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COPD Disease not Disorder?. Alyn Morice University of Hull HYMS. What is COPD?. Asthma ( eosinophilic bronchitis). Chronic Bronchitis ( neutrophilic bronchitis). Emphysema. 2010. Page 1 of 673!. COPD Treatment Pathway.

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Presentation Transcript
slide1

COPD

Disease not

Disorder?

Alyn Morice

University of Hull

HYMS

what is copd
What is COPD?

Asthma (eosinophilic bronchitis)

Chronic Bronchitis

(neutrophilic bronchitis)

Emphysema

slide5

COPD Treatment Pathway

Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio <70%) Establish severity of disease by FEV1 as % predicted

Management of RISK FACTORS plus EDUCATION plus IMMUNISATION

SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues

Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)

PHARMACOLOGICAL TREATMENT

Review at each step after one month before escalating treatment

SHORTNESS OF BREATH

COUGH AND SPUTUM

prn short acting β2 agonist

MUCOLYTICS

THEOPHYLLINE

Tiotropium + short acting β2 agonist

Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol

Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss)

Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)

Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)

Consider Palliative Care Referral in End Stage Disease

telemonitoring in copd the evidence base
Telemonitoring in COPD – the evidence base
  • Numerous pilot projects with accompanying evaluation reports;
    • Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions)
    • Often methodologically limited (e.g. before-and-after studies; small sample sizes)
  • Systematic reviews demonstrate that high-quality evidence base is still immature;
    • Bolton (2010): studies included were positive but of a low-quality
    • Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations
evaluation
Evaluation…
  • Evaluation of first 3 months deployment (24 patients) showed:
    • - Patient satisfaction generally very good
    • - 68% reduction in n/e admission costs
    • - net saving per month
    • - achievement of £0.5m QIPP saving feasible
  • Evaluation by Hull University – full year evaluation due Dec 11
the east riding model
The East Riding Model

IDENTIFY

GP’s/NCT

Patient at risk

of deterioration

REFER

MONITOR

1. Referral for telehealth

intervention

2. Patient registered & unit installed

1. Monitoring

  • Risk stratification identifies patient
  • MDT agrees intervention

RESPOND

Telephone patient

Visit - within identified

timescale

Emergency Response

Step up / Step down

Community Beds

2. Alerts

3. Triage

4. Response

Protocols for response in place:

GP, NCT , specialist services, secondary care

telemonitoring in copd suggested mechanisms of action
Telemonitoring in COPD – suggested mechanisms of action
  • It has been suggested that telemonitoring can support COPD patients by;
    • Providing reassurance and support
telemonitoring in copd suggested mechanisms of action1
Telemonitoring in COPD – suggested mechanisms of action
  • It has been suggested that telemonitoring can support COPD patients by;
    • Increasing knowledge of disease process and enhancing self-care
    • Providing reassurance and support
roger
Roger
  • 64 year old with chronic, severe COPD
  • Housebound and anxious
  • Frequently uses standby medication
  • Frequent hospital admissions – anxiety rather than healthcare need
  • Distrustful of clinicians due to previous experience
  • After telehealth:
  • Telephone contact to reassure
  • Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns
  • More proactive about asking for help
  • Reduced hospital admissions
telemonitoring in copd suggested mechanisms of action2
Telemonitoring in COPD – suggested mechanisms of action
  • It has been suggested that telemonitoring can support COPD patients by;
    • Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms)
    • Increasing knowledge of disease process and enhancing self-care
    • Providing reassurance and support
the impact of frequent copd exacerbations more frequent attacks increase mortality

1.0

0.8

0.6

0.4

0.2

0

0

10

20

30

40

50

60

The impact of frequent COPD exacerbations - more frequent attacks increase mortality

n=304

A

p<0.0002

Survival probability

B

p<0.0001

p=0.069

C

Time (months)

Group A: no exacerbations

Group B: 1–2 exacerbations

Group C: ≥3 exacerbations

Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

copd patients with productive cough
COPD patients with productive cough

More likely to have exacerbations

Seemungal TA et al. Am J RespirCrit Care Med 98

More rapid decline in lung function

Vestbo J 1996, KannerRA et al. Am J RespirCrit Care Med 01

More likely to die early

Prescott E et al. EurRespir J 1995

timing of symptoms when was each symptom the most troublesome
Timing of symptoms: when was each symptom the most troublesome?

40

30

20

10

0

Cough (n=1,433)

Breathlessness (n=1,769)

50

40

30

20

10

0

48.9

31.0

24.0

22.5

% of patients

% of patients

19.5

22.3

18.7

17.3

14.9

10.6

On Later in the In the In the At night Waking morning afternoon evening

On Later in the In the In the At night Waking morning afternoon evening

40

30

20

10

0

Phlegm (n=1,551)

Chest tightness (n=690)

60

50

40

30

20

10

0

56.7

28.8

25.9

25.4

25.5

% of patients

% of patients

26.2

16.7

16.6

16.3

11.8

On Later in the In the In the At night Waking morning afternoon evening

On Later in the In the In the At night Waking morning afternoon evening

Partridge et al. ERS Vienna 2009

slide20

HULL AIRWAYS REFLUX QUESTIONNAIRE

Name:

D.O.B:____________________________ UN: _________________

DATE OF TEST:

Please circle the most appropriate response for each question

www.issc.info

TOTAL SCORE_____________ /70

slide21

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

slide22

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

cough counting in exacerbations of copd
Cough counting in exacerbations of COPD
  • Day 1 546 coughs
  • Day 5 162 coughs