Diploma Course in COPD Management

1. Diploma Course in COPDManagement

2. Introduction to faculty • Dr John Haughney • Dr Abdel GhafourGari • Dr SherifRefaat

3. Agenda & Programme for Today22 March 2013 • 13:00 – 14:00 Lunch • 14:00 – 14:10 Introduction to CIPD Diploma Course from Professor Price via video link • Introduction and agenda run through – Dr Abdel GhafourGari and Dr John Haughney • 14:10- 14:50 Differential Diagnosis of COPD to include asthma, causes of breathlessness, Questions – Dr John Haughney • 14:50-15:30 Pathology of COPD: to include early detection, Questions – Dr Abdel GhafourGari • 15:30-16:00 Lecture: – Dr SherifRefaat • 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 faculty • Spirometry, FEV6, Peak flow meters • 17:00-17:45 Plenary Session - Dr John Haughney • Case history Presentations • What have we learnt & what we will take back to clinics next week • Feedback for next course – white cards, green 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. Dr John Haughney Differential Diagnosis of COPD & Breathlessness

9. 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

10. 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

12. 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

13. NICE UK 2010 values

14. 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

15. 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

16. Not always Respiratory Cause BREATHLESSNESS

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

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

19. 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

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

21. 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

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

23. 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

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

25. 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

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

27. 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

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

29. 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

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

31. 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

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

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

34. 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 COPD2 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.

35. Worldwide under diagnosis of COPD • Estimated COPD prevalence 8-10% in >40yrs age • What is your prevalence in your practice population?

36. 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.

37. 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

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

39. Can we do anything about it? • Make a correct diagnosis • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent & treat complications / exacerbations • Reduce mortality Global Initiative for chronic obstructive lung disease (GOLD) NIH, April 2001

40. Why we MUST GET IT RIGHT • Lifelong smoker • 1994 diagnosis of “asthma” made • Miner lived in council estate

41. Arthur • Lifelong smoker • 1994 diagnosis of “asthma” made • Miner lived in council estate • 1998 COPD diagnosed (severe) • Died 12 months later • Cor pulmonale • On LTOT

42. 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)

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

44. 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

45. 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

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

47. Diagnosis for likely moderately severe COPD patients by country France% Germany% US% UK% Ref*% Emphysema 0 5 44 14 Chronic bronchitis 45 46 14 12 Asthma 27 31 24 47 44 Chest infection 0 3 3 8 - Other 46 15 15 19 18 34 *Freeman D et al. Am J Respir Crit Care Med 1999

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

49. Prevalence of COPD in primary care at risk populations Gold category and the primary groups 100% Not COPD 80% Severe COPD 60% Moderate COPD 40% Mild COPD At risk 20% 0% Asthma Diagnosis no Rx Respiratory Medication Smokers Opportunistic Freeman D et al ERS 2002

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