Asthma/COPD 8 th Sept 2011 South Birmingham VTS

1. Asthma/COPD 8th Sept 2011 South Birmingham VTS

2. Homework • Ask GPs in your practice to name patients on the practice list with severe life threatening asthma. • Find out how many patients are on the QOF asthma and COPD lists? • Ask older clinicians (hospital based and GP) about their views on whether asthma is more common/ more severe than it used to be?

3. Homework QOF prevalence for England • Asthma 5.8% • COPD 1.4%

4. Key facts (Asthma UK) • 5.4 million people in the UK are currently receiving treatment for asthma: 1.1 million children (1 in 11) and 4.3 million adults (1 in 12). • There were 1,131 deaths from asthma in the UK in 2009 (12 were children aged 14 years or under). • On average, 3 people per day or 1 person every 8 hours dies from asthma. • An estimated 75% of hospital admissions for asthma are avoidable • On average there are two children with asthma in every classroom in the UK. • The UK has among the highest prevalence rates of asthma symptoms in children worldwide. • The NHS spends around £1 billion a year treating and caring for people with asthma. • As many as 90% of the deaths from asthma are preventable.

5. http://www.patient.co.uk/doctor/Bronchial-Asthma.htm • Asthma diagnoses have become much more common since the 1950s, with childhood prevalence increased by two to three times. • The trend in childhood prevalence appears to have flattened or even fallen recently whilst it remains plateaued in adults. • Incidence (based on new asthma diagnoses from the GP) has risen in all ages to a plateau in the 1990s and subsequently fallen. • Hospital admission rates rose from the 1960s to the late 1980s and are now falling. • There was an asthma death 'epidemic' in the 1960s, particularly amongst children and young adults. This has been ascribed to treatment-related changes. A second, more gradual peak was seen in the 1970s-1980s in adults and mortality has tended to decline since. • A common feature of deaths from asthma is that the patient and/or the medical staff have underestimated the severity of the attack. • It is suggested that 'at-risk' asthma registers in primary care may improve recognition and management of high-risk patients.

6. An ongoing Confidential Enquiry into asthma deaths (under age 65 years) in the Eastern Region of the UK, 2001-2003. • Total study population was 5.25 million. • Only 57/95 notified deaths (60%) were confirmed as asthma deaths. • 311 asthma deaths have been studied between 1988 and 2003. • In 2001-2003, male:female ratio was 3:2. • 53% of patients had severe asthma and 21% moderately severe disease. • In 33% at least one significant co-morbid disease was present. • Monthly death rates peaked in August, with a smaller peak in April. • In 20%, mostly males aged under 20, the final attack was sudden and 10/11 occurred between April and August. • In 81% of cases there were significant behavioural and/or psychosocial factors such as poor compliance (61%), smoking (46%), denial (37%), depression (20%) and alcohol abuse (20%). • The overall medical care of the patient was appropriate in 33% of cases.

7. Thankfully asthma death is relatively rare, but this highlights the need to spot high risk situations and treat patients appropriately Data from the Confidential enquiry: • 57 deaths/3 years approx = 4 deaths/million/year • average GP list approx 1 700 • 4 deaths / per 588 GPs per annum • 1 death per 147 GPs per annum

8. Weekly seasonal indices of general practice episodes and hospital admissions by age group plotted as three week moving averages1990-97 Weekly seasonal indices of general practice episodes and hospital admissions by age group plotted as three week moving averages. (A) 0–4 years; (B) 5–14 years; (C) 15–44 years; (D) 45–64 years; (E) 65 years and over. Fleming D M et al. Thorax 2000;55:662-665 ©2000 by BMJ Publishing Group Ltd and British Thoracic Society

9. Weekly seasonal indices of general practice episodes and deaths by adult age groups plotted as three week moving averages 1990-97 Weekly seasonal indices of general practice episodes and deaths by adult age groups plotted as three week moving averages. (A) 15–44 years; (B) 45–64 years; (C) 65 years and over. Fleming D M et al. Thorax 2000;55:662-665 ©2000 by BMJ Publishing Group Ltd and British Thoracic Society

10. Comparison of the seasonal patterns of asthma identified in general practitioner episodes, hospital admissions, and deathsThorax 2000 • In children aged 0–4 and 5–14 years general practice episodes and admissions to hospital were strikingly congruent in timing and in magnitude, except in September when particularly high rates of admission (absolute and relative to general practice episodes) occurred. In the 15–44 age group there were marked mid summer peaks of general practice episodes and deaths but admissions to hospital were at about the annual average; in September/October there were peaks of episodes and admissions whereas deaths peaked in November. In the 45–64 age group a peak in general practice episodes of asthma was evident in mid summer when admissions were about average and deaths were at a minimum; all three measures tended to increase gradually with the approach of winter. Finally, in those age over 65 years, general practice episodes of asthma, admissions to hospital, and deaths followed similar ‘U’ shaped patterns with substantial peaks in mid winter.

11. COPD – HSE definition (DoH website) • Chronic Obstructive Pulmonary Disease (COPD) is a term used to describe a progressive and irreversible decline in lung function which results in reduced airflow in the lungs. It includes two main diseases: • bronchitis - in which inflammation of the bronchi (tubes carrying air to and from the lungs) both narrows them and causes chronic bronchial secretions; and • emphysema - a permanent destructive enlargement of the airspaces within the lung without any accompanying fibrosis of the lung tissue. • Asthma may also be included within the term COPD if there is some degree of chronic airway obstruction.

12. Epidemiology • Though smoking is the most important risk factor for Chronic Obstructive Pulmonary Disease (COPD), occupational exposures to fumes, chemicals and dusts may together account for around 4000 deaths each year. • Assessed cases of chronic bronchitis and emphysema in coal miners have fluctuated widely from over 3000 cases to a few hundred each year; in 2009 it was 115. • Typically there have been between 20 and 150 estimated cases of chronic bronchitis and emphysema each year reported to THOR by occupational and chest physicians; in 2009 it was 68.

13. Epidemiology contd • COPD is a long-latency disease - meaning that cases tend to develop a number of years after first exposure to the particular causative agents - and in many cases symptoms become manifest during mid-life or later. • The most important causative factor is smoking - but others include occupational exposures to fumes, chemicals and dusts, as well as genetic susceptibility and environmental pollution.

14. COPD mortality • COPD accounts for a substantial number of deaths in Great Britain: it has consistently given rise to between 25,000 and 30,000 deaths each year over the last 25 years. • The number of people suffering from the disease at any given time is difficult to estimate because of different definitions of the disease and under-diagnosis. • One recent estimate suggested that there are currently 900,000 diagnosed cases in England and Wales and that, allowing for under-diagnosis, the true prevalence could be 1.5 million. • However, results from a survey in 2001 estimated the prevalence of COPD, as defined by lung function test, to be much higher than this: an estimated 13.3% (95% CI: 12.6-14.0%) of those aged over 35 years in England had COPD, equivalent to 3.4-3.8 million cases. • Most people in this survey with COPD (as defined by lung function test) did not report having had a diagnosis for respiratory disease.

15. COPD due to Occupational Causes • The multi-factorial nature of COPD and the fact that cases resulting from different causes are clinically indistinguishable means that it is difficult to determine how many cases may be due to occupational exposures. • No detailed assessment is available for Great Britain. However, the estimated proportion of COPD which is work-related based on a recent review of epidemiological studies in various countries was 15%, which confirms estimates of the proportion based on an earlier review. • None of the studies in these reviews were based in Great Britain, however, if this figure is broadly applicable to the British population, this would suggest that there could be around 4000 annual deaths due to COPD resulting from workplace exposures in the past. • Working from these statistics, it is suggested there could be several hundred thousand occupational cases

16. Compensation and Occupational COPD • Various agents and occupational groups have been implicated as being associated with an increased risk of COPD. • Coal dust exposure through mining activities is an established cause of the disease, and cases of chronic bronchitis and emphysema (CBE) in coal workers with a specified level of lung function impairment and at least 20 years underground exposure have been eligible for compensation under the Department for Work and Pensions Industrial Injuries and Disablement Benefit (IIDB) scheme since 1993. • This scheme also compensates those with emphysema arising from exposure to cadmium.

17. Compensation and COPD contd • Epidemiological studies have identified associations between a number of other occupational exposures, including cotton dust, grain dusts and endotoxin, flour dust, welding fumes, other minerals - such as silica and man-made vitreous fibres, other chemicals - such as isocyanates, cadmium, vanadium, and polycyclic aromatic hydrocarbons (PAHs) - and wood dust. • The strength of the evidence about the extent of these risks is variable and of these other agents currently only emphysema in relation to cadmium poisoning is compensatable under the IIDB scheme.

18. COPD and emphysema

19. Explanation of graph • There was a large number of compensation claims for chronic bronchitis and emphysema among coal miners following its specification as a prescribed disease in September 1993. This resulted in a total of over 4000 assessed cases up to the end of 1994. • Numbers fell back in 1995 and 1996 to around 270 per year, which is probably closer to the annual incidence of new cases meeting the DWP criteria. • However, the number then rose dramatically in 1997 and 1998 to over 3000 per year, as a result of a relaxation in the criteria for benefit effective from April 1997, and in association with heightened publicity, particularly following successfully civil litigation in 1998 against the former British Coal Board. • The number of cases fell to 600 in 2000, and since then has declined steadily to 205 cases in 2007

20. Your tasks • Devise a practice formulary for the management of either asthma or COPD • Draw up a practice plan outlining the logistics as to how you will manage patients with either asthma or COPD. Consider staffing issues, equipment ... who? with what? clinics or booked appointments? opportunistic management etc. In your plan consider the range of severity of disease and any special circumstances of your practice.

21. three practices • Rural 5,000 patients in Cumbria, 3 full time partners, one nurse, patients spread over 30 miles, higher than average number of elderly patients, predominantly a farming community • Inner city 15 000 patients in inner city Birmingham, 9 full/part time doctors, 3 nurses, age distribution reflects national average, Many ethnic minority patients including asylum seekers much higher than average levels of deprivation, alcohol problems and drugs problems • Suburban 10 000 patients in a newly developed area (e.g. Monkspath 30 years ago) 7 full/part time doctors, 2 nurses Compact geographical area Few elderly patients, predominantly middle-class families with young children.

22. Rural practice • 5,000 patients in Cumbria, 3 full time partners, • one nurse, • patients spread over 30 miles, • higher than average number of elderly patients, • predominantly a farming community

23. Inner city practice • 15 000 patients in inner city Birmingham, • 9 full/part time doctors, 3 nurses, • age distribution reflects national average, • Many ethnic minority patients including asylum seekers • Much higher than average levels of deprivation, alcohol problems and drugs problems

24. Suburban practice • 10 000 patients in a newly developed area (e.g. Monkspath 30 years ago) • 7 full/part time doctors, 2 nurses • Compact geographical area • Few elderly patients, • predominantly middle-class families with young children.

25. Group a. Asthma, rural practice • Group b. Asthma, inner city practice • Group c. Asthma, suburban practice • Group d. COPD, rural practice • Group e. COPD, inner city practice

26. See pre screening folder for BTS/SIGN asthma guidelines and NICE COPD guidelines

27. Asthma Ideas • Acute asthma attack.....run an emergency on the afternoon? • Hay fever c wheezing, Respiratory Infection c wheezing.., how to treat on merits rather than conventional wisdom? Think about seasonality in asthma? • Step up/step down guidance, pros and cons? • Asthma deaths, how many and who dies? • Hyperventilation..how common/significant is it? • use of peak flow meters/diaries, prescribing them. • instructing in use of inhalers (role of doctors, nurses, pharmacists).

28. COPD Ideas • Diagnosis • Staging • Treatment • LAMA • LABA • steroids • Oxygen HOOF