirm
Hospital
Initial outpatient management:
1. Increase bronchodilator therapy, +/- use nebulizer
2. Consider adding anticholinergic therapy, if not already taking
3. Oral prednisone/ prednisolone for 10 days
Does the patient have one of the following:
Add antibiotic therapy with one of the following:
1. All three of the cardinal symptoms
1. Amoxicillin
2. Purulent sputum plus 1 other cardinal symptom
2. Tetracycline/doxycycline
3. Sulfamethoxazole/trimethoprim
1. Amoxicillin/clavulanic acid
2. Macrolides
Reevaluate regularly until stable or improving
Cephalosporins -- second or third gen.
HEALTH SERVICES POLICY & PROCEDURE MANUAL
North Carolina Department Of Correction POLICY # CD-5
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EFFECTIVE DATE: October 2007 SUPERCEDES DATE: None References

Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National
Heart, Lung and Blood Institute (NHLBI). Global strategy for the diagnosis, management, and prevention of chronic
obstructive pulmonary disease. Bethesda (MD): Global Initiative for Chronic Obstructive Lung Disease, World
Health Organization, National Heart, Lung and Blood Institute; 2005. 115 p. [62 references] as summarized by the
National Guideline Clearinghouse.
Institute for Clinical Systems Improvement (ICSI). Chronic Obstructive Pulmonary Disease. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2004 Dec. 67 p. [118 references] as summarized by the National
Guideline Clearinghouse.
Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary
and secondary care. National Institute of Clinical Excellence. February, 2004.
Practical Guide for the Diagnosis and Management of Asthma. Based on the Expert Panel Report 2: Guidelines for
the Diagnosis and Management of Asthma. National Institutes of Health, National Heart, Lung, and Blood Institute.
October, 1997.
Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002. Executive Summary of
the NAEPP Expert Panel Report. National Institutes of Health, National Heart, Lung, and Blood Institute. June,
2002.

Source: http://www.doc.state.nc.us/div/Prisons/HealthServices/CD_ChronicDiseaseGuidelines/cd5.pdf