1. Obstructive Airways Disease Asthma and COPD Dr H Ahmad VTS 29/04/2009

2. Definitions: Asthma: It's a chronic respiratory condition that causes the airways to constrict become inflamed and collect mucus. It can be triggered by natural allergens, cigarette smoke, pets, exercise or emotional stress. COPD: is characterized by air flow obstruction. The airflow obstruction is usually progressive, not fully reversible and doesn't change markedly over several months. The disease is predominantly caused by smoking.

3. Diagnosis of COPD It should be considered in patients over the age of 35 who have a risk factor, generally smoking, and who present with exertional dyspnoea, chronic cough, regular sputum production, frequent winter bronchitis or wheeze. The presence of airflow obstruction should be confirmed by performing spirometry. All health professionals should be competent in the interpretation of the results

4. COPD contd. Airflow obstruction is defined as a reduced FEV1 and reduced FEV1/FVC ratio, such that FEV1 is less than 80percent predicted and FEV1/FVC is less than 0.7. The airflow obstruction is due to a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction and lung damage may be present before the individual is aware of it. COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on airflow obstruction.

5. COPD contd: Other symptoms Weight loss Effort tolerance Waking at night Ankle swelling Fatigue Occupational hazards Chest pain Haemoptysis

6. MRC dyspnoea scale Grade 1. Degree of breathlessness except on strenuous exercise. Grade 2. Short of breath when hurrying or walking up a slight hill. Grade 3. Walks slower then contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. Grade 4. Stops for breath after walking about 100meters or after a few minutes on level ground. Grade 5. Too breathless to leave the house, or breathless when dressing or undressing.

7. Investigations of COPD Spirometry CXR FBC BMI Additional investigations: serial PEFR, alpha-1 antitripsin, CT Scan thorax, ECG, Echocardiogram, pulse oximetry, sputum culture if sputum persistently purulent.

8. HistoryCOPDAsthma Smoker or ex-smokerAlmost always Possibly Symptoms under age 35RareCommon Chronic productive coughCommonUncommon BreathlessnessPersistent/ Progressive Variable Night time waking with sob and wheeze UncommonCommon Significant diurnal or day to day variability of symptoms UncommonCommon

9. Assessment of severity of COPD MILD AIRFLOW OBSTRUCTION MODERATE AIRFLOW OBSTRUCTION SEVERE AIRFLOW OBSTRUCTION FEV1 50-80% PREDICTED FEV1 30-49% PREDICTED FEV1 <30% PREDICTED

10. Management of COPD Quit smoking Short acting bronchodilator – beta-2 agonist or anticholinergic Combination of the above inhalers Long acting beta-2-agonists or long acting anticholinergic In moderate to severe COPD; if symptoms persist, with at least two exacerbations requiring oral antibiotics and steroids, consider a combination of a long-acting beta-2 agonist and inhaled corticosteroid; discontinue if no benefit after 4 weeks If still symptomatic-consider adding Theophylline Mucolytics e.g. carbocystiene

11. Devices to Deliver Medications Delivery system used to treat patients with stable COPD: Several devices are available – best may be MDI with a spacer. Make sure the technique is good with regular checks. Nebuliser therapy should not continue to be prescribed without proper assessment. LTOT: PO2 <7.3KPa or PO2 between 7.3 to 8KPa with secondary polycythaemia, nocturnal hypoxia i.e. less then 90% SaO2 for more than 30% of time, peripheral oedema or pulmonary hypertension.

12. Cor pulmonale COPD associated with peripheral oedema, A raised venous pressure, a systolic parasternal heave and loud second heart sound. These patients need to be considered for LTOT, diuretics, ACE inhibitors, calcium channel blockers, alpha blockers and Digoxin

13. Pulmonary rehabilitation This should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention.

14. Other therapies Vaccination Lung surgery Physiotherapy Management of anxiety and depression Nutritional factors Exercise Palliative care Assessment for occupational therapy Social services Self-management - Rescue packs etc Follow up of patients with COPD- AT LEAST TWICE A YEAR IN GP PRACTICE Need spirometry once a year etc. Multi-disciplinary team - unique care

15. ReasonPurpose There is diagnostic uncertainty confirm diagnosis and optimise therapy Suspected severe COPDConfirm diagnosis and optimise therapy The patient requests a second opinion. Confirm diagnosis and optimise therapy Onset of cor pulmonaleConfirm diagnosis and optimise therapy Assessment for oxygen therapy Optimise therapy and measure blood gases Assessment for long-term nebuliser therapy Optimise therapy and exclude inappropriate prescriptions Assessment for oral corticosteroid therapy Justify need for long-term treatment or supervise withdrawal Bullous lung diseaseIdentify candidates for surgery Reasons for Referral to Secondary care

16. ReasonPurpose A rapid decline in FEV1Encourage early intervention Assessment for pulmonary rehabilitation Identify candidate for rehab Assessment for lung transplantation To identify candidates for surgery Age under 40 or a family history or alpha-1 antitripsin deficiency Consider therapy and screen family Uncertain diagnosisMake a diagnosis Frequent infectionsExclude bronchiectasis HaemoptysisTo exclude carcinoma Reasons for Referral to Secondary care contd.

17. Use short acting bronchodilator prn (either beta-2-agonist or anticholinergic) If still symptomatic, try combined therapy with a short-acting beta-2-agonist and short-acting anticholinergic If still symptomatic, use a long-acting bronchodilator (beta-2-agonist or anticholinergic) In moderate or severe COPD: If still symptomatic, consider a combination of a long-acting beta-2-agonist and inhale corticosteroid (discontinue if no benefit after 4 weeks) If still symptomatic- consider adding theophylline Consider mucolytic agents if patient complains of thick, tenacious sputum which is hard to cough up Guide to Therapy

20. No.IndicatorPointsPayment Stages COPD 1 The practice can produce a register of patients with COPD 3 COPD 12 The percentage of all patients with COPD diagnosed after 1 st April 2008 in whom the diagnosis has been confirmed by post- bronchodilator spirometry 5 40-80% COPD 10 The percentage of patients with COPD with a record of FEV1 in the previous 15 months 7 40-70% COPD 11 The percentage of patients with COPD received inhaled treatments in whom there is a record that inhaler technique has been checked in the previous 15 months 7 40-90% COPD 8 The percentage of patients with COPD who have had influenza immunisation in the preceding 1 st September to 31 st March 6 40-85% QOF indicators and points for COPD

21. QOF Indicators and points for Asthma IndicatorPts Max. Threshold ASTHMA 1. The practice can produce a register of patients with asthma excluding patients with asthma who have been prescribed no asthma related drugs in the last twelve months 7 ASTHMA 2. The percentage of patients age eight and over diagnosed as having asthma from 1st April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement 15 70% ASTHMA 3. The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months 6 70% ASTHMA 4. The percentage of patients age 20 and over with asthma whose notes record smoking status in the past 15 months except those who have never smoked where smoking status should be recorded at least once 6 70% ASTHMA 5. The percentage of patients with asthma who smoke, and whose notes contain a record that smoking cessation advice has been offered within last 15 months. 6 70% ASTHMA 6. The percentage of patients with asthma who have had an asthma review in the last 15 months 20 70% ASTHMA 7. The percentage of patients age 16 years and over with asthma who have had influenza immunisation in the preceding 1st September to 31st March 12 50%

22. Tasks 1.How would you achieve maximum QOF points in patients with COPD in your practice? 2.How would you achieve maximum points in patients with asthma in your practice? 3.How would set up an asthma clinic in your practice? Include various equipment required and staff involved in achieving this task 4.How would you audit asthma control in your patients in your practice? Focus on one or two criteria. Complete audit cycle