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COPD Update

COPD Update. Jacqui Carrett Respiratory Clinical Lead. Aim of the session. Overview of COPD Look at the COPD Assessment Tool - CAT score GOLD classification of patients Spirometry update

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COPD Update

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  1. COPD Update Jacqui Carrett Respiratory Clinical Lead

  2. Aim of the session • Overview of COPD • Look at the COPD Assessment Tool - CAT score • GOLD classification of patients • Spirometry update • Leave the session with at least one piece of information that you did not know at the start of the session!

  3. COPD • COPD is the only major cause of death which in increasing in the UK1 • There are over 30,000 deaths from COPD annually in the UK– which equates to one person dying from COPD every 20 minutes in England1 • Death rates from COPD are almost double the EU average 1 • 15% of those admitted to hospital with COPD die within 3 months and around 25% die within a year1 1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012. 2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011

  4. COPD is projected to be the third biggest killer by 2020 1990 2020 Ischemic heart disease CVD disease Lower respiratory infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accident Lung cancer Ischemic heart disease CVD disease Lower respiratory infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accident Lung cancer 3rd 6th Stomach cancer HIV Suicide Murray & Lopez 1997

  5. COPD • Cost – COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS 1 • 80% of people with COPD have at least one other long-term condition. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and / or an anxiety disorder 1 • 24 million working days are lost each year from COPD with 3.8 billion lost through reduced productivity1 1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.

  6. COPD • Under diagnosis – estimated to be 2 million un-diagnosed • COPD is characterised by accelerated decline in lung function • Patients are not normally aware of a problem until half their lung function is lost

  7. Drivers • Local and national guidelines / priorities – Locality commissioning framework • NICE quality standards for COPD – (updated 2016) • NICE clinical guidelines for COPD • NHS outcomes framework – 2016/2017 • GOLD – Global strategy (2017 Report)

  8. So…… what is COPD Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterised by persistent airflow limitation, that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients. Although COPD affects the lungs, it also produces significant systemic consequences

  9. Defining COPD Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation previously diagnosed as having chronic bronchitis andemphysema

  10. Risk factors • Smoking – accounts for 90% cases • Alpha 1 antitrypsin deficiency – 1% cases • Increasing age • Gender • Occupation – coal mining, cotton processing, dusty occupations • Outdoor and indoor air pollution – e.g. burning of wood and other biomass fuels • Airway hyper-responsiveness • Lower socio-economic status • Low birth weight

  11. Presenting features of COPD • Over 35 years age • Smoker or ex-smoker • Breathlessness on exertion • Chronic cough • Regular sputum production – common but not universal • Recurrent chest infections

  12. Clinical features differentiating COPD and Asthma

  13. Inflammation in Asthma V COPD Although Asthma and COPD are both associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells involved in the two diseases, which in turn account for differences in symptoms and response to treatment • Asthma – eosinophils • COPD - Neutrophils

  14. Diagnosis • There is no single diagnostic test and very often there are no physical signs

  15. Diagnosis • Take a full history • Confirmed by SPIROMETRY – this measures lung function • FEV1 - forced expiratory volume in 1 second • FVC – forced vital capacity • EVC – relaxed vital capacity • FEV1 FVC ratio – less than 70% demonstrates airflow obstruction • Mild disease – FEV1 > 80% predicted • Moderate disease – FEV1 – 50-79% predicted • Severe disease - FEV1 – 30-49% predicted • Very Severe disease – FEV1 less than 30%

  16. New National Spirometry register • By 31st March 2021 All practitioners to be certified & listed on the register • Phased implementation of this requirement from 1st April this year (2017) • The National Register will be maintained by the ARTP - Association for Respiratory Technology & Physiology

  17. 3 Certificates 1. Foundation: those who have been assessed as competent to perform safe, accurate and reliable spirometry tests without interpretation 2. Interpretation only: Those who have been assessed as competent in interpretation only (ie those with no responsibility / requirement to perform spirometry but who do have a requirement to interpret accurately the results of spirometry) 3.Full: those who have been assessed as competent to perform and interpret spirometry in terms of the physiological changes.

  18. Foundation – performing tests • A professional portfolio is required relating to all aspects of preparation for, & performance of spirometry. This comprises compilation or creation of protocols, cleaning & calibration logs that ensure safety of the patient, checking for contraindications & preparation of the equipment to ensure accuracy etc. • This will include 10 patient tests. • Applicants will also complete a practical assessment of competence where spirometry is performed & observed by an ARTP approved assessor.

  19. Full Certificate – performing tests and interpretation • Assessment at Full level includes both an observed practical assessment of competence and submission of a professional portfolio as required at Foundation level. • The 10 spirometry tests will cover a range of scenarios (obstruction, restriction & reversibility) & within this, these will then be interpreted within the context of the history of the patient described. • There will also be a written assignment.

  20. Interpretation Only – interpreting tests without performing • Some prior knowledge of spirometry interpretation is advisable • There is no observed practical assessment at this level • A portfolio of 10 tracings that the individual has interpreted is required • Plus a written assignment.

  21. Experienced Practitioner Scheme • Those with significant experience can apply to be confirmed as competent by having their skills assessed against ARTP standards. The Experienced Practitioner Scheme enables them to undertake an assessment of competence without attending any training • To achieve certificate of competence at either Foundation or Full levels – individuals must undertake an observed assessment of competence at their workplace, Portfolio requirements are assessed at the same time • For the full level, there is also an interpretation Viva and a written assignment. • Interpretation only level - A portfolio of 10 tracings plus interpretation is required – there is no written assignment

  22. Re-certification • Required on a 3-yearly basis • An observed assessment of competence • Plus submission of a comprehensive portfolio (continued calibration, quality assurance, infection control, evidence of quality spirometric measurements) • Where interpretation is required, an analysis of 5 traces provided by ARPT to review for technical quality & interpretation.

  23. Treatment • Smoking cessation • Bronchodilators are the mainstay of COPD treatment – short acting and long acting – B2 and anticholinergic • Combination inhalers – LABA+LAMA, LABA+ICS • Steroid inhaler now only recommended in patients who experience >2 or > 1 exacerbation leading to hospital admission and high symptom scores or those with a history of Asthma-COPD overlap • http://www.enhertsccg.nhs.uk/respiratory-system • Mucolytics • Pulmonary rehab • oxygen

  24. CAT – COPD Assessment Tool • 8 questions • Score ranges from 0 – 5 • 0 = no symptoms 5 = more symptoms • Helps guide your consultation to what are the most important symptoms for the patient • Helps monitor any response to changes • Change of 2 points is clinically significant

  25. MRC DYSPNOEA SCALE

  26. Oxygen therapy • Indicated if resting sats< 92% and on maximal inhaled therapy • Refer to the Integrated Community Respiratory Service (ICRS) • Referral form • Either fax : 01462 427129 or send via email – enhertscommunity.respiratoryteam@nhs.net • Not an emergency service

  27. Other factors • Breathlessness, fatigue and anxiety occur more commonly in COPD patients than those with advanced cancer, heart disease or renal disease • Need to screen COPD patents for anxiety and depression • People with COPD frequently have other co-existing diseases or co-morbidities • Cardiovascular mortality in COPD – for every 10% decrease in FEV1 cardiovascular mortality increases by 28% and non-fatal coronary events increase by 20%

  28. Any questions?

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