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Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
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Prevalence and severity is increasing
The socioeconomic burden for societies and
individuals is high
COPD is a preventable and treatable disease
Despite this:
COPD is under- recognised
COPD is under- diagnosed
COPD is under- treated
Amund Gulsvik et al ERS.
Number Deaths x 1000
KOLS Mortality by
Gender,
U.S., 1980-2000
70
60
Men
50
40
Women
30
20
10
0
1980
1985
1990
1995
2000
1990
Ischemic heart disease
CVD disease
Pneumonia
Diarrhoeal disease
Perinatal disorders
KOLS
6th
Tuberculosis
Measles
Road traffic accident
Lung cancer
2020
Ischemic heart disease
CVD disease
3rd KOLS
Pneumonia
Lung cancer
Road traffic accident
Tuberkulos
Stomach cancer
HIV
Suicide
Ref. Murray and Lopez Lancet 1997:349-1498
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Dødelighet
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Sykehus
Diagnose
Vast variation in
diagnosis rate
Vast variation in
service provision
Major differences
in health
outcomes
although unclear
whether
prevalence is key
factor here
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
5
Results of spirometry in 125 patients previously
diagnosed as COPD on the basis of history and examination
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
Patients (%)
70
n=260 (prescribed bronchodilator therapy)
60
Post-study
60
Pre-study
50
44
40
34
30
17
20
13
10
0
4
0
None
COPD
7
10
0
Mixed
11
0
Other
NRD
Asthma
Freeman D et al. Am J Respir Crit Care Med 1999
119
120
100
91
92
80
cough
wheeze
dyspnoea
60
40
20
0
126 patients with COPD
Glenfield Surgery Audit
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COPD 4th largest killer globally
COPD may be present before symptoms and
signs occur, exacerbations may be unrecognised
Most people with early COPD do nor recognise
and/or report symptoms
All with COPD will benefit from:
◦ Targeted smoking cessation
◦ Vaccination
◦ Lifestyle advice, Diet advice
◦ Optimisation of therapy
Fleming D. Prim Care Resp J2002: 11(3);86-87
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Screening with spirometry?
Target those most as risk-’Case Finding’
Case finding = focusing detection efforts
on subgroups at known increased risk
GOLD recommendation:
◦ consider a diagnosis of COPD "in any patient
who has dyspnea, chronic cough or sputum
production, and/or a history of exposure to
risk factors for the disease" and that the
"diagnosis should be confirmed by spirometry"
Responders without CHD diagnosis (%)
30
25
20
Number who said they were too breathless to
leave their house or became breathless when
dressing/undressing
15
10
5
0
France
Germany
UK
US
Price D, Freeman D. Primary Care Respiratory
Journal 2002; 11: s12-s14
Sought medical help (n=291)
Did not seek medical help (n=155)
To be told to stop smoking
To have tests done
A diagnosis
A medicine/prescription
To have a discussion about the condition
Education and information
To be referred to a hospital specialist
0%
20%
40%
60%
Price D, Freeman D. Primary Care Respiratory Journal 2002; 11
n=236
Told to stop smoking
Had tests done
Diagnosis
Medicine/prescription
Had a discussion about the condition
Education and information
Referred to a hospital specialist
0%
20%
40%
60%
Price D, Freeman D. Primary Care Respiratory Journal 2002; 11: s12-s14
MRC dyspnoea score
0 no breathlessness
1 breathless after Xs
2 breathless when
hurrying
3 walks slower than
others
4 stops for breath every
100 m
5 too breathless to leave
house
Patients (%)
35
30
n=2,442
25
20
15
10
5
0
1
2
3
4
5
Living with COPD BLF survey Aug 2000
What really matters to patients is not their
MRC dyspnoea score……
Climbing stairs
Gardening
Walking outside
Making the bed
Washing / bathing
Socialising outside house
Dressing
Working
n=2,413
0
20
40
60
Responders (%)
80
100
Living with COPD BLF survey Aug 2000
A smoking aware practice
GP time
5-7 fold
>5 mins
Increase in
quit rate
Intense
intervention
2-5 mins
<1 mins
Moderate intervention
Brief intervention
A ‘no-smoking practice’
Page 17 - © IPCRG 2007
Svein Høegh Henrichsen AIMEF Bari 2008
© IPCRG 2007
4 fold
3 fold
2 fold
Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9
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Smoking is dominant cause of COPD
Smoking cessation is the most (cost-)
effective therapy
Smoking COPD patients need intensive
treatment
No special smoking cessation
interventions for COPD patients
Cardiovascular heart disease (CHD) risk is similar to never smokers
Lung cancer risk is 30-50% that of continuing smokers
Stroke risk returns to the level of people who have never
smoked at 5-15 years post-cessation
15 years
10 years
5 years
1 year
3 months
Cessation
CHD: excess risk is reduced by 50%
among ex-smokers
Lung function may start to improve
with decreased cough, sinus
congestion, fatigue, and shortness of
breath
1. CDC. Surgeon General Report 2004: http://www.cdc.gov/tobacco/sgr/sgr_2004/sgranimation/flash/index.html. American Cancer
Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 2. American Cancer Society. Guide
to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 3.US Department of Health & Human Services. The
Health Benefits of Smoking Cessation: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office
on Smoking and Health. 1990. Available at: http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed July 2006.
Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe IV: Very Severe
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
FEV1 > 80%
predicted
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
50% < FEV1 < 80%
predicted
30% < FEV1 < 50%
predicted
FEV1 < 30%
predicted
or FEV1 < 50%
predicted plus
chronic respiratory
failure
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting
bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic
respiratory failure.
Consider surgical
treatments
Rehabilitation (training), COPD and treatment:
24
Rehabperiod
*
*
Average time work (minutes)
22
Tiotropium n=47
20
42%
32%
18
16
Usual care n=44
14
16%
12
n=91
10
*p<0,05
8
1
3
5
7
9
11
13
15
17
19
21
23
25
Treatment weeks
Reference: Modified from Casaburi et al, Chest 2005; 127:809-17.
22
CCQ?
www.ccq.nl
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COPD exacerbations are an important cause of the
considerable morbidity and mortality associated with COPD
Prevention of exacerbations is a primary goal in treating COPD
COPD exacerbations are closely associated with symptomatic
and physiological deterioration and impaired health status1,2
Following a COPD exacerbation, the likelihood of further
exacerbations increases3
High frequency of COPD exacerbations is associated with a
rapid decline in lung function and increased risk of
hospitalization4,5
1. Osman LM et al. Thorax 1997; 2. Seemungal TA et al. Am J Respir Crit Care Med 1998
3. Seemungal TA et al. Am J Respir Crit Care Med 2000; 4. Donaldson GC et al. Thorax 2002
5. Garcia-Aymerich J et al. Am J Respir Crit Care Med 2001
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To many COPD patients are diagnosed at
their first admission to hospital for
respiratory problems
Most of these have an advanced serious
disease with high mortality:
Death during hospitalization 9%
Death rate after 3 months 19%
1 year mortality after admission36%
25% of death occurs in people under 65 yrs
Nanna Eriksen et al: Ugeskrift for
Kostnad
Hjem S.h Rehab
Hjem……
Tid
Kostnad som funksjon
av komplikasjoner
Dagens situasjon
Ønsket forløp
Røyk
Fødsel
Kols 1
Kols2
Kols 3
KOLS4
Død
Tid
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
29
2/3 av
ressursene
brukes
idag på
10-20% av
pasientene
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Kronisk sygdom- patient,sunnhedsvæsen
Svein Høegh Henrichsen
og sygdom Sundhetsstyrelsen Danmark 2005
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
31
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Results Hospital admissions for exacerbation of COPD were
reduced by 39.8% in the intervention group compared with the
usual care group (P = .01), and admissions for other health
problems were reduced by 57.1% (P = .01). Emergency
department visits were reduced by 41.0% (P = .02) and
unscheduled physician visits by 58.9% (P = .003). Greater
improvements in the impact subscale and total quality-of-life
scores were observed in the intervention group at 4 months,
although some of the benefits were maintained only for the
impact score at 12 months.
Conclusions A continuum of self-management for COPD
patients provided by a trained health professional can
significantly reduce the utilization of health care services and
improve health status. This approach of care can be
implemented within normal practice.
Reduction of Hospital Utilization in Patients With COPDJean Bourbeau, MD; et al. for the Chronic Obstructive Pulmonary Disease
axis of the Respiratory Network Fonds de la Recherche en Santé du Québec
Arch Intern Med. 2003;163:585-591.
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Pulmonary rehabilitation improves HRQOL in
patients with COPD. Grade of recommendation, 1A
Regarding changes in health-care utilization
resulting from pulmonary rehabilitation, the
previous panel concluded that there was B level
strength of evidence supporting the
recommendation that “pulmonary rehabilitation has
reduced the number of hospitalizations and the
number of days of hospitalization for patients with
COPD.”
Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical
Practice Guidelines\\\CHEST May 2007 vol. 131 no. 5 suppl 4S-42S
33
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Pulmonary rehabilitation should be made
available to all patients who need it. This will
require the education of health care professionals
at all levels of training as to the rationale, scope,
and benefits of pulmonary rehabilitation, with a
goal of incorporating it into the mainstream of
medical practice. In addition, concerted efforts
are needed to encourage health care delivery
systems to provide this therapy and make it
affordable. Recent studies that demonstrate that
long-term benefits (including health care
resource reductions) are attainable with relatively
low-cost interventions should help with these
efforts
American Thoracic Society, European Respiratory Society.. ATS/ERS
statement on pulmonary rehabilitation. Am J Respir Crit Care Med
Norsk Forening for Allmennmedisins
2006;173,1390-1413 F
referansegruppe for astma og kols
Svein Høegh Henrichsen
P
M
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08
.
COPD starts before
the patient gets any
symptoms...
Do not forget primary
prevention.
Thank
You!!
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
P
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08
Forløpsdiagram ved kols. De fleste pasienter kan og skal følges i primærhelsetjenesten som
har ansvar for oppfølging og koordinering. 80% av pasientene har fev1>50, MRC<3
Forebygging primær
Tidlig
oppsporingcase finding
Oppfølging
Røykere(+eks),yrkesbelastede /symptomatiske FEV1>50
Symptomer-hostte, slim og spes.dyspnoe MRC 1-2
MRC 3
prevensjon
Case-finding
Myndighetene bør
fokusere på fysisk
aktivitet, ernæring og
røykeslutt/forebygging
Gjennom kampanjer,
lovverk,informasjon
Leger og annet
helsepersonel læres
opp i
røykesluttmetoder.
Arbeidsmiljø:
Industri/yrker med
eksponering for støv,
gasser og partikler må
pålegges et særlig
ansvar for verneutstyr
-case-finding
Allmennlege
Allmenlegens
ansvar
Diagnostikk
Case finding
ved
spørreskjema til
alle røykere
over 40 år?
Spirometri av
alle med
hyppige/kronisk
e
luftveisproblem
Hvem bør
vurderes av
lungelege?
Fysioterapi?
Rehabilitering
?
Kols register
Oppfølging
svarende til
alvorlighetsgr
ad
Årskontroll
Egenbehplan
Inf.vaksine
fysioterapi
Koordinering
Individuell
Plan
Bruker-medv
Komorbiditet
Rehabilitering
FEV1 30-50
Forverrelse
Rask
Akutt
rehab/oppfølg
in
Hospital at home
Terminal pleie
Oksygen?
FEV1 <30
MRC 4
Allmenlege
vurderer
grad-evt
henvisning
Spes rehab
Eller i
primærhelse
Yrkesveiledni
ng
Trening
Kost
Pasientopplæ
ring
ergonomi
Helhetsvurdering
komorbiditet
Brukermedvirk
MRC 5
Allmennlege
/spesialist
Bruker
vurdering/
egenbehandlin
g
Vurdere behov
for innleggelse
Komorbiditet
Medikamenter
Prosedyrer for
hvem gjør hva
og samarbeid
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
spesialist
Samarbeid
allmenlege –
kommunespesialist
Bruker
Videre-føring
Oppfølgingmonotorering
Avlastning?
Beredskap
Samarbeid
spes/
allmenlegekommune/Bruk
er
Rask vurdering
Utredes med
tanke på nytte av
ltot /kirurgi
evt terminal team
Tilrettelegging
bolig/transport
Trening/rehab
P
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350
Kan unngås hvis
halvparten av
dagens røykere
slutter innen 2020
Unngåelig hvis
halvparten så
mange unge
starter
Andre dødsfall
Millioner døde
300
250
200
150
100
50
0
2000-2024
Lunger i Praksis
2025-2049
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
38
Proportion of 1965 Rate
3.0
3.0
2.5
2.5
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
–59%
–64%
–35%
+163%
–7%
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0 0
1965 - 1998 1965 - 1998
1965- 1998 1965 - 1998 1965 - 1998
Norsk Forening for Allmennmedisins
referansegruppe for astma og kols
Svein Høegh Henrichsen
P
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25% død/uførhet før 65 år
Norsk Forening
for Allmennmedisins
Kostnad
x4 innen 2020
referansegruppe for astma og kols
Svein Høegh Henrichsen
Kvinner
rammes hardere
PMU08