Download the file

COPD
The Why, The How, and The Where
Jo Congleton
Consultant in Integrated Respiratory Care
COPD
• Why
• Why has the CCG commissioned a LCS for COPD?
• How
• To Diagnose
• To Manage
• Where
• To get help
Prevalence of COPD
• WHO Global Burden of Disease 5th Cause of Death in 2002
• BOLD programme Global 10.5% Adults aged >30yrs
• QOF B+H CCG 1.3% of total population
• EPHO Predicted for B+H CCG 3.6% of population
QoF Registered COPD in B+H CCG
• EHPO Predicted 9,998
COPD QoF Registrations
4200
• PMA Majority of COPD deaths
on QoF register
4100
4000
3900
• Exception rate 37% vs 14%
3800
3700
• Current exception rate 11%
3600
3500
2012/13
2013/14
2014/15
2015/16
National COPD Audit Primary Care
National COPD Audit Programme Data from 48,029 COPD registered patients in
Wales
High Quality COPD Annual Reviews
COPD, not on
Register
Not COPD and on
QoF Register
COPD and on QoF register
AECOPD admissions at BSUH
• Slight upward trend of no. of
admissions
• Low length of stay (downward
trend)
• High 30 day re-admission rate
(trend static for all cause,
upward for COPD related)
• Low in hospital mortality
(downward trend)
The How: GUIDELINES
• NICE 2010
• GOLD 2017
• ATS/ERS Exacerbations 2017
COPD Definition GOLD 2017
• COPD is a common, preventable and treatable disease
that is characterised by persistent respiratory symptoms
and airflow limitation that is due to airway and/or
alveolar abnormalities
usually caused by significant exposure to noxious
particles or gases
Diagnosing COPD
Exposure to risk
factors
(significant
smoking history)
AND
Spirometry
Postbronchodilator
FEV1/FVC <
70%
Typical
Symptoms
(dyspnoea,
cough, sputum,
production)
Airways narrowing due to
Chronic irritation of the bronchi causing
inflammation and changes to the mucociliary
escalator; often results in chronic cough
Large airway
inflammation
Airways collapse due to
destruction of alveolar walls
– may lead to bullae
Small
Emphysema airways
Airways narrowing due to
bronchoconstriction and
inflammation; duration and
severity are risk factors for
development of airway
remodelling and COPD
Evolution of COPD
TTrash Can
Normal flow-volume curve
Obstructive disorder:
Severe obstructive disorder:
Airflow obstruction: severity
• FEV1:FVC ratio < 70% (i.e. < ¾ of lung volume expired in
1 second)
• Graded by FEV1 % predicted:
• Mild
<100% predicted
• Moderate
<80% predicted
• Severe
<50% predicted
• Very severe <30% predicted
Symptoms:
MRC dyspnoea grade
CAT score
Does my patient have asthma or COPD?
or
What is this Asthma COPD Overlap Syndrome? (ACOS)
• Many patients have features of asthma and COPD
• Older age group
• Childhood asthma
• Significant smoking history
Aims of Management
• Reduce Symptoms
• Reduce Risk of Exacerbations
• Prolonging life
Management
• Reducing Symptoms
• Bronchodilators
• PR
• Reducing Risk of Exacerbations
• Bronchodilators
• PR
• LABA/ICS
• Prolonging life
• Smoking Cessation
• LTOT
• (Reducing exacerbations)
The Value Pyramid
Triple Therapy
£35,000£187,000
LABA
£8,000/QALY
LAMA
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk”
population
Exacerbations
Symptoms
23
High risk, less
symptoms
High risk, more
symptoms
Low risk, less
symptoms
Low risk, more
symptoms
Exacerbator
2 or more per
year
Non-exacerbator
0 /1 per year
MRC < 3
CAT < 10
MRC 3 or more
CAT 10 or more
MRC 3 Walks slower than most people on the level, stops after a mile or
so, or stops after 15 minutes walking at own pace
Exacerbations
Symptoms
High risk, less
symptoms
Exacerbator
2 or more per
year
Non-exacerbator
0 /1 per year
24
LABA/LAMA
High risk, more
symptoms
LAMA
LABA/LAMA
(LABA/ICS)
(Triple therapy)
Low risk, less
symptoms
Low risk, more
symptoms
prn SABA or SAMA
LAMA or LABA
(LAMA or LABA)
(LAMA /LABA)
LAMA
MRC < 3
CAT < 10
MRC 3 or more\
CAT > 10
MRC 3 Walks slower than most people on the level, stops after a mile or
so, or stops after 15 minutes walking at own pace
Inhaled Therapy
• B agonists
• SABA
• LABA
• Anti-Muscarinics
• SAMA
• LAMA
• Inhaled Corticosteroids
• ICS
• Low dose/ Medium dose /high dose
Evohaler
Metered Dose
Inhalers (MDI’s)
Autohaler
Easi-breathe
Breath Actuated MDI’s
MDI’s with dose counters
Respimat
Accuhaler
Handihaler
Twisthaler
Forspiro
Zonda
Inhaler & caps
Ellipta
Dry
Powder
Inhalers
Easyhaler
Genuair
Breezhaler
Turbohaler
Novolizer
NEXThaler
Spiromax
Devices
• MDI
• Slow and Steady
• Dry Powder
• Fast and Deep
The correct inhaler device….
• …Is the one that the patient is able to use and
will use
• There is no place for an ICS containing mdi
without concurrent use of a spacing device
Long Acting
Muscarinics
Eklira ▼
Genuair (Aclidinium)
Incruse ▼
Ellipta (Umeclidinium)
Braltus
Zonda (Tiotropium)
Spiriva (Tiotropium)
Respimat
Handihaler
Seebri ▼ Breezhaler
(Glycopyrronium)
Formulary
LAMAs
Eklira ▼
Genuair (Aclidinium)
Braltus
Zonda (Tiotropium)
Spiriva (Tiotropium)
Respimat
Handihaler
Long acting bronchodilators and long acting muscarinics
LAMA/LABAs
Spiolto Respimat ®▼
(Oldaterol/
Tiotropium)
Anoro Ellipta ® ▼
(Vilanterol & Umeclidinium)
Duaklir Genuair ® ▼
(Formoterol & Aclidinium)
Ultibro Breezhaler ®▼
(Indacaterol & Glycopyrronium)
Formulary LABA/LAMAS
Spiolto Respimat ®▼
(Oldaterol/
Tiotropium)
Duaklir Genuair ® ▼
(Formoterol & Aclidinium)
SOON
Ultibro Breezhaler ®▼
(Indacaterol & Glycopyrronium)
ICS + COPD
• Only positive trials are when used in combination with LABA
(LABA/ICS)
• Only effect is on exacerbation rate
• Balance with increase in pneumonia
• New (GOLD) guidelines defer adding ICS (LABA/ICS)
• If using ICS keep steroid burden as low as possible
Time to 1st pneumonia
Probability (%)
NNT 44 patients with FP/SV for 3 years to prevent one exacerbation of COPD
NNH 16 patients to induce one pneumonia
Time to first event (weeks)
SCO100250 study
Long Acting
Bronchodilators and
Inhaled Corticosteroids
Relvar Ellipta ®▼ – (vilanterol
& Fluticasone Furoate)
MDI
NEXThaler
Seretide Accuhaler ®
(Salmeterol &
Fluticasone
propionate)
AirFluSal Forspiro ®
(Salmeterol &
Fluticasone
propionate)
Symbicort Turbohaler ®
(Formoterol & Budesonide)
Fostair ® – (Formoterol &
Beclometasone)
DuoResp Spiromax ®
(Formoterol & Budesonide)
Formulary LABA/ICS
Seretide Accuhaler ®
(Salmeterol &
Fluticasone
propionate)
MDI
NEXThaler
AirFluSal Forspiro ®
(Salmeterol &
Fluticasone
propionate)
Symbicort Turbohaler ®
(Formoterol & Budesonide)
Fostair ® – (Formoterol &
Beclometasone)
DuoResp Spiromax ®
(Formoterol & Budesonide)
Asthma COPD Overlap Syndrome (ACOS)
Management
• Older age group
• Childhood asthma
• Significant smoking history
• Main therapeutic difference is to use LAMA earlier (than
if pure asthma)
• And to use lower doses of ICS (than if pure COPD)
Tips for prescribing in COPD
• Always check inhaler technique
• Remember non-pharmacological
interventions (PR)
• Inhaled corticosteroids only for:
• co-existent asthma
• frequent exacerbations despite other
measures
• If use ICS, aim for low steroid
burden
• Always include a spacer for mdi
prescription
• Only make one change at a time
• Check inhaler technique again!
Where: To get help
Secondary Care
• Management of severe exacerbations (IP)
• COPD discharge bundle
• Diagnostic clarification (OPA), assess for additional
conditions (ILD, pulmonary hypertension)
• Assess for referral for home NIV
• Assess for LVRS / Lung Transplant referral
Brighton General Hospital
Dyke Building
Elm Grove
Brighton, BN2 3EW
Mon-Fri 8am-8pm
Sat/Sun/BH 8.30am-4.30pm
Patients accepted:
• COPD
• Asthma – chronic asthmatic patients
• ILD
• Bronchiectasis
Referral time frame:
• URGENT within 24 hours – must speak to IRS rapid clinician prior to
referral and be reasonable request for visit.
• ROUTINE within 2-4 weeks
Referrals cannot be processed until the team have received:
• Up to date medical history and drug history
• Confirmation of diagnosis (Spirometry, PEF diary, CT scan)
• Lone worker risk specified
•
COPD
– Spirometry must include trace and be reproducible to be accurately
interpreted.
– If CT shows emphysema will accept onto service pending spirometry from PN
– If the hospital refer we will expect the spirometry to be done by them.
– If any difficulties with obtaining reproducibility please call IRS to discuss
•
Asthma
– Spirometry if obstructive with reversibility
– PEF diary
– If long standing diagnosis but no diagnostic test available as confirmation of
disease to refer to secondary care to confirm
•
Bronchiectasis and ILD
– CT Scan
Respiratory
Nurses
BSUH COPD
Nurse
Physios
The
patient
Consultant
Respiratory
rehab assistant
Oxygen
practitioners
Occupational
therapist
CBT therapist
• Airway clearance – physios will develop individual regimes
with/without adjuncts
• Review inhaler medications – nebs not given to patients who
are able to use inhalers
• Rapid response – after initial assessment patients can self
refer if difficulty with their breathing. Patient will be
contacted within 2 hours and triaged over the phone.
• Anxiety – CBT and OT
•
Benefits - ↑exercise capacity, dyspnoea, health status, psychological wellbeing, muscle
strength. ↓exacerbations
•
Inclusions/exclusions – able to walk 100m, cardiac stable, pain/functional/cognition
issues
•
Waiting list – Aim to enroll and start PR within 13 weeks of referral
•
Pre assessment – walk test in clinic, check obs and meds, questionnaires
•
Content – individualised CV and resistance work, education
•
Duration – twice weekly for 6 weeks
•
Venues:
– Salvation Army, Brighton
Tuesday and Friday afternoon 2pm-4pm
– Portslade Town Hall
Monday and Thursday Morning 10am-12pm
Referrals
• LTOT: Spo2 ≤92% at rest and not within 5-8 weeks of
exacerbation, SpO2 ≤94% with secondary conditions PH,
RSHF, Polycythaemia (to provide Blood Test)
• Ambulatory: Never urgent referral
• Palliative: If GP/pall care seen. GP to Px oxygen on Part A
and refer in. SpO2 ≤ 92%
Risk assessment vital
What information would you like in Oxygen clinic letters?
• Identifying patients: gold standard framework (recurrent
admission, LTOT, MRC 4/5, RSHF, NIV, Low BMI, >6 weeks
steroids in last 6/12)
• Breathlessness Mx – oromorph (side effects)/fan therapy
• Anxiety Mx – lorazepam
• Cough Mx - Simple linctus-codeine linctus-oramorphmethadone 2-4mg nocte (long half life)
• IBIS – upload ACP, inform paramedic crew re: DNAR and
situation. Reduce unecessary hospital admissions
• DNAR – clinician will contact GP to do following discussion