Spirometry interpretation and COPD treatments Hetal Dhruve Chandra Sarkar

Aims Overview of spirometry and interpretion Treatment of COPD COPD Care plans Questions

Why spirometry? Discrepancy in prevalence of COPD from rightcare/ population modelling suggest there are a number of undiagnosed cases in hackney. Incorrect diagnosis Useful tool in disease progression monitoring Poor quality of spirometry –performance and interpretation Accreditation This session does not qualify you to be on the register

Basis function of the lungs Provide oxygen to the cells of the body To remove carbon dioxide from the body Few non-respiratory functions e.g. acid-base homeostasis, speech, some metabolism, filtering of toxic material, etc

Lung dysfunction Obstructive and Restrictive patterns can arise from 1 of 5 abnormalities: Respiratory disorders Airway disease Pleural cavity Chest wall Muscle disorders

Asthma and COPD Asthma: a heterogenous disease, usually characterised by airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA 2016) COPD: is a common preventable disease, characterised by persistent airway limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients (GOLD 2018).

Persistent and progressive Asthma and COPD   Asthma COPD Smoker or ex-smoker Nearly all Possibly Symptoms under age 35 Rare Common Chronic productive cough Uncommon Breathlessness Persistent and progressive Variable Night-time waking with breathlessness and/or wheeze Significant diurnal or day-to-day variability of symptoms

Diagnosis Measures flow (l/s) against volume (L) Important part of a spirometry report A quick way of distinguishing between normal, obstructive & restrictive COPD – always obstructive (unless v. severe COPD; mix of Obstruction and restriction)

Spirometry results FEV1: Forced expiratory volume in 1 second FVC: Forced vital capacity FEV1/FVC: <0.7 = obstruction Post bronchodilator spirometry: 12% change in FEV1; positive reversibility

FEV1/FVC lower limit of normal Increase in disease – The new definition estimates COPD prevalence at 22% in those aged over 40 years in England and Wales compared with 13% using LLN criteria. Evidence of misdiagnosis and missed diagnosis – Up to 13% of people thought to have COPD on GOLD criteria have been found to be misdiagnosed. Harms from misdiagnosis and missed diagnosis – cardiovascular mortality is unexpectedly high among mildly breathless patients with GOLD-diagnosed COPD GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Report. 2018. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115 2018. https://www.nice.org.uk/guidance/NG115 Eschenbache W in COPD Clinical Perspectives, Panos (Ed), 2014. Open access at https://intechopen.com/books/copd-clinical-perspectives. Cerveri I et al. Thorax. 2008;63:1040–5.

Pathophysiology 2 patterns of dysfunction Asthma; COPD Restrictive Obstructive Reduction in airflow/airflow limitation Asthma; COPD Restrictive Reduction in lung size/increase in lung stiffness Fibrosis; respiratory muscle disease; chest wall disorders

Belinda Breathless 46 F C/O breathlessness on exertion Ex smoker: 1-2/day when at university Weight – 66kg, BMI – 21 FH – sister has asthma Triggers – walking upstairs or rushing for the bus

Slides from Imperial Health College NHS Trust

Test valid. Good effort. Slides from Imperial Health College NHS Trust

FEV1/FVC ratio normal – no obstruction Slides from Imperial Health College NHS Trust

FEV1, FVC & VC all within normal limits – no restriction Slides from Imperial Health College NHS Trust

FV curve looks normal Slides from Imperial Health College NHS Trust

Normal spirometry. No further action. Slides from Imperial Health College NHS Trust

Patient 1: Belinda Breathless 46 F C/O breathlessness on exertion Ex smoker: 1-2/day when at university Weight – 66kg, BMI – 21 FH – sister has asthma Triggers – walking upstairs or rushing for the bus CONCLUSION: normal lung function, no obstruction ? Likelihood of asthma ? Deconditioned/anaemia.

Patient 2: Coughing Carl See trace 1 Age: 52 M PC: Cough, worse at night Ex smoker – 20/day Conclusion: No obstruction, restriction may be due to weight (BM1 31.8) ? Acid reflux ? CXR to rule out lung Ca/other co-morbidities.

Patient 3: Wheezy Wendy See trace 2 Asthma diagnosis since childhood Diagnosed with COPD approx. 4 years ago Ex Smoker Diagnosis?

Patient 4: Phlegmy Phil See trace 3 73 M Weight: 73kg BMI 22.5 PC: Coughing, breathlessness (MRC – 4), CAT – 22, Produces phlegm daily ++ Struggles to cough up Ex smoker.

Patient 5: Tight Timothy See trace 4.

Technique. Good peak. Expiration complete. Reproducible.

FEV1/FVC is reduced = obstruction

VC & FVC reduced – restrictive also? Further testing required

No significant change after salbutamol – no evidence of asthma

Severe obstructive defect Severe obstructive defect. Reduced FVC & VC likely to be caused by such severe obstruction (early airway closure). No BD response – no evidence of asthma. Cannot rule out a combined restriction – refer for further testing.

Accreditation Performing spirometry Interpretation spirometry ?a Hub and spoke model to ensure consistent good quality spirometry

COPD treatment

Aims of treatment Reduce Symptoms: Relieve symptoms Improve exercise tolerance Improve health status Reduce Risk: Prevent disease progression Prevent and treat exacerbations Reduce mortality.

Value Pyramid

‘Breathing, Thinking, Functioning’ model

National Guidelines NICE 2018 guidelines: https://www.nice.org.uk/guidance/ng1 15/chapter/Recommendations#inhale d-combination-therapy GOLD 2019 guidelines: https://goldcopd.org/wp- content/uploads/2018/11/GOLD-2019- v1.6-FINAL-08Nov2018-wms.pdf Both consider phenotyping patients.

Treatments B2: Bind to beta adrenoreceptors, smooth muscle relaxation. Bronchodilators: Beta agonists/muscarinic antagonists B2: Bind to beta adrenoreceptors, smooth muscle relaxation. M3: block bronchocontrictor effects of acetylcholine; smooth muscle relaxation. Anti-inflammatory: Inhaled corticosteroids Reduce inflammation in the airways . POET-COPD trial – 7376 patients, 1 year RCT.

City and Hackney Guidelines

Why Self management plans? Poor evidence – Cochrane Continues to be recommended by NICE Decreases hospital admissions Increases quality of life ACERs Webinar link

NICE guidance Self-management 1.2.120 Develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), and: include education on all relevant points from recommendation 1.2.117 review the plan at future appointments. [2018] 1.2.121 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. [2018]

Why Self management plans? Poor evidence – Cochrane Continues to be recommended by NICE Decreases hospital admissions Increases quality of life ACERs Webinar link

Self Management Plan – C&H

Thanks for listening Any questions