Alyn Morice University of Hull HYMS

1. COPD Disease not Disorder? Alyn Morice University of Hull HYMS

2. What is COPD? Asthma (eosinophilic bronchitis) Chronic Bronchitis (neutrophilic bronchitis) Emphysema

3. 2010

4. Page 1 of 673!

5. COPD Treatment Pathway Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio <70%) Establish severity of disease by FEV1 as % predicted Management of RISK FACTORS plus EDUCATION plus IMMUNISATION SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised) PHARMACOLOGICAL TREATMENT Review at each step after one month before escalating treatment SHORTNESS OF BREATH COUGH AND SPUTUM prn short acting β2 agonist MUCOLYTICS THEOPHYLLINE Tiotropium + short acting β2 agonist Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Consider Palliative Care Referral in End Stage Disease

6. Telemonitoring in COPD – the evidence base • Numerous pilot projects with accompanying evaluation reports; • Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions) • Often methodologically limited (e.g. before-and-after studies; small sample sizes) • Systematic reviews demonstrate that high-quality evidence base is still immature; • Bolton (2010): studies included were positive but of a low-quality • Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations

7. Evaluation… • Evaluation of first 3 months deployment (24 patients) showed: • - Patient satisfaction generally very good • - 68% reduction in n/e admission costs • - net saving per month • - achievement of £0.5m QIPP saving feasible • Evaluation by Hull University – full year evaluation due Dec 11

8. The East Riding Model IDENTIFY GP’s/NCT Patient at risk of deterioration REFER MONITOR 1. Referral for telehealth intervention 2. Patient registered & unit installed 1. Monitoring • Risk stratification identifies patient • MDT agrees intervention RESPOND Telephone patient Visit - within identified timescale Emergency Response Step up / Step down Community Beds 2. Alerts 3. Triage 4. Response Protocols for response in place: GP, NCT , specialist services, secondary care

9. Telemonitoring in COPD – How can it work?

10. Telemonitoring in COPD – suggested mechanisms of action • It has been suggested that telemonitoring can support COPD patients by; • Providing reassurance and support

12. Telemonitoring in COPD – suggested mechanisms of action • It has been suggested that telemonitoring can support COPD patients by; • Increasing knowledge of disease process and enhancing self-care • Providing reassurance and support

13. Roger • 64 year old with chronic, severe COPD • Housebound and anxious • Frequently uses standby medication • Frequent hospital admissions – anxiety rather than healthcare need • Distrustful of clinicians due to previous experience • After telehealth: • Telephone contact to reassure • Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns • More proactive about asking for help • Reduced hospital admissions

14. Telehealth then...

15. Telemonitoring in COPD – suggested mechanisms of action • It has been suggested that telemonitoring can support COPD patients by; • Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms) • Increasing knowledge of disease process and enhancing self-care • Providing reassurance and support

17. 1.0 0.8 0.6 0.4 0.2 0 0 10 20 30 40 50 60 The impact of frequent COPD exacerbations - more frequent attacks increase mortality n=304 A p<0.0002 Survival probability B p<0.0001 p=0.069 C Time (months) Group A: no exacerbations Group B: 1–2 exacerbations Group C: ≥3 exacerbations Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

18. COPD patients with productive cough More likely to have exacerbations Seemungal TA et al. Am J RespirCrit Care Med 98 More rapid decline in lung function Vestbo J 1996, KannerRA et al. Am J RespirCrit Care Med 01 More likely to die early Prescott E et al. EurRespir J 1995

19. Timing of symptoms: when was each symptom the most troublesome? 40 30 20 10 0 Cough (n=1,433) Breathlessness (n=1,769) 50 40 30 20 10 0 48.9 31.0 24.0 22.5 % of patients % of patients 19.5 22.3 18.7 17.3 14.9 10.6 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening 40 30 20 10 0 Phlegm (n=1,551) Chest tightness (n=690) 60 50 40 30 20 10 0 56.7 28.8 25.9 25.4 25.5 % of patients % of patients 26.2 16.7 16.6 16.3 11.8 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening Partridge et al. ERS Vienna 2009

20. HULL AIRWAYS REFLUX QUESTIONNAIRE Name: D.O.B:____________________________ UN: _________________ DATE OF TEST: Please circle the most appropriate response for each question www.issc.info TOTAL SCORE_____________ /70

21. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

22. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

23. Waveforms showing acoustic events – Pre and post filtering unprocessed file processed file

24. Cough counting in exacerbations of COPD • Day 1 546 coughs • Day 5 162 coughs

25. Futureof telemonitoring in COPD