Jacqui Carrett Respiratory Clinical Lead COPD Update Jacqui Carrett Respiratory Clinical Lead

Aim of the session Overview of COPD Look at the COPD Assessment Tool - CAT score GOLD classification of patients Spirometry update Leave the session with at least one piece of information that you did not know at the start of the session!

2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011 COPD COPD is the only major cause of death which in increasing in the UK1 There are over 30,000 deaths from COPD annually in the UK – which equates to one person dying from COPD every 20 minutes in England1 Death rates from COPD are almost double the EU average 1 15% of those admitted to hospital with COPD die within 3 months and around 25% die within a year1 1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012. 2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011

COPD is projected to be the third biggest killer by 2020 26/11/2017 05:46 COPD is projected to be the third biggest killer by 2020 1990 2020 Ischemic heart disease CVD disease Lower respiratory infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accident Lung cancer Ischemic heart disease CVD disease Lower respiratory infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accident Lung cancer 3rd 6th Stomach cancer HIV Suicide Notes: As part of the Global Burden of Disease Study, Murray and Lopez1 projected future mortality rates based on the most common causes of death in 1990. The top 10 most important causes of death are presented in this slide. The majority of these leading causes of deaths are projected to remain stable or decline. Notably, COPD is expected to rise from the sixth biggest killer in 1990 to the third in 2020. Of the top 10 leading causes of death in 1990, only deaths caused by COPD, lung cancer and road traffic accidents are projected to rise. Reference Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349:1498–504. Murray & Lopez 1997 4

COPD Cost – COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS 1 80% of people with COPD have at least one other long-term condition. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and / or an anxiety disorder 1 24 million working days are lost each year from COPD with 3.8 billion lost through reduced productivity1 1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.

COPD Under diagnosis – estimated to be 2 million un-diagnosed COPD is characterised by accelerated decline in lung function Patients are not normally aware of a problem until half their lung function is lost

Drivers Local and national guidelines / priorities – Locality commissioning framework NICE quality standards for COPD – (updated 2016) NICE clinical guidelines for COPD NHS outcomes framework – 2016/2017 GOLD – Global strategy (2017 Report)

So…… what is COPD Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterised by persistent airflow limitation, that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients. Although COPD affects the lungs, it also produces significant systemic consequences

Defining COPD Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation previously diagnosed as having chronic bronchitis and emphysema

Risk factors Smoking – accounts for 90% cases Alpha 1 antitrypsin deficiency – 1% cases Increasing age Gender Occupation – coal mining, cotton processing, dusty occupations Outdoor and indoor air pollution – e.g. burning of wood and other biomass fuels Airway hyper-responsiveness Lower socio-economic status Low birth weight

Presenting features of COPD Over 35 years age Smoker or ex-smoker Breathlessness on exertion Chronic cough Regular sputum production – common but not universal Recurrent chest infections

Clinical features differentiating COPD and Asthma

Inflammation in Asthma V COPD Although Asthma and COPD are both associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells involved in the two diseases, which in turn account for differences in symptoms and response to treatment Asthma – eosinophils COPD - Neutrophils

Diagnosis There is no single diagnostic test and very often there are no physical signs

Diagnosis Take a full history Confirmed by SPIROMETRY – this measures lung function FEV1 - forced expiratory volume in 1 second FVC – forced vital capacity EVC – relaxed vital capacity FEV1 FVC ratio – less than 70% demonstrates airflow obstruction Mild disease – FEV1 > 80% predicted Moderate disease – FEV1 – 50-79% predicted Severe disease - FEV1 – 30-49% predicted Very Severe disease – FEV1 less than 30%

New National Spirometry register By 31st March 2021 All practitioners to be certified & listed on the register Phased implementation of this requirement from 1st April this year (2017) The National Register will be maintained by the ARTP - Association for Respiratory Technology & Physiology

3 Certificates 1. Foundation: those who have been assessed as competent to perform safe, accurate and reliable spirometry tests without interpretation 2. Interpretation only: Those who have been assessed as competent in interpretation only (ie those with no responsibility / requirement to perform spirometry but who do have a requirement to interpret accurately the results of spirometry) 3.Full: those who have been assessed as competent to perform and interpret spirometry in terms of the physiological changes.

Foundation – performing tests A professional portfolio is required relating to all aspects of preparation for, & performance of spirometry. This comprises compilation or creation of protocols, cleaning & calibration logs that ensure safety of the patient, checking for contraindications & preparation of the equipment to ensure accuracy etc. This will include 10 patient tests. Applicants will also complete a practical assessment of competence where spirometry is performed & observed by an ARTP approved assessor.

Full Certificate – performing tests and interpretation Assessment at Full level includes both an observed practical assessment of competence and submission of a professional portfolio as required at Foundation level. The 10 spirometry tests will cover a range of scenarios (obstruction, restriction & reversibility) & within this, these will then be interpreted within the context of the history of the patient described. There will also be a written assignment.

Interpretation Only – interpreting tests without performing Some prior knowledge of spirometry interpretation is advisable There is no observed practical assessment at this level A portfolio of 10 tracings that the individual has interpreted is required Plus a written assignment.

Experienced Practitioner Scheme Those with significant experience can apply to be confirmed as competent by having their skills assessed against ARTP standards. The Experienced Practitioner Scheme enables them to undertake an assessment of competence without attending any training To achieve certificate of competence at either Foundation or Full levels – individuals must undertake an observed assessment of competence at their workplace, Portfolio requirements are assessed at the same time For the full level, there is also an interpretation Viva and a written assignment. Interpretation only level - A portfolio of 10 tracings plus interpretation is required – there is no written assignment

Re-certification Required on a 3-yearly basis An observed assessment of competence Plus submission of a comprehensive portfolio (continued calibration, quality assurance, infection control, evidence of quality spirometric measurements) Where interpretation is required, an analysis of 5 traces provided by ARPT to review for technical quality & interpretation.

Treatment Smoking cessation Bronchodilators are the mainstay of COPD treatment – short acting and long acting – B2 and anticholinergic Combination inhalers – LABA+LAMA, LABA+ICS Steroid inhaler now only recommended in patients who experience > 2 or > 1 exacerbation leading to hospital admission and high symptom scores or those with a history of Asthma-COPD overlap http://www.enhertsccg.nhs.uk/respiratory-system Mucolytics Pulmonary rehab oxygen

CAT – COPD Assessment Tool 8 questions Score ranges from 0 – 5 0 = no symptoms 5 = more symptoms Helps guide your consultation to what are the most important symptoms for the patient Helps monitor any response to changes Change of 2 points is clinically significant

MRC DYSPNOEA SCALE   GRADE Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 m or after a few minutes on the level 5 Too breathless to leave the house, or breathless when dressing or undressing

Oxygen therapy Indicated if resting sats < 92% and on maximal inhaled therapy Refer to the Integrated Community Respiratory Service (ICRS) Referral form Either fax : 01462 427129 or send via email – enhertscommunity.respiratoryteam@nhs.net Not an emergency service

Other factors Breathlessness, fatigue and anxiety occur more commonly in COPD patients than those with advanced cancer, heart disease or renal disease Need to screen COPD patents for anxiety and depression People with COPD frequently have other co-existing diseases or co-morbidities Cardiovascular mortality in COPD – for every 10% decrease in FEV1 cardiovascular mortality increases by 28% and non-fatal coronary events increase by 20%

Any questions?