Current management of COPD and when to refer? - PowerPoint Presentation

Slide1

Current management of COPD and when to refer?

Dr Maxine HardingeConsultant Respiratory Medicine Oxford University Hospitals NHS Foundation TrustSlide2

Aims of treatment – reducing risk and reducing symptoms

Inhaled therapy – new Oxfordshire guidanceSevere COPD – home oxygen therapy, palliative measures, surgical interventions

Out-patient referrals - who to refer and who is being referred?Slide3

Date of preparation: February 2015; ULT0046

GOLD 2014:

Treatment

goals for stable COPD

3

COPD, chronic obstructive pulmonary disease;

GOLD, Global initiative for chronic Obstructive Lung Disease

Reference:

GOLD

. COPD guidelines 2014. Available at http://www.goldcopd.org (Accessed December

2014)

Relieve

symptoms

Improve exercise

tolerance

Improve health status

Prevent disease

progression

Prevent and treat

exacerbations

Reduce mortality

AND

REDUCE

SYMPTOMS

REDUCE

RISKSlide4

Offer

Consider

* SABAs (as required) may continue at all stages

NICE 2010: Use of inhaled therapies

Who

should be treated with

LABA/ICS or LABA/LAMA?Slide5

“Value” in COPD

London respiratory team, NHS LondonSlide6

Getting the basics right

Diagnosis – quality assured spirometryVaccinationSmoking cessationPhysical activity – pulmonary rehabilitationDietSelf managementDepression/ anxiety Slide7

Smoking cessation – a treatment for COPD

Stopping smoking is only intervention in COPD that can reduce all four core symptoms (cough, wheeze, breathlessness and chest pain)

1

and simultaneously

slow the decline in lung function

1

reduce COPD readmissions

2

mortality 3

1 Scanlon PD et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir

Crit Care Med 2000;161:381-90.

2 Borglykke A et al. The effectiveness of smoking cessation groups offered to hospitalised patients with symptoms of exacerbations of chronic obstructive pulmonary disease (COPD).

Clin Respir J 2008;2:158-65.

3 Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD); 2010 http://www.goldcopd.org/. Slide8

Smoking cessation data (PHE)

Smoking prevalence in Oxfordshire in 2013 was 14.7% (12% in 2010)Numbers

setting a quit date

2013/14:  6065

2014/15:  3319

Percentage of successful 4 week quitters self-report

2013/14: 60%

2014/15: 58%

Percentage of successful 4 week quitters CO monitor validated

2013/14: 46%

2014/15: 43%Cost per quitter 2013/14 £181.1Slide9

NICE 2010: Pulmonary rehabilitation

Offer to all appropriate people with COPD

those who consider themselves functionally disabled by COPD (usually MRC grade 3 and above)

including those who have had a recent hospitalisation for an exacerbation

– early post discharge pulmonary rehabilitationSlide10

Oxon PR outcomesSlide11

Pulmonary rehabilitation

programme45% of patients invited to assessment attendOf those 77.23% who started the course managed to complete it (starter to completion rate has improved considerably from the previous years: 2011-12: 59.5%, 2012-13: 64.6% and 2013-14: 66.66%)

Therefore, just over 30% of all the referrals we receive complete courseSlide12
Slide13

Self management

Need to take a variety of approaches tailored to individual Slide14

Pharmacological management

Bronchodilators – single or dualRole of ICSTheophyllinesMucolyticsLong term oral steroids

Macrolides - azithromycinSlide15
Slide16
Slide17
Slide18

Severe COPD – additional treatments

Home oxygen therapyLong term oxygen therapyAmbulatory oxygen therapy

Surgical interventions

Lung volume reduction by

endobronchial

valves or surgery

Bullectomy

TransplantationSlide19

End

of Life Care in COPD:

Severe

AFO FEV

1

< 30% predicted

Respiratory failure

BMI < 19

Housebound or

MRC grade 5

2 or more admissions in previous yearRequired NIV for AECOPD“Surprise question”

Symptom relief

Fan therapy

Breathing control/pacing adviceDietary adviceDepression/anxiety

MorphineBenzodiazepinesHome oxygen therapy if resting O2 sats< = 92%Advance care planningSupport for carersSlide20

NICE 1.1.8

Referral for specialist advice (2004, 2010)should be made when clinically

indicated

may

be appropriate at all stages

and

not solely in

most

severely disabled

patientsSlide21

Referrals for specialist advice

Diagnostic uncertainty: Is it all COPD? Symptoms disproportionate to lung function deficitIs it asthma or COPD?Assessment for additional treatments;

oxygen therapy, pulmonary rehabilitation

, transplantation, nebulisers, long term steroids or antibiotics

Advice about management of recurrent exacerbations

Advice about management of breathlessness

Significant disease in young person:

Alpha 1 antitrypsin deficiency

cannabisSlide22

Who is being referred?

69 year old womanCOPD diagnosed following hospital admission Sept 2015 Fostair and salbutamol. Tried Carbocisteine twice – rash both times.

O2

sats

95

%

‘

extremely SOB and afraid to

out. Please advise on breathlessness’What is her spirometry?

Why tried carbocisteine if problem is breathlessness?Why isn’t she on a LAMA?Has she done PR?Is she still smoking?

Is her CXR normal?FEV1 0.7L (51% pred

), FVC 1.1L (64%) Thoracic kyphoscoliosis

CXR normal Slide23

Who is being referred?

63 yr old womanCOPD breathlessness grade 4Continues to smokeOn maximal therapyRequires frequent courses of oral steroids

O2

sats

93%

What is her spirometry?

Has she has a CXR or

Hb

recently?

If recurrent exacerbations what’s growing in her sputum?

Is she eosinophilic and would long term low dose steroids be appropriate? Has she been to PR?What's been tried for her smoking?O2 sats

90-91%No CXR or Fbc since 2010

Dry powder inhalers – try MDI/ mistDeclined PR or smoking

adviceSputum culture ? PSADiscussion about smoking – prognosis and oxygenSlide24

Summary

Treatments as risk reduction and symptom treatmentNew inhaler guidanceSmoking cessation is a treatment for COPDChampioning exercise and PRTailoring self-managementReferrals – overview of COPD severity and problem which needs addressing