www.pspbc.ca shared system of care copd/heart failure learning session 2
TRANSCRIPT
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www.pspbc.ca
Shared System of Care COPD/Heart Failure
Learning Session 2
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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)
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Patient Voice
(10 minutes)
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COPD Medications
(15 minutes)
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Comprehensive Management of COPD
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Classification of Disease Severity in COPD
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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
Treatment of stable COPD
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Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)
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Short-acting Bronchodilators
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Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)
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Stepwise increased therapy
Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)
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Mild
Increasing Disability and Lung Function Impairment
Infrequent AECOPD
(< 1/year)
Frequent AECOPD
(> 1/year)
LAAC or LABA+ SABA prn
LAAC + LABA + SABA prn
LAAC + ICS/LABA* + SABA prn
LAAC + ICS/LABA +
SABA prn
SABA prn
persistent
disability
LAAC + SABA prn
or
LABA + SABA prn
persistent disability
LAAC + ICS/LABA +
SABA prn +/- Theophylline
persistent disability
Moderate Severe
persistent disability
* 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
Optimal Pharmacotherapy in COPD
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Comprehensive management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)
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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.
Summary
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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
Stable COPD: Who should be referred?
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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?
Case #1
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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
Case #1
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Spirometry with post bronchodilator assessment showed a 12% improvement consistent with the diagnosis of asthma.
Echocardiogram: Normal
Stress test: No ischemic changes
Case #1
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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
Case #1
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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?
Case #2
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Clinically this patient has deteriorated with a recent exacerbation.
What would you do next?
Case #2
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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.
Case #2
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Larsson et al, J Intern Med 2013
Patient Flow
Patients who met the inclusion criteria identified within the study period n=21 361 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=9893Patients with a record of fixed ICS/LABA therapy (Index date) n=9893
FLU/SAL cohort
n=2734BUD/FORM cohort n=2734
Linked data from 76 centres throughout SwedenLinked data from 76 centres throughout Sweden
Matched populations
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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
Larsson et al, J Intern Med 2013
COPD Exacerbations
0.80
1.09
0.0
0.2
0.4
0.6
0.8
1.0
1.2
BUD/FORM (n=2734) FLU/SAL (n=2734)
Exa
cerb
atio
n r
ate
RR = 0.74 (CI: 0.69, 0.79)
p<.0001
RR, rate ratio
BUD/Form
Flutic/salmeterol
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Stepwise increased therapy
Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)myr
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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.
Case #2
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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?
Case #3
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Repeat spirometry and FEV1 unchanged. Next steps?
Case #3
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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?
Case #3
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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
Case #3
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Questions
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Management of severe COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)
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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
Severe COPD
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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
Long term O2 therapy indications
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Continuous home O2 minimum 20h /day
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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.
Nebulizer treatment in severe COPD
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Chronic oral prednisone therapy in COPD
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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-of-1 trial of alternate day OCS can be considered.
Bone density and osteoporosis risk should be regularly reassessed.
Chronic oral prednisone therapy in COPD
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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.
Roflumilast: indication:
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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.
Other antibiotics for severe COPD
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Heart Failure (15 min)
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0
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All Ages Age < 85
ACE/ARB
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Evidence Based HF Therapies in BC
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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
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Heart Failure Therapies
Therapy Agent Reduction in 1° Endpoint
Self Management 23%
Pharmacological ACE-I 8% - 26%
Beta Blocker 23% - 65%
MRA 35%
ARB 15%
Device ICD 23% - 31%
CRT 24% - 36%
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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)
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Beta-Blockers Reduce Mortality and Decrease the Risk of Hospitalization
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Impact of ACE Inhibitors on Mortality in HF
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Benefits of ACE Inhibitors Persist
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Spironolactone: EF<30 & Advanced Symptoms
10%
ARR
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Combining Therapies Improves Outcomes
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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.
Relative risk 2-yr Mortality
None --- 35%
ACE Inhibitor 23% 27%
MRA (Spironolactone) 30% 19%
Carvedilol 25% 19%
Cumulative Impact of Heart Failure Therapies: All Cause Mortality
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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
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RAFT
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NEJM 1996
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Important Therapeutic Considerations in HF Patients
Smoking cessation Cardiac rehab Action plans for acute decompensation Addressing co-morbidities
COPD CKD
Immunizations Symptom management End of life care
some synergies and therapeutic overlap
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Break
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Patient Self-Management
Generating an Action Plan
COPD and AECOPD Management
Patient Education Materials
Smoking Cessation
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COPD and AECOPD Management
(30 minutes, 20 didactic + 10 questions)
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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.
Case
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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….
Case continued
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Clinical course of COPD
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Burden of illness Under diagnosis and role of targeted screening The role of spirometry in diagnosis and staging Staging by symptoms and by FEV1
Last time…
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Goals of COPD care
Preventing/
managing
exacerbations
Relieving
symptoms
Improving
quality of life
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5 point “PRIME” Plan:1. Prevent further damage to your lungs2. Relieve your symptoms
› optimize drug therapy
› work on mental outlook and coping mechanisms3. Improve your general health and physical activity level4. Manage COPD flare-ups with an “Action Plan”5. Establish your COPD team
› family, friends, physician, healthcare professionals, COPD educator
A “Personal Management Plan” for COPD
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Stepped approach to careEnd of Life Care
Surgery
Oxygen
Theophyline (in certain patients)
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
Individuals at Risk
• Smokers
• Environmental Exposure
All Patients:
• Exercise Rehabilitation
• Smoking Cessation
• Healthy Lifestyle
• Patient Education
Increasing severity of COPD
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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
Acute exacerbations (AECOPD) or lung attacks
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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)
Acute exacerbations (AECOPD) or lung attacks
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AECOPD frequency: mortality
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Time course of AECOPD recovery
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Benefits of COPD self management education
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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.
Management of symptomatic: mild COPD
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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.
Management of symptomatic: mild COPD
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Consider oxygen Mobility assistance Consider roflumilast Consider co-morbidities again Initiate advanced care planning, maybe DNR form Consider palliative help with dyspnea
Management of severe COPD
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Increasing disability & lung function impairment
Mild
Infrequent AECOPD
(< 1/year)
Frequent AECOPD
(> 1/year)
LAAC + ICS/LABA +
SABA prn
SABD prn
persistent dyspnea
LAAC + SABD prn
or
LABA + SABD prn
LAAC + ICS/LABA +
SABA prn +/- Theophylline
persistent dyspnea
Moderate Severe
LAAC or LABA+ SABA prn
LAAC + LABA + SABA prn
LAAC + ICS/LABA + SABA prn
persistent dyspnea
persistent dyspnea
Can Respir J 2008;15(Suppl A):1A-8A.
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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.
AECOPD: Prevention Strategies
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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
Take Home Points:
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Nishimura K, et al. Chest 2002; 121: 1434: 40
Survival in COPD – Relationship to Lung Function and Disability
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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%
Prognosis
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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)
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Prognosis - Survival by BODE Index
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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
Long Term Oxygen Therapy: Survival
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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/
Summary
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Heart
Failure
101
Patient Education Resources
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Heart Zones
Patient Education Resources
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Daily
weight
Patient Education Resources
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Sodium
Restriction
Patient Education Resources
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Fluid
Restriction
Patient Education Resources
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Activity
Patient Education Resources
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95Clinical Care Algorithms
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PATIENT RESOURCES
MEDICATIONS
SODIUM
FLUID
EXERCISE
EXACERBATION PLAN
HF 101
A Comprehensive List of Patient and Provider Resources
PROVIDER RESOURCES
REFERRAL FORMS
PATIENT ASSESMENT FORMS
CARE MAPS & TX ALGORITHMS
MEDICATION TITRATION
PATIENT SYMPTOM STATUS
VISIT SNAP SHOT
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Smoking Cessation
101
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Progress in British Columbia
Progress in BC
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
5
10
15
20
25
Percentage Smoking Prevalence in BC, 1999-2011
BC
Year
QuitNow
19-24 projects
1st Quit Contest
NRT ac-cess
BC sues tobacco
companies
Prevention program in schools
BC Quitline
Govt funding to $6.5M
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Intention to Quit
Intention to Quit
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Physicians discussing quitting
Physicians Discussing Quitting
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Effect of Physician intervention
Effect of Intervention
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What can Physicians do?
What can Physicians do?
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Strategies to help your patients quit
Strategies
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)
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What is QuitNow?
What is QuitNow?
Behavioural quit smoking supportProvincially Funded Managed by the BC Lung AssociationEvidence-based Free, confidential, 24/7
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Fax Referral Forms
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Indications for
Referral
to a HFC
Heart
Function
Clinic
Referral
Form
Referral Resources
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Patient History/Assessment
Heart Failure
Patient
Questionnaire
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A Guide to HF Patient Assessment
Patient Assessment
Tool
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Snapshot of Patient
Visit
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Referral and Consult Process
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Planning for Action Period 2