1. 20 minute update Asthma and COPD
Jo Congleton
Consultant in Integrated Respiratory Care

2. 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

3. 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

4. Asthma: Eosnophilic bronchitis
Adapted from British guideline on the management of asthma Available from: (accessed Oct 2016)

5. 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 yrs
Flat PEFR chart
Constant symptoms
Progressive SOB
Little / no reversibility
Significant smoking history
Spirometry confirms AFO

6. 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)

7. 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

8. TTrash Can

9. 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:

10. 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

11. 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

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

13. Pulmonary Rehabilitation
Salvation Army, Tues and Friday
Portslade Town Hall Mon and Thurs
supervised exercise training (the core of PR)
comprehensive educational programme
psychosocial support

15. 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

16. The low value pyramid

17. 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!

18. Asthma Management: Moving up and moving down
Adapted from British guideline on the management of asthma Available from: (accessed Oct 2016)

19. British guideline on the management of asthma Available from (accessed October 2016)

20. British guideline on the management of asthma Available from (accessed October 2016)

21. High Dose Inhaled Steroids B+H CCG vs National

22. PAAP

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

25. 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