Diploma Course in COPD Management

1. Diploma Course in COPDManagement

2. Introduction to faculty • Prof David Price • Dr Abdullah Al Dalaan • Dr HussamSakkijha

3. Agenda & Programme for Today22 March 2013 • 14:00 – 14:10 Introduction to CIPD Diploma Course – Prof David price • Introduction and agenda run through – Dr Abdullah Al Dalaan and Prof David Price • 14:10- 14:50 Differential Diagnosis of COPD to include asthma, causes of breathlessness– Prof David Price • 14:50-15:30 Pathology of COPD: to include early detection– Dr Abdullah Al Dalaan • 15:30-16:00 Lecture: – Dr HussamSakkijha • How to perform spirometry • How to assess and grade COPD • Introduction to pharmacological therapy • 16:00 – 16:15 Coffee break • 16:15-17:00 Practical session - all groups facilitated by faculty • Spirometry, FEV6, Peak flow meters • 17:00-17:45 Plenary Session – discussion with all faculty and group • Case history Presentations • What have we learnt & what we will take back to clinics next week • Feedback for next course – questions cards and feedback forms

4. Agenda & Programme for Today22 March 2013 • 17.00-17.45 Plenary Session • Case history Presentations 30 mins • What have we learnt & what we will take back to clinics next week • White Question cards • Green comment cards • These are for your feedback to form first session for next course • FEEDBACK FORMS ON YOUR CHAIRS

5. Agenda day 2 • Recap of diagnosis of COPD • To include GOLD matrix of severity • Pharmacological management of COPD • New & established therapies • Exacerbations – how to manage • Case histories ( exacerbations) • Workshop session • Lecture on inhalers & practical session looking at different deviced

6. Agenda Day 3 • Pulmonary rehabilitation • Outcome measures in COPD • Their use or misuse • Advanced care to include LTOT, palliative care • Practical session – pulse oximetry, exercise testing • Examples of integrated care systems in other countries • Case histories to look at how integrated care may have altered care of that patient • Quiz/assessment of learning objectives

7. Agenda & Programme for Today22 March 2013 • White Question cards • On your chairs • Floor walkers will take them from you at any time during lectures • There will be ample time at the end ( or during) presentations to take questions

8. Differential diagnosis of COPD & breathlessness David Price Professor of Primary Care Respiratory Medicine, University of Aberdeen Honorary Professor University of Adelaide Member of ARIA and EPOS Executive Community Based Respiratory Specialist Norfolk

9. Conflict of Interest • David Price has consultant arrangements with Almirral, Astra Zeneca, BoehringerIngelheim, Chiesi, GlaxoSmithKline, Merck, Mundipharma, Meda Novartis, Napp, Nycomed, Pfizer, Sandoz and Teva. • He or his research team have received grants and support for research in respiratory disease from the following organisations in the last 5 years: UK National Health Service, Aerocrine, AstraZeneca, BoehringerIngelheim, Chiesi, GlaxoSmithKline, Merck, Mundipharma, Meda, Novartis, Nycomed, Pfizer, and Teva • He has spoken for: Almirral, AstraZeneca, Activaero, BoehringerIngelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Merck, Meda, Mundipharma, Novartis, Pfizer and Teva • He has shares in AKL Ltd which produces phytopharmaceuticals. He is the sole owner of Research in Real Life Ltd.

10. Aberdeen & Norwich Surrounded by castles

12. Differential diagnosis of Obstructive Lung Disease • How do we decide what’s going on? • What features in history are going to help? • Smoking • Age • Family history atopy • Personal history of atopy • Timing of symptoms/attacks • What caused this • Birth weight • SE class • Occupation

13. Asthma defined as: Chronic inflammatory condition of the airways causing Hyper-responsive airways that narrow easily to a wide number of stimuli Narrowing is easily reversible In some patients inflammation may lead to irreversible airflow obstruction COPD defined as: Chronic, slowly progressive disorder Airways obstruction: Which does not change markedly over months Impairment largely fixed But partially reversible by bronchodilator therapy How do we start to differentiate between COPD & asthma

15. Need spirometry to formally make the diagnosis • Asthma • Lung function may be normal when stable • Classically should see obstruction (FEV1/FVC ratio <70%) • Should see >400mls bronchodilation with salbutamol • Should see PEFR variability • COPD • Little variability • PEFR usually unhelpful but can EXCLUDE • Spiro- see obstruction (FEV1/FVC ratio <70%) • FEV1 (post BD values) predict severity

16. NICE UK 2010 values

17. Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1> 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

18. Global Strategy for Diagnosis, Management and Prevention of COPDCombinedAssessment of COPD When assessing risk, choose the highest risk according to GOLD grade or exacerbation history

19. Not always Respiratory Cause BREATHLESSNESS

20. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

21. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

22. Breathlessness • Anaemia • Common in (vegetarian) women • May be dietary in elderly • Often presentation of GI problems • Patient often pale • Syx may be similar to heart failure in susceptible individuals • Investigation • FBC

23. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

24. Breathlessness • Heart failure • Very common • History • Breathless on exertion • Orthopnoea/paroxysmal nocturnal dyspnoea • Ankle oedema • Previous cardiac history- MI, hypertension, diabetes • Drugs-NSAIDS • Examination findings • Raised JVP • Gallop rhythm • Fine creps in lungs • Investigations • CXR • ECG • BNP • FBC • Echocardiogram

25. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

26. Breathlessness • Restrictive lung disease • Relatively uncommon • Idiopathic Pulmonary Fibrosis • BOOP • Bronchiolitisobliterans • Extrinsic allergic alveolitis • Features • History of rheumatoid arthritis • Pigeon/budgerigar exposure • Family history IPF • Symptoms • Breathlessness • Examination findings • Fine creps • Often cyanosed • Investigations • Restrictive pattern on spirometry • Ambulatory oximetry • CT scanning to identify extent of disease

27. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

28. Breathlessness • Pleural Effusions • Symptom of underlying problem • Symptoms • Progressive breathlessness • Examination findings • Bronchial breathing above level of fluid • Dull bases of lungs • Investigations • CXR • Causes • Heart failure • TB • Malignancy • Lung (primary/secondary) • Ovary • Lymphoma • Pulmonary emboli

29. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

30. Breathlessness • Lung cancer • Usually ex/current smoker • Often presents with • Haemoptysis • Chest pain • Weight loss • Breathlessness • Investigation • CXR • CT scan • Bronchoscopy & biopsy • Common in patients with COPD • GOLD recommends CXR for all patients diagnosed with COPD

31. Breathlessness • Anaemia • Heart Failure • Restrictive lung disease • Pleural effusions • Lung cancer • Pulmonary Embolisms

32. Breathlessness • Common • Incredibly difficult to diagnose-often done as process of elimination • Symptoms • Chest pain • Haemoptysis • Unexplained breathlessness • Examination findings • May have pleural effusion • May have signs right heart strain • May have nothing! • Investigations • CXR • ECG • D-dimer • VQ scan • CT scan • CONSIDER • Patients with DVT • Malignancy • Recent surgery (esp pelvic) • Pelvic masses

33. How do we assess and diagnose? OBSTRUCTIVE LUNG DISEASE

34. RISK FACTORS for Obstructive Lung disease • ASTHMA • Family history • Atopy • Onset at young age • Exposure to allergens • Obesity • Smoking ( & maternal smoking) • Occupational triggers • Exhaust fumes & outdoor pollution • Low Birth Weight • COPD • Family History • Exposure to particles • Smoking • Occupational dust • Indoor pollution • Outdoor pollution • Small birth weight • Socio-economic status • Age • Respiratory infections • Inc Chronic Bronchitis • Asthma or Bronchial Hyper-reactivity

35. Screening the pros and cons How Hard SHOULD WE LOOK FOR COPD?

36. Diagnostic iceberg • Among smokers with no prior history of obstructive lung disease, 18.7% have COPD1 • Amongst patients currently treated with asthma therapy and no diagnosis of COPD, 24.5% have COPD Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and Asthma in Primary Care Patients 40 Years of Age and Over. J Asthma. 2006;43:75-80.

37. The unknown and undiagnosed COPD population: the UK An estimated 3.5 million people have COPD, but only 835,000 are diagnosed. This undiagnosed population represents a significant future healthcare and economic burden for England (Graph based on DH unpublished estimate, 2009). What is your prevalence in your practice population?

38. ERS Sept 2011 P4138 Prevalence of chronic bronchitis in the Middle-East and North Africa: Interim results of the BREATHE study A. Khattab, A. Sayiner, J. Ahmed Khan, G. Iraqi, S. Nafti, A. Benkheder, B. Mahboub, M. L. Konisky, C. Nejjari, N. Rashid, The BREATHE Study Group (Cairo, Egypt; Izmir, Turkey; Karachi, Pakistan; Rabat, Fez, Morocco; Algiers, Algeria; Tunis, Tunisia; Dubai, United Arab Emirates; Beirut, Lebanon) Background: Few data are available on the epidemiology of COPD outside developed countries. Objectives: The objective of this epidemiological study was to assess the prevalence and burden of COPD, chronic bronchitis and smoking in eleven countries (Algeria, Morocco, Tunisia, Egypt, Jordan, Lebanon, Saudi Arabia, Syria, UAE, Pakistan and Turkey). Methods: A general population sample of 10 000 subjects ≥ 40yrs in each country was generated from random phone numbers. A structured interview was proposed to all subjects by telephone. Screening questions, including history of cough and sputum production, was used to identify subjects with chronic bronchitis. Individuals who smoked ≥ 10 pack-yrs and who had either chronic bronchitis or a previous diagnosis of COPD were considered to have possible COPD. In a subset of the study sample, assignment of COPD was confirmed by spirometry. This interim analysis assesses the prevalence of chronic bronchitis. Results: Of 118 039 subjects contacted, 44 892 were interviewed. 978 subjects reported having symptoms of chronic bronchitis.This corresponds to a prevalence of chronic bronchitis of 2.2% [95% CI: 2.0-2.3%], ranging from 0.6% [95% CI: 0.4-1.0%] in UAE to 2.9% [95% CI: 2.1-3.7%] in Algeria. The prevalence of chronic bronchitis was higher in women (2.4%; 95% CI: 2.2-2.6%) than in men (1.8%; 95% CI: 1.6-2.0%). Prevalence increased with age: 1.6% in subjects aged 40-49 yrs, 2.2% in those aged 50 to 59 yrs and 3.0% in those aged ≥ 60 yrs. Conclusion: The prevalence of chronic bronchitis in the Middle East and North Africa seems to be lower compared to other regions of the world.

39. Can we identify risk factors? • Environmental risk factors • Cigarette smoking • Occupational exposure to dust chemicals et • Indoor fuel biomass • Indigenous • Ageing lung • Sex • Co-morbidities • Genetics- α1 antitrypsin defiency

40. CIGARETTES • Pack Years • Helpful in assessing risk & exposure to cigarette smoke • Number of cigs per day x years smoked / 20 = pack years

41. Effects of smoking on FEV1 100 Never smoked or not susceptible to smoke 75 Susceptiblesmoker FEV1 (% of value at age 25) 50 Disability 25 Death Predicted lifetime if patient stops smoking 25 50 75 Age (years)

42. Current COPD severity in primary care: data from the Optimum Patient Care Research Database n = 19,425 Data on file, Optimum Patient Care: Price D. 2012

43. Respiratory resource use prior to COPD diagnosis Years prior to COPD diagnosis Price et al. Presented IPCRG 2012

44. Why diagnose?-data from Lung Health Group 2000 Lancet vol374 aug 2009

45. Why Don’t we screen for COPD? • Hypertension • Hyperlipidaemia/CVS risk factors • Diabetes All have active and easily available screening programmes

46. WHY SCREEN? • Recent estimates suggest COPD may exist in 40-50% of smokers & clinical consequences of mild disease has been under-estimated 1 • COPD is not just a disease of the lungs • Elevated levels of CRP/fibrinogen/leucocytes/TN alpha seen in patients with COPD2 1 2

47. Diagnosis after spirometry:Glenfield Practice of 12,000 patients n=260 (prescribed bronchodilator therapy) Pre-study Post-study 70 60 60 50 44 Patients (%) 40 34 30 17 20 13 10 11 7 10 4 0 0 0 0 None COPD Mixed Other NRD Asthma Freeman D et al. Am J Respir Crit Care Med 1999

48. Accuracy of GP Diagnosis in UK in patients over 40 receiving respiratory medication Freeman D, Price D et al ERS 2002

49. So we can’t assume the patients are going to run into see us • Spirometry • Essential for diagnosis • How to start screening

50. GOLD stage 1 therapy- stop smoking – prn SABA Does early therapy help?