20 minute update Asthma and COPD Jo Congleton Consultant in Integrated Respiratory Care

COPD Definition GOLD 2018 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 Spirometry Typical Symptoms Post bd FEV1:FVC < 70% Exposure to risk factors (age,significant smoking history) Typical Symptoms (dyspnoea, cough, sputum, production) AND

Asthma: Eosnophilic bronchitis Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)

Clinical Features Asthma COPD Wheezy Child DV PEFR chart Day to day variation b2 reversibility Steroid reversibility Atopy, Family History Mild eosinophila Spirometry may be normal Onset 35- 55yrs Flat PEFR chart Constant symptoms Progressive SOB Little / no reversibility Significant smoking history Spirometry confirms AFO

Asthma COPD Overlap (ACO) Older age group Childhood asthma / convincing asthma history Significant smoking history Airflow obstruction Main therapeutic difference is to use LAMA earlier (than if pure asthma) And to consider low dose ICS (cf COPD)

Spirometry Interpretation: In Six Steps 1. LOOK AT VOLUME TIME TRACE, Is it physiological or should it be thrown in the trash can? 2. If physiological LOOK AT FLOW VOLUME TRACE. Does it look normal, obstructive or restrictive? 3. Note FEV1/FVC ratio 4. Does the ratio match your visual assessment? 5. If FEV1/FVC < 70% (obstructive) calculate severity of AFO (FEV1 % predicted) 6. Is VC reduced (<80%)? If so can you explain this clinically e.g. secondary to hyperinflation, chest wall deformity or obesity? If not consider restrictive disorder

TTrash Can

Normal flow-volume curve On exhalation, there is a rapid rise to the maximal expiratory flow followed by a steady, uniform decline until all the air is exhaled. Obstructive disorder: Severe obstructive disorder:

Exacerbations Symptoms High risk, less symptoms LAMA LABA/LAMA (LABA/ICS) High risk, more symptoms (LAMA) 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 Symptoms 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

Presence of 2 major symptoms for at least 2 days Exacerbation … a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Major symptoms Dyspnoea Sputum volume Sputum purulence Presence of 2 major symptoms for at least 2 days NICE COPD Guidelines 2010 11

Treatment of exacerbations Increased bronchodilators Corticosteroids Oral antibiotics if 3 majjor symptoms (sputum purulence) (Manage Respiratory Failure) Early treatment

Pulmonary Rehabilitation Salvation Army, Tues and Friday 14.00-16.00 Portslade Town Hall Mon and Thurs 10.00-12.00 supervised exercise training (the core of PR) comprehensive educational programme psychosocial support

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.’ 15 15

The low value pyramid

Make the most of COPD annual reviews Get the patients to bring in their meds to check inhaler technique Check the diagnosis is correct If have quality spirometry, hand held FEV1 is fine Think about stopping or reducing dose of medication Check patient undertsands Exacerbation Action Plan Consider PR referral for MRC3 and above Consider CRS referral if frequent exacerbations, high symptom burden, advanced COPD Don’t let the GPs do them!

Asthma Management: Moving up and moving down Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)

  British guideline on the management of asthma. 2016. Available from https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (accessed October 2016)

  British guideline on the management of asthma. 2016. Available from https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (accessed October 2016)

High Dose Inhaled Steroids B+H CCG vs National

PAAP

Asthma Out of Control Inhaler technique Compliance Drugs Occupation Allergens Wrong or 2nd diagnosis Rhinitis GORD Vocal cord dysfunction Asthma PLUS ABPA Churg Strauss

https://www.rightbreathe.com

Key points Unless we make the correct diagnosis we cannot manage the patient correctly Don’t let spirometry phase you - follow the 6 steps ICS are indicated in (nearly) all asthma patients ICS are rarely indicated in COPD (but often prescribed) HDICS are associated with adverse events (and are expensive) All regular MDI prescriptions should include check that patient has an up to date spacer AND is using it Remember non-pharmacological therapies