1. Gold standard COPD care
Jacqui Carrett
Respiratory Clinical Lead

2. Aim of the session Overview of COPD and the treatments available
Leave the session with at least one piece of information that you did not know at the start of the session

3. Drivers Local and National guidelines/priorities
NICE quality standards for COPD
NICE clinical guidance for COPD
NHS outcomes framework
Outcomes strategy for COPD and Asthma
QOF

4. 2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011
COPD
One person dies from COPD every 20 minutes in England1
UK mortality rates remain considerably higher than the European average 1
15% of those admitted to hospital with COPD die within 3 months and around 25% die within a year1
Under diagnosis – estimated to be 2 million un- diagnosed 2
1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.
2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011

5. 2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011
Cost – COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS 1
80% of people with COPD have at least one other long-term condition. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and / or an anxiety disorder 1
24 million working days are lost each year from COPD with 3.8 billion lost through reduced productivity1
1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.
2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011

6. COPD
COPD is an umbrella term – comprises of emphysema, chronic bronchitis and small airways disease, and some cases of chronic asthma
COPD is characterised by accelerated decline in lung function
Patients are not normally aware of a problem until half their lung function is lost

7. Symptoms Breathlessness on exertion Cough
Sputum production – common but not universal
Wheezing – rarely wheeze at rest and are not woken at night by wheeze
Recurrent chest infections

8. Diagnosis
There is no single diagnostic test and very often there are no physical signs

9. Diagnosis Consider a diagnosis of COPD if patient is:
over 35 years age
presence of a risk factor (normally smoking)
typical symptoms – breathlessness on exertion, cough, frequent winter bronchitis
absence of clinical features of asthma
Airflow obstruction Confirmed by post bronchodilator SPIROMETRY

10. Quality assured spirometry
Be aware of the relative contraindications
Patient must be clinically stable for diagnostic spirometry
Inhalers must be withheld for diagnostic spirometry
Ideally one person at the practice is accredited
Regular calibration / verification using a 3 litre syringe
Regular cleaning

11. Calibration record Transducer Serial number Device serial number Date
Time
Calibration volume
Volume difference
Pass / fail
signature
38773
69057
3.2.14
13.05
3 litres
Exp: -2%
Insp: +1.7%
pass
4.2.14
12.58
Exp: +2.7%
Insp: +2.3%
5.2.14
12.31
Exp: -2.3%
Insp: + 1.7%
- 1.7%
6.2.14
12.53
Exp: -1.7%
Insp: +2%
7.2.14
13.01

12. Cleaning record Date Transducer Serial Number Cleaned Disinfection
Batch number
Expiry
date
signature  
 10584
 yes
 no
 warm soapy water
 N/A    
 5/2018

13. Spirometry RVC – relaxed vital capacity
FEV1 - forced expiratory volume in 1 second
FVC – forced vital capacity
There should be no more than 100mls / 5% variation between the highest two blows
FEV1 FVC ratio or FEV1 RVC – less than 70% demonstrates airflow obstruction

14. Treatment Smoking cessation
Inhaled therapies – bronchodilators are the mainstay of treatment – LABA, LAMA, combination inhalers – ICS/LABA
Need right device for the patient
Be aware of dexterity problems – use of haleriad with MDI’s
Pulmonary rehab
Oxygen therapy

15. Pulmonary rehab 8 week programme of exercise and education
Suitable for those patients with an MRC 3 and feel functionally disabled by their breathlessness or
those with an MRC 2 that are having frequent exacerbations
Inclusion and exclusion criteria
New address

16. Oxygen therapy
Indicated if resting sats < 92% and on maximal inhaled therapy
Refer to the home oxygen assessment and review nurse
Referral form
Either fax or send via
Not an emergency service

17. Exacerbations

18. Definition – ‘sustained worsening’
Important events that carry significant consequences for patients
It is recognised that some patients are more susceptible to exacerbations ‘frequent exacerbators’
Occurs across disease severities
Many exacerbations go un-reported by patients
Many are over treated ?

19. causes A third due to viral infection
A third due to bacterial infection
A third – no known cause identified – cold weather, atmospheric pressure, ‘huddle factor’ – more common in the dark months Nov-march

20. Risk factors Susceptibility to viral infections
Genetic pre-disposition of exacerbation susceptability
Non-adherence to medications
Low BMI
Advanced disease
Gastro-esophageal reflux disease (GORD) - growing evidence to suggest it plays an important role in exacerbations
Depression

21. Treatment
First step - Increase bronchodilator – up to 4 puffs qds – some patients may need a nebuliser
If just an increase in symptoms / thought to be ‘viral’ start prednisolone 30mg for 5 days - 2 weeks
If phlegm changes colour - start antibiotics and prednisolone –amoxicillin 500mg tds for 5 days/Doxycycline 200mg stat 100mg OD for 4 days or as prescribed by HCP

22. Self management plans / action plan
Allow enough ‘time’
Ensure partnership working
Important that we all give the same message
Definition of ‘exacerbation’ or ‘flare up’
Causes of an exacerbation
Signs and symptoms
Action to be taken – must be personalised
What to do if that does not work
List of triggers
How to prevent
Useful numbers

23. Self management / prevention
Important for the patient to know what is ‘normal’ for them
Quit smoking – no matter at what stage benefits can be obtained
Avoid second hand smoke
Ensure patients have a ‘one off’ pneumovax and yearly flu jab
Exercise regularly - keep body strong – pulmonary rehabilitation
Advise to stay away from anyone with a cold - avoid crowds

24. Wash hands frequently, use hand sanitiser and practice good hygiene
Get to know what their triggers are – look at the weather forecasts and plan accordingly
Stay indoors and close windows on bad air pollution days
Avoid extremes of temperatures – cold snap
Winter months – keep cupboards stocked
Aim to keep bedroom at 18 0C – windows closed

25. Use of a ‘handheld’ fan in heat / help manage breathlessness
Healthy diet – nutrition is so important - plan ahead with meals be prepared
Watch alcohol limits – drinking more than 3-4 for men and 2-3 for women a day can increase the risk of pneumonia
Compliance with medication – correct inhaler technique
‘Standby meds’ at home
Regular review
Support

26. Remember Prompt treatment is vital Breathlessness is part of COPD
The more the patient Understands their condition the better they will be able to ‘self manage’
Don’t forget the value of a support network – ‘Breathe easy’ – they all understand each others symptoms , share information and support one another
It can take up to 3 months to fully recover from an exacerbation
Not everyone is happy to ‘self manage’

27. Any questions?