COPD The Why, The How, and The Where Jo Congleton Consultant in Integrated Respiratory Care

COPD Why How Where Why has the CCG commissioned a LCS for COPD? To Diagnose To Manage Where To get help

Prevalence of COPD WHO Global Burden of Disease 5th Cause of Death in 2002 BOLD programme Global 10.5% Adults aged >30yrs QOF B+H CCG 1.3% of total population EPHO Predicted for B+H CCG 3.6% of population

QoF Registered COPD in B+H CCG EHPO Predicted 9,998 PMA Majority of COPD deaths on QoF register Exception rate 37% vs 14% Current exception rate 11%

National COPD Audit Primary Care National COPD Audit Programme Data from 48,029 COPD registered patients in Wales

High Quality COPD Annual Reviews COPD, not on Register Not COPD and on QoF Register COPD and on QoF register

AECOPD admissions at BSUH Slight upward trend of no. of admissions Low length of stay (downward trend) High 30 day re-admission rate (trend static for all cause, upward for COPD related) Low in hospital mortality (downward trend)

The How: GUIDELINES NICE 2010 GOLD 2017 ATS/ERS Exacerbations 2017

COPD Definition GOLD 2017 COPD is a common, preventable and treatable disease that is characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases

Diagnosing COPD AND Typical Symptoms Spirometry Post-bronchodilator FEV1/FVC < 70% Exposure to risk factors (significant smoking history) Typical Symptoms (dyspnoea, cough, sputum, production) AND

this is how we understand COPD now-the airflow obstruction can occur 3 ways: in the larger airways, the smaller airways (fibrosis-most important site of airflow obstruction in COPD) and due to loss of elastic recoil causing pressure dependant airflow obstruction in emphysema and the three components can vary in their extent.  In addition emphysema causes destruction of the alveolar-capillary interface, and this affects gas exchange.

Evolution of COPD

TTrash Can

Normal flow-volume curve Obstructive disorder: Severe obstructive disorder:

Airflow obstruction: severity FEV1:FVC ratio < 70% (i.e. < ¾ of lung volume expired in 1 second) Graded by FEV1 % predicted: Mild <100% predicted Moderate <80% predicted Severe <50% predicted Very severe <30% predicted

Symptoms: MRC dyspnoea grade CAT score

Many patients have features of asthma and COPD Does my patient have asthma or COPD? or What is this Asthma COPD Overlap Syndrome? (ACOS) Many patients have features of asthma and COPD Older age group Childhood asthma Significant smoking history

Aims of Management Reduce Symptoms Reduce Risk of Exacerbations Prolonging life

Management Reducing Symptoms Reducing Risk of Exacerbations Bronchodilators PR Reducing Risk of Exacerbations LABA/ICS Prolonging life Smoking Cessation LTOT (Reducing exacerbations)

The Value Pyramid Triple Therapy £35,000-£187,000 LABA £8,000/QALY LAMA £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £?1,000/QALY in “at risk” population This is why we should always ensure best value from our management! The value pyramid was devised by the London Respiratory Programme and we find  it a useful way of demonstrating value from various interventions. Note the big step up in cost per QALY (Quality Adjusted Life Year) at the peak of the pyramid (triple therapy, i.e LABA and ICS in combination plus LAMA). It is therefore lf evident that interventions lower down the pyramid should be addressed before considering prescribing ‘at the peak.’ 21 21

Exacerbations Symptoms High risk, less symptoms High risk, more symptoms Low risk, less symptoms Low risk, more symptoms Exacerbator 2 or more per year Non-exacerbator 0 /1 per year MRC < 3 CAT < 10 MRC 3 or more CAT 10 or more MRC 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

Exacerbations Symptoms High risk, less symptoms LAMA LABA/LAMA High risk, more symptoms LABA/LAMA (LABA/ICS) (Triple therapy) Low risk, less symptoms prn SABA or SAMA (LAMA or LABA) Low risk, more symptoms LAMA or LABA (LAMA /LABA) Exacerbator 2 or more per year Non-exacerbator 0 /1 per year MRC < 3 CAT < 10 MRC 3 or more\ CAT > 10 MRC 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

Inhaled Therapy B agonists Anti-Muscarinics Inhaled Corticosteroids SABA LABA Anti-Muscarinics SAMA LAMA Inhaled Corticosteroids ICS Low dose/ Medium dose /high dose

Metered Dose Inhalers (MDI’s) Evohaler Metered Dose Inhalers (MDI’s) Autohaler Easi-breathe Breath Actuated MDI’s MDI’s with dose counters Respimat

Dry Powder Inhalers Novolizer Ellipta Genuair Accuhaler Forspiro NEXThaler Breezhaler Handihaler Zonda Spiromax Inhaler & caps Easyhaler Turbohaler Twisthaler

Devices MDI Slow and Steady Dry Powder Fast and Deep

The correct inhaler device…. …Is the one that the patient is able to use and will use There is no place for an ICS containing mdi without concurrent use of a spacing device

Long Acting Muscarinics Eklira ▼ Genuair (Aclidinium) Incruse ▼ Ellipta (Umeclidinium) Braltus Zonda (Tiotropium) Spiriva (Tiotropium) Seebri ▼ Breezhaler (Glycopyrronium) Respimat Handihaler

Formulary LAMAs Eklira ▼ Genuair (Aclidinium) Braltus Zonda (Tiotropium) Spiriva (Tiotropium) Respimat Handihaler

Long acting bronchodilators and long acting muscarinics LAMA/LABAs Spiolto Respimat ®▼ (Oldaterol/ Tiotropium) Anoro Ellipta ® ▼ (Vilanterol & Umeclidinium) Duaklir Genuair ® ▼ (Formoterol & Aclidinium) Ultibro Breezhaler ®▼ (Indacaterol & Glycopyrronium)

Formulary LABA/LAMAS Spiolto Respimat ®▼ (Oldaterol/ Tiotropium) SOON Duaklir Genuair ® ▼ (Formoterol & Aclidinium) Ultibro Breezhaler ®▼ (Indacaterol & Glycopyrronium)

ICS + COPD Only effect is on exacerbation rate Only positive trials are when used in combination with LABA (LABA/ICS) Only effect is on exacerbation rate Balance with increase in pneumonia New (GOLD) guidelines defer adding ICS (LABA/ICS) If using ICS keep steroid burden as low as possible

Time to 1st pneumonia NNT 44 patients with FP/SV for 3 years to prevent one exacerbation of COPD NNH 16 patients to induce one pneumonia Probability (%) Time to first event (weeks) SCO100250 study

Long Acting Bronchodilators and Inhaled Corticosteroids Seretide Accuhaler ® (Salmeterol & Fluticasone propionate) Relvar Ellipta ®▼ – (vilanterol & Fluticasone Furoate) AirFluSal Forspiro ® (Salmeterol & Fluticasone propionate) MDI NEXThaler Symbicort Turbohaler ® (Formoterol & Budesonide) DuoResp Spiromax ® (Formoterol & Budesonide) Fostair ® – (Formoterol & Beclometasone)

Formulary LABA/ICS Seretide Accuhaler ® (Salmeterol & Fluticasone propionate) AirFluSal Forspiro ® (Salmeterol & Fluticasone propionate) MDI NEXThaler Symbicort Turbohaler ® (Formoterol & Budesonide) DuoResp Spiromax ® (Formoterol & Budesonide) Fostair ® – (Formoterol & Beclometasone)

Asthma COPD Overlap Syndrome (ACOS) Management Older age group Childhood asthma Significant smoking history Main therapeutic difference is to use LAMA earlier (than if pure asthma) And to use lower doses of ICS (than if pure COPD)

Tips for prescribing in COPD Always check inhaler technique Remember non-pharmacological interventions (PR) Inhaled corticosteroids only for: co-existent asthma frequent exacerbations despite other measures If use ICS, aim for low steroid burden Always include a spacer for mdi prescription Only make one change at a time Check inhaler technique again!

Where: To get help Secondary Care Management of severe exacerbations (IP) COPD discharge bundle Diagnostic clarification (OPA), assess for additional conditions (ILD, pulmonary hypertension) Assess for referral for home NIV Assess for LVRS / Lung Transplant referral

Integrated Respiratory Service Brighton and Hove Locality Brighton General Hospital Dyke Building Elm Grove Brighton, BN2 3EW Mon-Fri 8am-8pm Sat/Sun/BH 8.30am-4.30pm

Referrals Patients accepted: COPD Asthma – chronic asthmatic patients ILD Bronchiectasis Referral time frame: URGENT within 24 hours – must speak to IRS rapid clinician prior to referral and be reasonable request for visit. ROUTINE within 2-4 weeks Referrals cannot be processed until the team have received: Up to date medical history and drug history Confirmation of diagnosis (Spirometry, PEF diary, CT scan) Lone worker risk specified

Diagnostic confirmation of disease COPD Spirometry must include trace and be reproducible to be accurately interpreted. If CT shows emphysema will accept onto service pending spirometry from PN If the hospital refer we will expect the spirometry to be done by them. If any difficulties with obtaining reproducibility please call IRS to discuss Asthma Spirometry if obstructive with reversibility PEF diary If long standing diagnosis but no diagnostic test available as confirmation of disease to refer to secondary care to confirm Bronchiectasis and ILD CT Scan

IRS Multidisciplinary Team The patient Respiratory Nurses Physios Oxygen practitioners Occupational therapist CBT therapist Respiratory rehab assistant Consultant BSUH COPD Nurse

Purpose of referral Airway clearance – physios will develop individual regimes with/without adjuncts Review inhaler medications – nebs not given to patients who are able to use inhalers Rapid response – after initial assessment patients can self refer if difficulty with their breathing. Patient will be contacted within 2 hours and triaged over the phone. Anxiety – CBT and OT

Pulmonary Rehabilitation Benefits - ↑exercise capacity, dyspnoea, health status, psychological wellbeing, muscle strength. ↓exacerbations Inclusions/exclusions – able to walk 100m, cardiac stable, pain/functional/cognition issues Waiting list – Aim to enroll and start PR within 13 weeks of referral Pre assessment – walk test in clinic, check obs and meds, questionnaires Content – individualised CV and resistance work, education Duration – twice weekly for 6 weeks Venues: Salvation Army, Brighton Tuesday and Friday afternoon 2pm-4pm Portslade Town Hall Monday and Thursday Morning 10am-12pm

Oxygen therapy Referrals LTOT: Spo2 ≤92% at rest and not within 5-8 weeks of exacerbation, SpO2 ≤94% with secondary conditions PH, RSHF, Polycythaemia (to provide Blood Test) Ambulatory: Never urgent referral Palliative: If GP/pall care seen. GP to Px oxygen on Part A and refer in. SpO2 ≤ 92% Risk assessment vital What information would you like in Oxygen clinic letters?

End of life care Identifying patients: gold standard framework (recurrent admission, LTOT, MRC 4/5, RSHF, NIV, Low BMI, >6 weeks steroids in last 6/12) Breathlessness Mx – oromorph (side effects)/fan therapy Anxiety Mx – lorazepam Cough Mx - Simple linctus-codeine linctus-oramorph-methadone 2-4mg nocte (long half life) IBIS – upload ACP, inform paramedic crew re: DNAR and situation. Reduce unecessary hospital admissions DNAR – clinician will contact GP to do following discussion