City and Hackney Respiratory Diagnostic Hub - PowerPoint Presentation

1. City and Hackney Respiratory Diagnostic Hub Laura Graham – Cardiorespiratory Consultant Physiotherapist, ACERS Team Lead Jane Osei-Wusu – Respiratory Nurse Specialist, Joint Clinical Lead Jacqui Jarhouvey – Respiratory Nurse Specialist – Joint Clinical Lead

2. Overview of sessionBackgroundWhat quality assured spirometry meansDifferential diagnosis NICE Guidelines The City and Hackney Diagnostic HubNorth-East London FormularyCase Studies

3. Background NHS Long Term Plan (2019) outlined importance to “accurate and timely access to diagnostic tests for anyone with a suspected lung condition”Why? Because of the high number of people being admitted to hospital with a probably exacerbation of a respiratory disease

4. National Ambition“increase the percentage of patients that receive a diagnostic test within six weeks in line with the March 2025 ambition of 95%”

5. Importance of accuratediagnosisAccurate diagnosis ensures: Right care and treatmentImproves patient outcomesEnsures people live well and reduces health care utilisationInaccurate or delayed diagnosis:Can be harmful - increase exacerbations Increases the cost to the NHS Can be life limiting – lead to increased morbidity and mortality

6. Is it Asthma or COPD?

7. Diagnosing Chronic Obstructive Pulmonary Disease Diagnosis made based on typical clinical featuresSupported by SpirometryRisk FactorsSmoker >10 year pack history Over 35 years oldBreathlessness – worse on exertion Chronic/recurrent coughSputum production – regularFrequent respiratory tract infections Wheeze

8. Diagnostic Criteria for Asthma in Adults Symptoms or features that support a diagnosis of asthma1Wheeze, shortness of breath, chest tightness or coughTriggers to symptomsPersonal or family history of atopic disease/disorders Do not use symptoms or atopic disorders alone, without a diagnostic testExpiratory polyphonic wheeze on auscultation Use of Spirometry (with reversibility), FeNO, PEFR monitoring

9. What is Quality Assured Spirometry and FeNO?Undertaken by an ARTP Accredited Practitioner3 levels of certification:Full PerformerReporter Both Spirometry and FeNO are reproducible diagnostic testsShould not be used in isolation, but alongside a clinical history

10. Diagnosis by SpirometryVariable airflow obstruction is characteristic of uncontrolled asthma, with bronchodilator reversibility of 12%+ in FEV1 diagnostic.Post-bronchodilator FEV1/FVC ratio < 0.7LLN together with reduced FeV1 (LLN) and an appropriate history including a risk factor (e.g. smoking) is needed to establish the diagnosis of COPD.FEV1 Z Score would then determine the severity

11. Severity/Grading for COPD

12. Diagnosis by FeNOFeNO devices measure fractional exhaled nitric oxide in the breath of patients 5 years <Assessment of type 2 inflammation, of which Nitric oxide is a biomarker (in 93% of asthma cases)Smoking or caffeine can lower, nitrate-based foods can increase levels https://wessexahsn.org.uk/programmes/56/feno-fractional-exhaled-nitric-oxide-for-the-diagnosis-and-management-of-asthma<25 ppb = unlikely uncontrolled asthma25-39 ppb = uncertain zone>40 ppb = likely uncontrolled asthma in a patient with appropriate symptoms (>35ppb in children)

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15. Differential Diagnosis: Larnygeal DysfunctionCommon symptoms include:triggering by perfumes and aerosols acute onset episodesthroat tightening and vocal symptoms poor response to asthma treatmentscoughWhen the larynx does not open and close appropriately during respiration. Can be at the level of the vocal cords or above. Inducible laryngeal obstruction (ILO) is when the larynx closes on inspiration rather than remaining open. Hicks et al. 2008

16. Differential Diagnosis: Breathing Pattern DisordersSymptoms can include breathlessness, gasping, yawning and the feeling of not getting enough air in. Common in patients with and without other respiratory diseases.“An alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms which may be respiratory or non-respiratory” (Barker & Edwards 2015)

17. Diagnostic Hub Service

18. The Diagnostic Hub pathway – will sit within the ACERS ServiceHybrid Model – Clinical space and Diagnostic vanDaily staffing – one B7 clinician and B3 HCAManaged Cardiorespiratory Consultant Physiotherapist Service Operational Leads:Jane Osei-Wusu - Respiratory Clinical Nurse Specialist Jacqui Jarhouvey – Respiratory Clinical Nurse Specialist Supported by Band 3 Health Care AssistanceEventual aim – 1 clinic (whole day), per fortnight, per PCNService Overview

19. Inclusion Criteria Patients aged 6 or above requiring diagnostic respiratory diagnostic hubWho present with clinical features that suggest the possibility of COPD or asthma: Such features might include night time cough, breathlessness, chronic cough, regular sputum production, frequent winter “bronchitis” and wheeze)Patients with respiratory symptoms who are over 35 years and who are smokers with > 10 pack years of smokingPatients with a diagnosis of COPD whose previous diagnosis of COPD has been made without post-bronchodilator spirometry or where the patient has a diagnosis of COPD with a FEV1/FVC ratio of greater than 0.70Patients who have had confirmed or suspected COVID-19 pneumonia and continue to experience breathlessness

20. Highest Priority Middle Priority Lowest Priority Patients with a provisional diagnosis but poor response to treatment (although one hopes further investigation would have already been considered). Patients for whom diagnostic spirometry will potentially impact their treatment pathway or determine their onward care.Those who are symptomatic with cough and breathlessness but no clear diagnosis.Spirometry to confirm diagnosis is valuable but not an immediate priority. If a patient’s history and clinical picture fits with the provisional diagnosis and they respond well to treatment it is important to confirm diagnosis but not at the expense of patients in whom spirometry might alter the diagnosis or treatment.Reviews of progression of disease but if you still regularly perform spirometry on stable patients (e.g. those with pulmonary fibrosis) these should be at the back of the queue.Case finding-non symptomaticAnnual Reviews Prioritisation

21. Referral ProcessReferrals will be sent via e-RSNEL referral form currently being built into EMIS (adults)Local referral form for children (with pan NEL Form eventually)Paediatric clinics will initially be adhoc, around school holidays and linked with children centres. Patient will be booked into their local clinic within their PCN or to the nearest PCN clinicKPI – Referral to appointment – within 30 days

22. Service objectives To improve the accuracy of diagnosis provided to people with breathlessness and other respiratory symptoms, leading to improved accuracy of long-term condition registers and higher value patient-centred care To improve outcomes of patients with COPD and asthma through earlier access to the correct treatment pathway and high value treatments To reduce health inequalities through equitable service provision across City and Hackney.To ensure that users of the service have a positive experience of care To be an educational resource to primary care through the provision of training in diagnosis and management of breathless and airways disease delivered by the specialist respiratory team and integrated respiratory consultants supporting the service

23. High level objectives Increasing accuracy of COPD and asthma diagnoses on long term condition registers.Allowing earlier appropriate and high value interventions for patients with respiratory disease, yielding more cost-effective prescribing, less waste of medicines and reduced harm Improved patient understanding and self-management of their respiratory condition

24. Exclusion Criteria

25. What will the Report ContainA confirmation or not of a probable diagnosisFEV1, whether the readings are pre- or post-bronchodilatorFEV1 % predicted and severity categorisation according to NICE 2010 guidelinesFVCFEV1/FVC ratioExhaled CO – and implications of this as to tobacco dependenceFENOMRC dyspnoea scoreFlow volume loop interpretationResting oxygen saturationsThe report will also document whether onward referral is recommended in line with locally agreed pathways or if further diagnostic tests are required in line with local guidelines, providing rationale for the recommendation e.g., CXR, ECG, BNP, echocardiogram, peak flow diary

26. The report will contain recommendations of potential medication management recommendationsIt may also contain recommendations of onward referrals such as smoking cessation or pulmonary rehabilitationThis is a one stop clinic, so the patient will then be dischargeDuty of care to action these will sit with the referring clinician. Report continued

27. North East London Prescribing Formularies COPD: https://www.bing.com/search?pglt=169&q=nel+copd+guidelines&cvid=e535ba80a1874b29bb7ea99ccafe96a7&gs_lcrp=EgZjaHJvbWUqBggAEAAYQDIGCAAQABhAMgYIARBFGEDSAQg5ODEzajBqMagCALACAA&FORM=ANNTA1&PC=U531Asthma:https://primarycare.northeastlondon.icb.nhs.uk/wp-content/uploads/2023/08/Asthma-guidelines-adults-NEL-v2_07.2023.pdf

28. Case studies

29. Background/Clinical History80 years oldSex: MalePresenting complaint: Breathless on minimal exertion, gradually got worse over the past 2 years. Expectorates clear sputum in the mornings, no ankle oedema, no orthopnoea, no paroxysmal nocturnal dyspnoea. Sleeps with 1 pillow.Frequent winter 'bronchitis’ x 2 within a year No respiratory related hospital admission within 12 monthsEx- smoker of 20 packed yearsNo recreational drugsNo alcohol

30. No allergiesCH: No hay fever, no AsthmaFH: No AsthmaSocial:Lives with his wifeOccupation retired TeacherNo petsVaccinations up to date, flu and COVID, no pneumonia vaccinationBackground continued

31. Outcome measures:MRC dyspnoea score 3, Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own paceCAT score: 20 ( < 10 low, 10-20 medium, > 20 high, > 30 very high)Investigations:No CT scanChest X-ray hyperinflated lungsEosinophils 0.0 ( range 0 - 0.4)Further investigations/Outcomes

32. Spirometry test – Results Post-bronchodilator spirometry confirms diagnosis of COPDModerate airflow obstructionMeasurementValue % predicted (lower limits normal)Vital Capacity 1.78L56Force Expiratory Volume in 1 second (FEV1)1.16L 51% 2.21 (Z-score)Forced Vital Capacity (FVC)2.17L90%FEV1/FVC ratio0.53L

33. Severity/Grading for COPD

34. Results – Flow, volume loop & volume/time graph

35. What would you do next?NEL Primary and Secondary Care Chronic Obstructive Pulmonary Disease (COPD) Prescribing Guidelines 2022 https://www.bing.com/search?pglt=169&q=nel+copd+guidelines&cvid=e535ba80a1874b29bb7ea99ccafe96a7&gs_lcrp=EgZjaHJvbWUqBggAEAAYQDIGCAAQABhAMgYIARBFGEDSAQg5ODEzajBqMagCALACAA&FORM=ANNTA1&PC=U531

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38. Asthma Case Study

39. Background69 year old gentlemanNon-smokerHistory of asthma in his family - sister and daughter Long term history of wheezeAtopic – reports seasonal hayfever and possible rhinitis – takes over the counter medicationPossible asthma as a child, but not confirmed Breathlessness reported Retired PostmanBlood eosinophils: 0.67 (>0.3)

40. Post Bronchodilator Spirometry was performedFeNO 37ppm (26-49ppm, mild airway inflammation)Results MeasurementValue% predictedValue % predicted % changeFEV1 2.12L 66%2.45LN/A15% (330ml)FVC2.87L68%3.03LN/AFEV1/FVC ratio0.7499%0.80N/A9.2%

41. DiagnosisFeNO is borderline = 37ppbSpirometry confirms a diagnosis of probable asthma

42. Possible treatment plan: NEL Primary and Secondary Care Adult Asthma Prescribing Guidelineshttps://primarycare.northeastlondon.icb.nhs.uk/wp-content/uploads/2023/08/Asthma-guidelines-adults-NEL-v2_07.2023.pdf Start at step 1Monitor symptom and PEFR Optimise upper airwaysymptoms

43. Thank you & QuestionsACERS ServiceHomertonCOPD@nhs.net or Laura.Graham5@nhs.net X - @ACERSHomerton T: 0208 510 5107Diagnostic Hub Main line (when live)Direct line – 07584520092Diagnostic Hub email (when live)huh-tr.acersdiagnostichub@nhs.net

44. References A Guide to Performing Quality Assured Diagnostic Spirometry (2013) https://pcc-cic.org.uk/sites/default/files/articles/attachments/spirometry_e-guide_1-5- 13_0.pdfGlobal Initiative for Asthma (GINA) Global Initiative for Asthma - Global Initiative for Asthma - GINA (ginasthma.org)Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline [NG115] Published date: December 2018 Last updated: July 2019 Overview | Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICERestarting Spirometry - guidance from ARTP and PCRS, Last updates May 2021: https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid- 19/restarting-spirometry/Asthma: diagnosis, monitoring and chronic asthma management. NICE guideline [NG80] Published date: November 2017 Overview | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICESIGN158. British guideline on the management of asthma. A national clinical guideline. First published 2003. Revised edition published July 2019 British guideline on the management of asthma (sign.ac.uk)ARTP: Standard Operating Policy for Spirometry accessed at: SOP - Spirometry (artp.org.uk)