copd webinar: diagnosis, monitoring and management
TRANSCRIPT
COPD Webinar: Diagnosis, Monitoring and Management including SIMPLES
Thursday, 3rd December 2020, 12.00pm – 1.15pm
Jacqui Hodgson RGN, PGCert(Teachers in Primary Care)(Advanced Level Nurse Practitioner)
Femeeda Padhani MPharm, Non Medical Prescriber, GP pharmacist
COPD- What it is
Diagnosis, objective testingCOPD diagnosis during covid
Management and Monitoring
Essentials of COPD reviews
Treatment choices
Remote Consultations and COVID
Aims of session
Smoking statusInhaler techniqueinvestigationsMonitoringPharmacotherapyLifestyleEducationSupport
SI
MPLES
What is Chronic Obstructive
Pulmonary Disease COPD
This is an umbrella term that describes a group of lung conditions including emphysema and chronic bronchitisCharacteristics:
– Inflamed airways– Airways obstruction that is not fully reversible – Damaged and collapse of walls of alveoli – Chronic– Progressive
Definitions • The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
guidelines define COPD as a disease state characterized by airflow limitation that is not fully reversible, is usually progressive, and is associated with an abnormal inflammatory response of the lungs to inhaled noxious particles or gases
• Chronic obstructive pulmonary disease (COPD) is a common, treatable (but not curable) and largely preventable lung condition. It is characterised by persistent respiratory symptoms (such as breathlessness, cough, and sputum) and airflow obstruction (usually progressive and not fully reversible).
• Airflow obstruction results from chronic inflammation caused by exposure to noxious particles or gases (usually tobacco smoke but also from environmental and occupational exposures). NICE
https://www.nice.org.uk/guidance/ng115https://goldcopd.org/
Types of COPD – Phenotypes
EMPHYSEMA CHRONIC BRONCHITIS
OVERLAP or Mixed COPD-Asthma
Emphysema due to alpha-1-antitrypsin
deficiency
?Bronchiectasis
COPD: The scale of the problem
Diagnosis
Have you got the correct diagnosis
NEW QOF 2021 Guidance ---evidence required
Spirometry
• Airflow limitation defined as post bronchodilator FEV1/FVC ratio < 0.7
• Code as Suspected COPD• Reversibility (>12% or 200mL
increase in FEV1) may reduce probability but can be seen in COPD (should not normalise)
• FeNO can be a useful additional test to rule out asthma (> 40 most likely asthma)
https://www.artp.org.uk/Spirometry-Register
This register will ensure that commissioners, employers, and patients can be assured that healthcare staff performing and/or interpreting diagnostic spirometry hold a valid, current certificate of competence.
Although spirometry is essential for confirmation of diagnosis, during COVID comprehensive history is key
A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
Document as suspected COPD in patients notes and highlight for spirometry when services running normally
Opening up services?Adequate ventilation changesDrive Through
COPD Diagnosis
During COVID
Symptoms pointing to diagnosisCoughDyspnea Sputum productionChest tightness/wheezeFrequent winter ‘bronchitis’
History 90% Smoker/Ex-smoker/ secondhand smoke Illicit drug use Occupation exposureGenetic factorsAge >35
Objective TestingSpirometry – unavailable CRT/CT scansFBCBMIOxygen saturationsPeak flow (<75% → obstruction)
System questionnaires to access:CATCCQSGRQ
PCRS Position Statement Diagnostic work up of the patient presenting with respiratory symptoms during the COVID-19 pandemic
• For some people, testing procedures such as spirometry will be essential at a later date. COPD, for example, can only be formally diagnosed if fixed airflow obstruction is demonstrated. For those with suspected COPD:
2.4.19 (pcrs-uk.org)
GOLD ABCD ASSESMENT TOOL
CAT
Clinical Practice (catestonline.org)
COPD Assessment Test (CAT) - MDCalc
COPD ASSESMENT
TEST (CAT)
Modified MRC dyspnoea SCALE
mMRC (Modified Medical Research Council) Dyspnea Scale - MDCalcMRC Dyspnoea Scale | Primary Care Respiratory Society (pcrs-uk.org)
NHS Long Term Plan (2019)London Clinical Respiratory Networks
• Accurate and Timely Diagnosis—inaccurate asthma diagnosis
• Correct Prescribing and use of medications—responsible respiratory prescribing/ steroid cards/inappropriate use of steroid inhalers
• Pulmonary Rehabilitation and Activity—poor completion rate
• Treating Tobacco Dependency—1st most important thing to do
• Flu and Pneumonia Vaccination (COVID vac)—poor HCP uptake
• Other areas –pollution and sustainable prescribing
Dr Vince Mak, Consultant Physician in Integrated Respiratory Care and Clinical Director of the London Respiratory Network.
CHECK INHALER TECHNIQUE AT EACH REVIEW AND BEFORE STEPPING UP TREATMENT
Use of questionnaires -> CAT, mMRC. USE ICE
Essentials of COPD REVIEW
https://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245
2012 Measuring quality: a complicated task
Patient Education—Smoking Cessation
Fletcher C & Peto R. The natural history of COPD. BMJ, 1977;1:1645-1648.
>20 pack-year smoking history---Significant for COPD
It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked
https://www.pcrs-uk.org/resource/instigating-quit-attempt
9 in 10 case of COPD are thought to be attributed
to
Smoking
Pulmonary Rehabilitation
LOCAL SERVICE DELIVERY—check your local area6-8 weeks/ mixture of face to face and virtual during COVID
https://www.blf.org.uk/support-for-you/breathe-easyBREATHE EASY—PATIENT PASSPORTHome Exercises improve Quality of Life
https://www.england.nhs.uk/wp-content/uploads/2020/03/pulmonary-rehabilitation-service-guidance.pdf
Impact on 6 Minute Walk DistanceImprovement in Functional AbilityQuality of life MeasuresAnxiety/Depression ScoresKnowledge of Condition
SELF MANAGEMENT ---COPD
EMERGENCY CARE PACKS
Comorbidities and COPD & Differential Diagnosis
• Pneumonia.• Lung Cancer.• Pulmonary Embolus.• Bronchiectasis.• Asthma.• Heart Failure.• Anxiety.• Depression.• Coronary Artery Disease (CAD)• Hypertension.• Osteoporosis.• Diabetes Mellitus.• Muscle Weakness.• Atrial Fibrillation.• COVID?
Quality of Life Psychological considerations
Mental and physical well-being.
Relationships with other people.
Social, community, and civic activities.
Personal development and fulfillment.
Recreation and fun.
Screening for Depression
Patient Health Questionnaire (PHQ-9)
Depression Severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.
• BMI <20 --poor prognosis---high protein/fat—small and often/ supplements– Cachexia and associated morbidity/ rapid weight loss https://respiratory-
research.biomedcentral.com/articles/10.1186/s12931-019-1073-3#citeas
• BMI >30—some mild obesity improved prognosis– Some research weight loss of 6.2%, and this was associated with improved
clinical outcomes including health status, symptoms, exercise and functional capacity Should we treat obesity in COPD? The effects of diet and resistance exercise training Respirology(2016) 21, 875–882
• Vitamin D < 25 nmol/l supplementation safely and substantially reduced the rate of moderate/severe COPD exacerbations in patients with baseline 25-hydroxyvitamin D levels <25 nmol/Lhttps://thorax.bmj.com/content/74/4/337
Clinically Extremely Vulnerable (Shielding)
• Significant degree of de-conditioning due to the pandemic
• Effects on mental health
• If someone with severe COPD develops COVID-19 symptoms they should follow standard advice but should only start oral corticosteroids if instructed to do so by a healthcare professional. This is in contrast to what they may previously have been advised, when rescue packs of oral steroids and antibiotics mighthave been provided for self-management.
Preparation for End of LifeBODE Index for COPD Survival
https://www.coordinatemycare.co.uk
Audit patients with hospital Admission –Quality Improvement Project?
?
COPD Treatment Guidelines
NICE Guidelines 2020
GOLD Report 2020
PCRS ‘keeping it simple’ approach Combines best of both to offer a simplified summary to help navigate through available guidance
Diagnosis Management• Symptoms• Post BD spirometry
• LABA/LAMA first choice
Diagnosis Management• Symptoms• Post BD spirometry
• Single bronchodilator first choice
Aims of treatment
Reduce symptoms:• Relieve symptoms• Improve exercise tolerance• Improve health status Reduce Risk:• Prevent disease progression• Prevent and treat exacerbations• Reduce mortality
GOLD Treatment Guidelines
Chronic ObstructivePulmonary Disease in over 16s:Non-pharmacological management and use of inhaler therapies
RRP COPD Guideline (ncl-mon.nhs.uk)
Asthma COPD overlap syndrome
• Asthma COPD different disorders• Asthma and COPD can co-exist in an individual• May share common traits (eosinophilia, and some reversibility• If asthma trait present-> follow asthma guidelines for
pharmacotherapy• For the COPD may need pharmacological and non-
pharmacological interventions
consider
LABA + LAMA + ICS
Continued or frequent exacerbations
Explore further treatment options if needed
NICE Inhaler strategy
Offer LABA/LAMA
No asthma features or features suggestive of steroid responsiveness
Consider 3 month trial ofLABA + LAMA + ICS
Person still limited by symptoms
Consider LABA + ICS
Asthmatic features suggestive of steroid responsiveness
Still limited by symptoms or has exacerbations despite LABA + ICS
https://www.nice.org.uk/guidance/ng115/resources/visual-summary-treatment-algorithm-pdf-6604261741
Offer SABA or SAMA to use when requiredLimited by symptoms or has exacerbations despite treatment
https://www.ncl-mon.nhs.uk/wp-content/uploads/Guidelines/3_RRP_COPD_Guidelines.pdf
www.ncl-mon.nhs.uk
OTHER TREATMENTS • Consider mucolytic drug therapy for people with a chronic cough productive of
sputum.Mucolytics
• Should only be used after a trial of inhaler therapies • For people who are unable to use inhaled therapy• little evidence base in COPD and high potential for drug interactions and side
effects, particularly in elderly. Theophylline
•Consider azithromycin (usually 250 mg 3 times a week) • do not smoke and• have optimised all treatments, relevant vaccinations,
referred for pulmonary rehabilitation and• frequent (typically 4 or more per year) exacerbations with
sputum production or hospital admission
Prophylactic antibiotics -
?respiratory input, Sputum culture
https://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease#path=view%3A/pathways/chronic-obstructive-pulmonary-disease/stable-copd-oral-therapy.xml&content=view-node%3Anodes-prophylactic-antibiotics
OTHER TREATMENTS
Nebulisers RoflumilastAmbulatory oxygen Oxygen saturation
<92% refer
LTOT NIV
Exacerbations: why they matter
COPD exacerbations
An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. The change in these symptoms often necessitates a change in medicationhttps://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245
Worsening breathlessness Cough
Increased sputum
Change in sputum colour
SYMPTOMS
How to treat an exacerbation
Increase frequency of SABA use. Check inhaler technique .
Spacer with pMDI
Oral prednisolone plain (non-enteric coated) 5mg tablets.
Prescribe 30mg OM for 5 days unless contraindicated
If purulent sputum – consider 5 days of oral antibiotics (amoxicillin 500mg TDS for 5 days or doxycycline 200mg on day 1 then 100mg OD for 4 further days or clarithromycin 500mg BD for 5 days)
Alternative choice antibiotic if patient at higher risk of treatment failure e.g. co-amoxiclav 625mg TDS
Seek medical help if:•symptoms worsen rapidly or significantly, Symptoms do not start to improve within 2-3 days•the person becomes systemically unwell •Arrange a follow up
Exacerbations of COPD - NICE Pathways
Self management plans and Rescue Packs
All patients need a jointly agreed personalised action plan on how to respond quickly to symptoms of exacerbations. This may or may not include ‘rescue pack’
• An ‘Rescue Pack’ is a course of corticosteroid tablets and antibiotics for a patient to keep at home.
Establish understanding of, and confidence in, managing exacerbations before prescribing an ‘exacerbation pack’
• Do not add rescue medications on repeat medication list
All patients should be reviewed in the practice after an exacerbation, log and read code the episode and discuss next steps
https://www.pcrs-uk.org/sites/pcrs-uk.org/files/Emergency_Care_Packs.pdfEmergency Pack/spacers for patients—PCRS Position Statement 2020
Why is the patient still symptomatic/exacerbating? Ineffective treatment:
• ? diagnosis, ? advance disease, ? suboptimal treatment
Suboptimal delivery of medication to lungs:
• technique/adherence/ inhaler device
Non- pharmacological interventions not addressed:
• vaccination, smoking, PR, trigger avoidance
Other factors:
• anxiety, obesity
Disease progression
Or could it be that the patient is having a ‘bad’ day?
• Increase frequency of bronchodilator use. Not every deterioration in symptoms is an exacerbation requiring antibiotics and steroids
• https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/12/nhs-rightcare-copd-pathway-v18.pdf
The Primary Care Respiratory Society ©2019. https://www.pcrs-uk.orgA population-focused respiratory service framework
Training
• https://respiratoryacademy.co.uk• https://www.educationforhealth.org• https://www.pcrs-uk.org/spirometry-training-what-are-my-
options
?