Deep breath and blow - the HCA role in respiratory care Hilary Andrews Nurse Advisor Woodlands Health Centre Paddock Wood, Kent What a title! Who am I Stress – not a full blown training session on practical use of spirometer. Training and Assessment of Competence elsewhere after this session

Respiratory Care Lung Function Tests Health Promotion Peak Flow (PEFR) Asthma Spirometry COPD – Monitoring, QOF Reversibility testing – to exclude asthma Opportunistic – Over 35yrs, asthmatic coughing smokers Health Promotion What do I mean by Respiratory Care? Why might someone need Respiratory Care? Patient scenarios Explain that in some practices HCAs help out in asthma or COPD clinics At other practices patients are booked in to see the HCA for spirometry alone and then return to see Dr or Practice nurse with results Opportunistic Spirometry

The Respiratory System Nasal Cavity Pharynx Larynx Trachea Right Bronchus Left Bronchus Right Lung Left Lung Heart Position

Asthma Tightening of muscles surrounding bronchiole causes Bronchospasm Allergens cause inflammation which further narrows airway Secretions Explain the terms:- Inflammation Bronchospasm – Intermittant Get them to breath through straws but explain ‘straw-wider-straw-wider’ Allergic triggers Diurnal variation Asthma Attack

COPD Chronic Obstructive Airways Disease Umbrella term for Emphysema and Chronic Bronchitis Walls of alveoli break down with loss of surface area COPD is an umbrella term used for Chronic Bronchitis and Emphysema Major cause – Smoking LETTER NEXT

Other respiratory terms Pack Years An estimation of the amount someone has smoked Dyspnoea Difficulty Breathing Orthopnoea Breathlessness relieved by sitting upright LTOT Long Term Oxygen Therapy Expectorating Coughing up sputum Haemoptysis Coughing up blood Exacerbation Increase in severity of a disease Cyanosis Blueness of skin Transcutaneous Oxygen Saturation Concentration of oxygen in the blood measured through the skin FEV1 Forced Expiratory Volume in 1 second (often expressed as % predicted) FVC Forced Vital Capacity (often expressed as % predicted) Preventers Medication given to prevent inflammation of airways eg steroids Relievers Medication given to relieve obstructed airways eg bronchodilators – salbutamol CXR Chest X-ray

PEFR Peak Flow demonstrates maximum flow rate of lungs What device is used? Peak Flow Meter Technique? ‘Fast Blast’ not ‘Slow Blow’ Limitations Insufficient effort Poor seal Not horizontal When can it be performed? Anytime, at home, in surgery, after exercise etc PEFR Diary Demonstrates – The key diagnostic tool for asthma Technique – Explanation Demonstration New Mouth Piece Horizontal Check zero Tight Seal ‘Fast Blast’ not ‘slow blow’ Record highest reading Reasons for inaccuracy:- Insufficient effort Tight seal not maintained Peak Flow meter Not held horizontally

Peak Flow Diary

Spirometry Spirometry demonstrates airflow obstruction Devices New Diagnosis COPD Monitoring COPD Devices Contraindications Technique & Accuracy Spirometry assess lung function by measuring the volume of air that the patient is able to expel from the lungs after a maximal inspiration. It is the most effective way of determining the severity of COPD. Useful for early detection of COPD (Onset of symptoms slow and insidious - many smokers initially put symptoms of COPD down to the smoking) Preparing the Patient

Spirometers

Contraindications to Spirometry Pneumothorax or within 2 weeks of resolution Following recent MI Unstable angina Haemoptysis Following recent eye surgery Following recent abdominal or thoracic surgery Following recent CVA Previous vasovagal episodes Cervical Disc problems Ruptured tympanic membrane in last 6 months

Other points to consider prior to Spirometry Chest infection in last four weeks Alcohol in last four hours Vigorous exercise in last 30 minutes Is clothing restrictive? Large meal eaten in previous 2 hours?

Technique and Accuracy Calibration of spirometer New mouthpiece Checklist Prepare the patient Standing preferably Breathe in as deeply as possible Blow breath out forcibly, as hard and fast as possible Keep blowing! Repeat at least twice Check for consistency in trace Store or print results Checklist useful for contraindications and also What information is needed to make calculations – sex, age, height, ethnic origin, recent exacerbation, use of inhalers Demonstrate Do a couple of practice goes (limit total goes to 8 though) Pinch nose or where nose clip Blowing breath out can take up to 15 seconds (especially in severe COPD) Repeat until best two readings are within 100mls or 5% of each other You may be asked to measure Vital Capacity (VC) – Full inspiration followed by slow full expiration – maybe for patients unable to perform FEV1 or FVC

Normal Spirometry Trace

Identifying abnormal spirometry traces Slow start to forced expiration Coughing during exhalation Other inaccuracies include:- Inadequate inhalation Lack of force Lips not tight around mouthpiece Breathing out through nose Extra breath taken during test Early stoppage of test

Health Promotion 900,000 people diagnosed with COPD in UK 450,000 estimated as being undiagnosed Cost of COPD to NHS £982,000,000 estimated cost/year (2004)

Health Promotion Therefore:- Smoking Offer help to stop smoking at every opportunity Smoking cessation allows the rate of decline in lung function to return to that of non-smoker Recognition of other problems that may be affecting the patients quality of life Get straws out again and give out sweets. Get them to try to eat sweet while breathing through straw (holding nose preferably so they cant cheat)

For more information ‘Spirometry in practice - A practical guide to using spirometry in primary care’ The BTS COPD Consortium www.brit-thoracic.org.uk www.patient.co.uk www.wipp.nhs.uk