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Dr Emma Denneny & Dr Sarah Clarke Respiratory SpRs Princess Alexandra Hospital 1. COPD & Asthma – the scale of the challenge - Prevalence globally to nationally 2. COPD & Asthma – diagnosis & risk factors 3. Our day-to-day service delivery challenges 4. The Future - Precision Medicine - Case for a ‘Chronic Airways Disease Spectrum’? - Challenge of delivering a tailored approach COPD (Chronic Obstructive Pulmonary Disease) Progressive airflow limitation that is not fully reversible Onset mainly in mid-life Preventable – usually associated with smoking Asthma Reversible airflow limitation Onset mainly in childhood Variability in symptoms For patients with FEV1/FVC <0.70; Severity Gold 1-Mild FEV1 % predicted ≥80 Gold 2-Moderate 50-79 Gold 3-Severe 30-49 Gold 4-Very Severe <30 WORLD - 2012 UK – 2005 & 2010 COPD • 835,000 people with COPD in the UK • Fifth leading cause of death in the UK • £800 million per year on managing COPD Asthma • 6 million people in UK receiving treatment for asthma • 8 million people have an asthma diagnosis (GP record) • 1200 deaths per year from asthma (245 <65 years old) • £1 billion per year on managing asthma Both conditions have a high rate of emergency hospital admissions Genetic Factors Environmental Exposures • • • • • • Comorbid Disease Tobacco smoking Occupational dusts & fumes Air pollutants Ageing Infections Genetics: α-1 antitrypsin deficiency & predictors of lung function • Comorbid disease • A complex metabolic syndrome associated with underlying illness • Loss of muscle mass with or without loss of fat mass • Impairs physical performance • Increases mortality risk • COPD specific cachexia drivers: • Emphysema • Decreased muscle oxidative phenotype • Exacerbations • • • • Calories – appetite stimulants Dietary protein – pharmacological intervention Exercise Cognitive Behavioural Therapy • Pulmonary Rehabilitation Individual & group sessions Exercises Breathing techniques • Home oxygen • Chest physiotherapy • Smoking cessation • GP services / community COPD teams – inhaler technique • Charity support groups Respiratory Team 4 consultants, 2 specialist respiratory nurses, 3 SpRs, 5 SHOs & 3 secretaries/administrators • Given the high prevalence, a great proportion of COPD/asthma patients are managed by GPs in the community. • In clinic we are involved in diagnosis, commencing treatment, reviewing complex patients & considering candidates for new therapies/surgical interventions. • On the ward we frequently manage patients with exacerbations of COPD/asthma. • Amongst our frequent attenders, many have co-existing psychosocial issues that we have to manage in addition. • Anxiety surrounding the symptom of breathlessness • Young asthma patients & compliance • Side effects of treatment • For our end-stage COPD patients, considering ceiling of care & palliative input • Respiratory failure & non-invasive ventilation • Hospital bed pressures & safe discharges • Continuity of care & services in the community • Are the historical diagnostic labels of asthma and COPD an outdated approach to understanding an individual's condition? • Are the terms too broad? • Should we use a more personalised approach to management that identifies 'treatable traits' in each patient? • New technologies • Previously we relied on analysis of symptoms and signs e.g. lung function and airway hyper-responsiveness • But now we have detailed imaging techniques available and we can access information regarding complex biological traits • cellular and molecular markers taken from blood samples, sputum and exhaled air and microbiome anaylsis. "We propose a label-free precision medicine approach based on treatable traits that categorise the clinical and biological complexity of airway disease. The approach we are suggesting would radicalise healthcare and have significant implications for the organisation of a healthcare system. By recognising the clinical and biological complexity of a disease, we can use causal mechanistic disease pathways to adopt a more precise approach, which is hopefully more effective at managing patients with these conditions.” Professor Alvar Agusti European Respiratory Journal February 2016 • Challenge of meeting the demands of an ageing population • Challenge of tailoring care to the individual patient • Challenge within field of research to identify disease targets and categorise disease appropriately • British Lung Foundation – Statistics • Office for National Statistics - Deaths Registered in England and Wales in 2010, by Cause • Mannino & Buist (2007) Global Burden of COPD: risk factors, prevalence & future trends. The Lancet 370; 765-773 • Hawkins et al. (2013) Heart Failure & COPD: the challenges facing physicians & health services. Eur Heart Journal 34; 2795-2803 • Augusti et al. (2015) Biomarkers, the control panel & personalised COPD medicine. Respirology 21; 1 • Schols et al. (2014) Nutritional Assessment & Therapy in COPD. European Journal Resp Med 44; 1504-20