‘Moving in the right direction’ Dr Nawaid Ahmad Clinical Lead for Community Respiratory Services in T&W Consultant Chest Physician @SaTHNHS Undergraduate Clinical Tutor Keele University nawaid.ahmad3@nhs.net @nav_doc

Lets DO it! SaTH Consultants Local GPs Event date to be finalized Will send an email to all through the organizers to gain expression of interest Lets DO it!

Why am I here today? Talk about COPD Look at some local data and opportunities for improvement Discuss the new local COPD guidelines Discuss a pathway for weaning COPD patients from Inhaled corticosteroids Discuss some interesting cases End the session with Q&A

Exertional Breathlessness Diagnosing C O P D Elderly Young RISK FACTORS SPIROMETRY SMOKING 45-50% Indoor Air pollution 20% HISTORY Winter Bronchitis Chronic Cough Exertional Breathlessness Age>35 Alpha-1 Lung dev. Chronic Asthma Marijuana Post bronchodilator spirometry Beasley et al. Smoking and COPD: what really are the risks? ERJ 2006 NICE COPD Pathway

Type 2 Respiratory failure COPD spectrum Emphysematous Obese Bronchitic Type 2 Respiratory failure Overlap With Sleep Apnea Colonizers Asthma Overlap Recurrent Exacerbrators Bronchiectasis Aspergillus Atypical TB So you can imagine that one treatment may not fit all the groups. Hence the need for individualized treatments for different patients or groups of patients. Frail End of Life Heart Failure

"We treat it. If she[he] gets better we know that we're right."

Challenges Time Validated Spirometry Asthma Confirmation bias Patient demands Occupational exposure in non smokers e.g. bakers

Smoking 18+ yrs self reported smokers (%) Smoking quit rates/100000 population aged 16+ years

COPD I Estimated Prevalence (%) Reported to Estimated Prevalence (%)

COPD II Diagnosis confirmed by Spirometry (%) Record of FEV1 in the last 12 months (%) Problem lies here. How do you confirm the diagnosis with just an FEV1?

Prescription of Inhaled Corticosteroids Worrying as ours is static as others are already deprescribing Source: Openprescribing.net

Influenza and Pneumonia Spend (£ per 1000 population) COPD patients who have had Flu immunization (%) Chronic lower respiratory non-elective spend (£ per 1000 population)

Respiratory Focus Pack Apr 2016 Opportunities Summary

THERE IS NO INCREASE IN MORTALITY CLASS EFFECT AND ALSO ASSOCIATED WITH A HIGHER DOSE More with Fluticasone (SERETIDE) than with Budesonide (SYMBICORT) THERE IS NO INCREASE IN MORTALITY

KARMA DEONTOLOGY

Guidelines

Treating Phenotypes

GOLD GUIDANCE

NICE Guidance 2015

ICS is NOT the first line treatment for patients with COPD RED ALERTS ICS is NOT the first line treatment for patients with COPD ICS is THE first line treatment for patients with Asthma

Inhalers SABA LABA SAMA LAMA ICS

REFERRAL TO SECONDARY CARE CHAOTIC DON’T KNOW WHAT TO DO COMPLEX REFERRAL TO SECONDARY CARE SIMPLE GUIDELINES P elsek, T Greenhalgh The challenge of complexity in health care. BMJ 2001;323:625-8

Cases

Mr Joe Bloggs 67 year old gentleman Previous HGV driver, now retired Ex-Smoker 40 pack years. Stopped 5 years ago BMI 30 Short of breath on exertion for last 5 years, getting worse Gets chest infection in the winters FEV1 1.23 Ltrs (60%) ratio: 0.5 (Post BD)

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Mrs Bloggs 69 year old lady Worked as a cleaner Ex-smoker 30 pack years, quit 2 years ago Shortness of breath and cough for 5 years FEV1 1.2 Ltrs (55%), FVC 2.6 Ltrs (70%) ratio 0.46 (Post BD) No hospital admissions. Already taking Serevent (LABA) and Ventolin inhalers

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Mr XYZ 45 yr old male Tree Surgeon Ex smoker 12 months, 25 pack years of smoking Short of breath, chest tightness, gets hay fever and coughs in presence of wife’s perfume Had Asthma as a child but grew out of it No hospital admissions and no antibiotics FEV1 1.8 Ltrs (45%), ratio 0.4. 30% reversibility. Taking LABA and Ventolin PRN but no better, comes for review

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