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

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

3. 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

4. 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

5. 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

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

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

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

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

12. 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?

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

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

19. Respiratory Focus Pack Apr 2016
Opportunities Summary

20. 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

21. KARMA
DEONTOLOGY

22. Guidelines

23. Treating Phenotypes

24. GOLD GUIDANCE

26. NICE Guidance 2015

30. 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

31. Inhalers
SABA
LABA
SAMA LAMA
ICS

32. 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

33. Cases

34. 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
FEV Ltrs (60%) ratio: 0.5 (Post BD)

35. Switch to Menti

36. 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

37. Switch to Menti

38. 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 % reversibility.
Taking LABA and Ventolin PRN but no better, comes for review

39. Switch to Menti