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Shared System of Care COPD/Heart Failure Learning Session 2 www.pspbc.ca Agenda • Introduction (35) • Patient Voice (15) • Medication (60, 40 didactic and 20 discussion) • MOA Breakout • Break (15) • PSM Support • COPD and AECOPD Management (30, 20 didactic, 10 questions) • Heart Zones and other PSM tools (30, 20 didactic, 10 questions) • Smoking cessation (10, 5 didactic, 5 questions) • Sharing the care with the specialist and the referral process • Planning for Action Period 2 (15) Patient Voice (10 minutes) COPD Medications (15 minutes) Comprehensive Management of COPD 5 Classification of Disease Severity in COPD 6 Treatment of stable COPD Goals Symptoms Exacerbations Exercise Beta - agonists Anticholinergics Short vs. long-acting Inhaled corticosteroids Combination therapies Antibiotics Oral prednisone- for AECOPD PDE4 inhibitors Oxygen Pulmonary rehabilitation Smoking cessation 7 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) 8 Short-acting Bronchodilators 9 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) 10 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) Stepwise increased therapy 11 Optimal Pharmacotherapy in COPD Increasing Disability and Lung Function Impairment Mild Moderate SABA prn Severe Infrequent AECOPD Frequent AECOPD (< 1/year) (> 1/year) LAAC or LABA+ SABA prn LAAC + ICS/LABA + SABA prn persistent disability persistent disability LAAC + LABA + SABA prn LAAC + SABA prn or LABA + SABA prn persistent disability persistent disability LAAC + ICS/LABA* + SABA prn LAAC + ICS/LABA + SABA prn +/- Theophylline * Inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower ICS dose i.e. SALM/FP 50/250 µg twice daily O’Donnell DE, et al. Can Respir J 2007 12 Comprehensive management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) 13 Summary Spirometry essential as screening tool in subjects at risk Beware false positive/false negative results with COPD 6. Treatment: Mild: Short acting BD’s Moderate: Long acting BD’s (single or comb) Severe: Combination BD’s + ICS +Pulmonary Rehabilitation. All: education, vaccinations and smoking cessation. 14 Stable COPD: Who should be referred? Dyspnea out of proportion to spirometry Young age of onset Remote smoking history and disease severity not consistent with smoking history Rapid deterioration (symptoms or FEV1) History of exacerbations Concern re multiple co morbidities 15 Case #1 79yo woman severe SOB PHx: overweight (BMI 32), diet controlled DM2, & HTN Allergy: mild seasonal allergies - rhinorrhea Smoking: 40 pack. years - quit 20 y ago. Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post BD change. Next step? 16 Case #1 Explore possibility of heart failure/ischemic heart disease/if acute onset consider PE. Could this patient have asthma? Exam patient and rule out heart failure. Unclear re CHF and COPD: BNP Request spirometry with reversibility. If COPD categorize severity. If non obstructive pattern: detailed lung function including lung volumes + DLCO Chest x-ray. Echocardiogram Stress test 17 Case #1 Spirometry with post bronchodilator assessment showed a 12% improvement consistent with the diagnosis of asthma. Echocardiogram: Normal Stress test: No ischemic changes 18 Case #1 Diagnosis: Adult onset asthma with likely added de-conditioning and obesity, Initiate low dose inhaled corticosteroids and short acting bronchodilators PRN Advise re immunizations Provide education about inhaler use and refer for education Provide a written action plan Key learning points: Asthma can occur late in life and can occur independently or in association with COPD Important to identify co-existence of asthma in COPD as it will effect adjunct therapies such as beta blockers. If asthma is a consideration request reversibility initially 19 Case #2 68yo man progressive SOB with a history of a recent exacerbation requirng a vist to the ED and a course of prednisone and antibiotics. PHx: HTN on metoprolol and ramipril. Allergy: no seasonal or environmental allergies Smoking: 55 pack years - quit 5 y ago. Spirometry: 3 years ago: FEV1 53% pred, FEV1/FVC ratio. No post BD improvement Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H PRN with increasing use in the last few weeks. Next step? 20 Case #2 Clinically this patient has deteriorated with a recent exacerbation. What would you do next? 21 Case #2 You repeat the spirometry and the FEV1 is now 45% of predicted. This patient has severe COPD and a history of exacerbation and therefore would qualify for the use of tiotropium and the addition of a LABA Need to consider emerging evidence of increased risk of pneumonia associated with fluticasone. 22 Patient Flow Linked data from 76 centres throughout Sweden Patients who met the inclusion criteria identified within the study period n=21 361 Patients with a record of fixed ICS/LABA therapy (Index date) n=9893 Matched populations BUD/FORM cohort n=2734 FLU/SAL cohort n=2734 Larsson et al, J Intern Med 2013 23 COPD Exacerbations The exacerbation rate was 26.6% lower with BUD/FORM vs. FLU/SAL The number needed to treat with BUD/FORM vs. FLU/SAL to prevent one exacerbation per patient-year was 3.4 Exacerbation rate 1.2 1.0 0.8 RR = 0.74 (CI: 0.69, 0.79) p<.0001 1.09 Flutic/salmeterol 0.80 BUD/Form 0.6 0.4 0.2 0.0 RR, rate ratio BUD/FORM (n=2734) FLU/SAL (n=2734) Larsson et al, J Intern Med 2013 24 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)myr Stepwise increased therapy 25 Case #2 Question: What reliever medication would you recommend for this patient? Key learning point: ipratropium should not be used as a rescue medication because of the use of tiotropium and the patient should be prescribed salbutamol on a PRN basis. 26 Case #3 60yo woman progressive SOB PHx: COPD Allergy: Seasonal allergies years ago Smoking: 25 pack years - quit 10 y ago. Spirometry: 3 years ago: FEV1 54% pred, FEV1/FVC ratio. Meds: salbutamol and ipratropium bromide PRN and now needing them up to five times daily. Next step? 27 Case #3 Repeat spirometry and FEV1 unchanged. Next steps? 28 Case #3 Add tiotropium bromide, stop ipratropium bromide and continue salbutamol PRN. Six weeks later patient reports some improvement but still short of breath and has developed peripheral edema? What are your concerns now and what would you do? 29 Case #3 Clinically there is evidence of congestive heart failure and you start a diuretic and get an ECHO. The ECHO shows a reduced EF of 35% predicted. Key learning point: HF and severe COPD often co-exist and treatment strategies need to take account of this 30 Questions 31 Management of severe COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) 32 Severe COPD Maximize inhaled therapy: › Combined ICS/ long acting beta-agonists › Long acting anti cholinergic Additional considerations: › Ensure patient is adherent and taking inhalers correctly if unable to use spacer and deliver medication correctly consider nebulized Rx. › Refer to pulmonary rehabilitation. › If having frequent exacerbations consider a trial of roflumilast. › Azithromax a consideration but important caveats: see next slide. › Ensure no untreated co morbidities such as CHF and GERD 33 Long term O2 therapy indications Continuous (Grade A evidence) Resting ABG pO2 < 55 mmHg Resting ABG pO2 55-60 mmHg › Cor pulmonale › Hct > 56% Intermittent (Grade B evidence) Exertion: sO2 <87% for > 1 min Nocturnal sO2 <88% for > 30% night 34 Continuous home O2 minimum 20h /day 35 Nebulizer treatment in severe COPD Important to note most patients can effectively use inhaler device and a spacer but nebuilizer: Beneficial in extremes of age Coordination not required Breath-hold not required Note because of the size of aerosol particles the use of a nebulizer does not lead to increased deposition into the lung. 36 Chronic oral prednisone therapy in COPD 37 Chronic oral prednisone therapy in COPD There is no evidence base for the regular use of oral prednisone in COPD. In one RCT of prednisone for ARCOPD one group who were left on prednisone had increased side effects. For patients who have frequent AECOPD and continue to exacerbate despise all the measures outlined above then an N-of1 trial of alternate day OCS can be considered. Bone density and osteoporosis risk should be regularly reassessed. 38 Roflumilast: indication: Patients with moderate-severe COPD (FEV1 < 50%) ± chronic bronchitis with frequent ( > 2/year ) exacerbations. Patients should be advised re the risk of GI side effects. 39 Other antibiotics for severe COPD Apart from azithromax there is no evidence that chronic antibiotic therapy is effective in COPD. For exacerbation: rotating antibiotics between classes are recommended A significant minority of COPD patients have co existing bronchiectasis and in the presence of significant sputum volume and purulence assessment for atypical TB infection and gram negative pathogens such as Pseudomonas should be completed. 40 Heart Failure (15 min) 41 2005/06 2006/07 2007/08 2008/09 Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior ACE/ARB % 68% 66% 64% 62% 60% 58% 56% 2009/10 Region/ year 42 2005/06 2006/07 2007/08 2008/09 Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Northern Vancouver Island Vancouver Costal Fraser Interior Beta Blocker % 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2009/10 Region/ year 43 Evidence Based HF Therapies in BC 100 90 80 70 60 ACE/ARB BB 50 40 30 20 10 0 All Ages Age < 85 44 Principle of HF Management Therapeutic Goals 1. prompt resolution of congestive symptoms 2. initiate patient self management related to lifestyle and medication compliance 3. initiate/enhance therapies direct to underlying disease process limit recurrent hospitalizations improve mortality 4. prevent adverse events related to administered therapies 45 Heart Failure Therapies Therapy Agent Self Management Pharmacological Device Reduction in 1° Endpoint 23% ACE-I 8% - 26% Beta Blocker 23% - 65% MRA 35% ARB 15% ICD 23% - 31% CRT 24% - 36% 46 Contemporary Management of HF Pharmacological Therapies (1) Beta Blockers (2) Inhibition of the RAAS ACE-inhibitors (ACEi) Angiotensin Receptor Blockers (ARB) Mineralocorticoid Receptors Antagonists (MRA) Device Therapies (1) ICD (2) Cardiac Resynchronization Therapy (CRT) 47 Beta-Blockers Reduce Mortality and Decrease the Risk of Hospitalization 48 Impact of ACE Inhibitors on Mortality in HF 49 Benefits of ACE Inhibitors Persist 50 Spironolactone: EF<30 & Advanced Symptoms 10% ARR 51 Combining Therapies Improves Outcomes 52 Cumulative Impact of Heart Failure Therapies: All Cause Mortality Relative risk 2-yr Mortality None --- 35% ACE Inhibitor 23% 27% MRA (Spironolactone) 30% 19% Carvedilol 25% 19% Cumulative risk reduction if all three therapies are used: 63% Absolute risk reduction: 22%, NNT = 5 Fonarow GC. Rev Cardiovasc Med. 2003;4:8–17. 53 RAFT 1798 patients with: NYHA class II or III heart failure, LVEF 30% intrinsic QRS > 120 msec Randomized to ICD alone or an ICD plus CRT Primary outcome was death from any cause or hospitalization for heart failure Follow up - mean of 40 months 54 RAFT 55 NEJM 1996 56 Important Therapeutic Considerations in HF Patients Smoking cessation Cardiac rehab Action plans for acute decompensation Addressing co-morbidities COPD CKD some synergies and therapeutic overlap Immunizations Symptom management End of life care 57 Break Patient Self-Management Generating an Action Plan COPD and AECOPD Management Patient Education Materials Smoking Cessation 60 61 COPD and AECOPD Management (30 minutes, 20 didactic + 10 questions) Case 72 year old male seen by me in clinic Jan 2012 with moderate COPD Quit smoking 4 years ago Comorbid illnesses including: CHF, Afib, AVR, CABG complicated by sternal infection, obesity, asbestos related pleural disease. Recurrent admissions for AECOPD and CHF (‘dirty’ x-ray). 90 days in hospital this past year. Discharged post AECOPD Oct 23. Readmitted Monday pm in distress. 64 Case continued Had seen GP in community 1 week prior started on higher dose prednisone, PO antibiotics Requiring high flow oxygen, BiPAP Increased work of breathing Uncontrolled Afib post ventolin and atrovent nebulizer HR 140-160. I’m consulted as on for ICU…. 65 Clinical course of COPD 66 Last time… Burden of illness Under diagnosis and role of targeted screening The role of spirometry in diagnosis and staging Staging by symptoms and by FEV1 67 Goals of COPD care Relieving symptoms Improving quality of life Preventing/ managing exacerbations 68 A “Personal Management Plan” for COPD 5 point “PRIME” Plan: 1. Prevent further damage to your lungs 2. Relieve your symptoms › optimize drug therapy › work on mental outlook and coping mechanisms 3. Improve your general health and physical activity level 4. Manage COPD flare-ups with an “Action Plan” 5. Establish your COPD team › family, friends, physician, healthcare professionals, COPD educator 69 Stepped approach to care End of Life Care Individuals at Risk • Smokers • Environmental Exposure Surgery Oxygen Theophyline (in certain patients) All Patients: • Exercise Rehabilitation • Smoking Cessation • Healthy Lifestyle • Patient Education Inhaled corticosteroids (with ‘LABA’) Referral for Pulmonary Rehabilitation Initial referral to Pulmologist, Respirologist or Other Specialist Additional therapy: long acting bronchodilators First line therapy: Short-acting beta2 – Agonists and Anticholinergics Care Plan & Exacerbation Plans Created & Shared Influenza & Pneumococcal Immunizations in GP Office Smoking Cessation Education & Self Management Exercise & Lifestyle Referral for Diagnostic Spirometry Case Finding Spirometry by Primary Care Physician Increasing severity of COPD 70 Acute exacerbations (AECOPD) or lung attacks An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” Acute Exacerbations are THE LEADING CAUSE* of deaths, hospitalization and ER visits among COPD patients. COPD and CHF and #1 and #2 for most common reason for medical admission to BC hospitals 71 Acute exacerbations (AECOPD) or lung attacks 22-43% of patients hospitalized with AECOPD die within 1 year (Eriksen et a., 2003; Groenewegen et al., 2003) In-hospital mortality for AECOPD is 7.8%-11.0% There is increasing mortality with increased number of AECOPD. A number of interventions can reduce the risk of AECOPD: › Long acting bronchodilator – tiotropium › LABA / ICS combo inhalers › Roflumilast (but not systematically assessed inpatients on triple therapy) › Education and Rehabilitation (AECOPD recognized earlier and treated before become severe) 72 AECOPD frequency: mortality 73 Time course of AECOPD recovery 74 Benefits of COPD self management education 75 Management of symptomatic: mild COPD Patient education, including smoking cessation program Prevention of exacerbations, vaccinations Initiation of bronchodilator therapy Encouragement of regular physical exercise Close follow-up and disease monitoring Can Respir J 2008;15(Suppl A):1A-8A. 76 Management of symptomatic: mild COPD Patient education, including smoking cessation program Prevention of exacerbations, vaccinations 2 long acting bronchodilators and add in ICS if chronic bronchitis or recurrent AECOPD Encouragement of regular physical exercise Close follow-up and disease monitoring Can Respir J 2008;15(Suppl A):1A-8A. 77 Management of severe COPD Consider oxygen Mobility assistance Consider roflumilast Consider co-morbidities again Initiate advanced care planning, maybe DNR form Consider palliative help with dyspnea 78 Increasing disability & lung function impairment Mild SABD prn Moderate Infrequent AECOPD Frequent AECOPD (< 1/year) (> 1/year) LAAC or LABA+ SABA prn LAAC + ICS/LABA + SABA prn persistent dyspnea persistent dyspnea LAAC + LABA + SABA prn LAAC + SABD prn or LABA + SABD prn Can Respir J 2008;15(Suppl A):1A-8A. Severe persistent dyspnea persistent dyspnea LAAC + ICS/LABA + SABA prn LAAC + ICS/LABA + SABA prn +/- Theophylline 79 AECOPD: Prevention Strategies Smoking Cessation Vaccinations Self-Management Education with Case Manager and written Action Plan Regular long-acting bronchodilator therapy Regular inhaled ICS/LABA therapy in moderate-severe COPD and > 1 episode per year of AECOPD necessitating therapy Appropriate treatment of episodes of AECOPD Can Respir J 2008;15(Suppl A):1A-8A. 80 Take Home Points: Reducing AECOPD or lung attacks is key to › Patient survival › Patient QOL › Patient lung function › Keeping patients at home How can we achieve this? › Medications › Vaccination › Smoking cessation/pulmonary rehabilitation. › Education / self management 81 Survival in COPD – Relationship to Lung Function and Disability Nishimura K, et al. Chest 2002; 121: 1434: 40 82 Prognosis BODE index helps guide prognosis: › BMI › Obstruction (degree of ) › Dyspnea (severity of) › Exercise tolerance (or lack thereof) Points add up to answer the Q: Am I going to survive for 4 years? › 0-2 Points: 80% › 3-4 Points: 67% › 5-6 Points: 57% › 7-10 Points: 18% 83 FEV1 % Predicted After Bronchodilator >=65% (0 points) 50-64% (1 point) 36-49% (2 points) <=35% (3 points) 6 Minute Walk Distance >=350 Meters (0 points) 250-349 Meters (1 point) 150-249 Meters (2 points) <=149 Meters (3 points) MRC Dyspnea Scale (5 is worst) MRC 1: Dyspneic on strenuous exercise (0 points) MRC 2: Dyspneic on walking a slight hill (0 points) MRC 3: Dyspneic on walking on the level; must stop occasionally due to SOB (1 point) MRC 4: Must stop for SOB after walking 100 yards or after a few minutes (2 points) MRC 5: Cannot leave house; SOB on dressing/undressing (3 points) Body Mass Index >21 (0 points) <=21 (1 point) 84 Prognosis - Survival by BODE Index 85 Long Term Oxygen Therapy: Survival Domiciliary oxygen (≥ 15 hours/day to achieve SaO2 ≥ 90%) improves survival in stable COPD patients with severe hypoxemia (PaO2 ≤ 55 mmHg) or when the PaO2 ≤ 60 mmHg in the presence of ankle edema, cor pulmonale or hemacrit ≥ 56%) Can Respir J 2008; 15(Suppl A):1 A-8A 86 87 Summary COPD care isn’t rocket science/brain surgery - you can do it! First screen for COPD, then assess severity Make a treatment plan (include an Action Plan for attacks) Recruit help to enact the plan (build the team). Promote advance care planning and when appropriate palliative components. http://www.advancecareplanning.ca/ 88 Patient Education Resources Heart Failure 101 89 Patient Education Resources Heart Zones 90 Patient Education Resources Daily weight 91 Patient Education Resources Sodium Restriction 92 Patient Education Resources Fluid Restriction 93 Patient Education Resources Activity 94 Clinical Care Algorithms 95 96 97 98 A Comprehensive List of Patient and Provider Resources PATIENT RESOURCES PROVIDER RESOURCES MEDICATIONS REFERRAL FORMS SODIUM PATIENT ASSESMENT FORMS FLUID CARE MAPS & TX ALGORITHMS EXERCISE MEDICATION TITRATION EXACERBATION PLAN PATIENT SYMPTOM STATUS HF 101 VISIT SNAP SHOT 99 BC’s Heart Failure Website www.bcheartfailure.ca 100 Smoking Cessation 101 101 Progress in British Columbia BC sues tobacco companies Percentage Smoking Prevalence in BC, 1999-2011 25 Govt funding to $6.5M QuitNow 20 19-24 projects 1st Quit Contest NRT access 15 10 5 0 BC Quitline 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year BC Prevention program in schools Progress in BC 102 Intention to Quit Intention to Quit 103 Physicians discussing quitting Physicians Discussing Quitting 104 Effect of Physician intervention Effect of Intervention 105 What can Physicians do? What can Physicians do? 106 Strategies to help your patients quit Complete Personal Risk Assessment for Rx for Health Brief advice to quit smoking Refer to behavioural support (like QuitNow) Recommend patients call 8-1-1 for NRT Order Buproprion or Varenicline (prescription) Strategies 107 What is QuitNow? Behavioural quit smoking support Provincially Funded Managed by the BC Lung Association Evidence-based Free, confidential, 24/7 What is QuitNow? 108 Fax Referral Forms 109 [email protected] Online Referral online 110 Referral Resources Indications for Referral to a HFC Heart Function Clinic Referral Form 111 Patient History/Assessment Heart Failure Patient Questionnair e 112 A Guide to HF Patient Assessment Patient Assessment Tool 113 Snapshot of Patient Visit 114 Referral and Consult Process Planning for Action Period 2