Update on Asthma and COPD

1. Update on Asthma and COPD Fiona Horwood & Diana Hart

2. We are both from:-

3. Our Roles • Diana – Nurse practitioner NP since 2006 Works in community 80% • Fiona – respiratory physician • Based at Middlemore • Works in multi disciplinary clinics • Interest in chronic respiratory conditions (COPD) and pulmonary rehabilitation

4. Aim of this session • Update on a few topical issues in Asthma and COPD • Encourage awareness and necessity of multidisciplinary and integrated management of these chronic conditions • Specialist • Nurse – NP and CNS • Physiotherapist • GP • PN / DN

5. Asthma • Asthma affects 1in 5 children and 1 in 10 adults (Asthma and Respiratory Foundation of New Zealand) • There are still tragic deaths despite improvements in knowledge and treatments to assist those who have the condition. • What is new and topical in asthma?

6. Inflammometry in asthma • Symptoms of asthma may be non-specific and may cross over with other syndromes • It can be difficult to treat for a number of reasons • Poor adherence to treatment regime • Improvement over time may be mistaken for response to treatment • Corticosteroids should be used judiciously • It makes sense to target asthma therapy to underlying inflammation

7. Inflammometry • Eosinophilic airway inflammation reliably responds to corticosteroid therapy • Identifying and treating eosinophilic inflammation can allow targeted use of corticosteroids • Induced sputum is the investigation of choice for identifying eosinophilic inflammation but its availability is limited • Can use FeNO or serum eosinophilia as proxy

8. Vitamin D • May have an effect on asthma morbidity • Antiviral (↓vit D associated with ↑respiratory illness) • ?enhanced steroid responsiveness • Down regulation of atopy

9. Vitamin D • Currently there is insufficient evidence of a causal association between vitamin D status and asthma to recommend for or against vitamin D supplementation • But there is consistent evidence from observational studies that vitamin D protects against asthma exacerbations. • There is no evidence to support screening for vitamin D deficiency • It would be advisable to screen high risk individuals • Low sun exposure • Pigmented skins

10. Medication Adherence • Researchers at Henry Ford Hospital in the USA have found that one-quarter of severe asthma attacks could be prevented if only patients consistently took their medication as prescribed. • Moreover, an asthma attack was only significantly reduced when patients used at least 75 percent of their prescribed dose, according to the study.

11. Chronic Obstructive Pulmonary Disease (COPD) • The Asthma Foundation estimates that 1 in 7 New Zealanders aged 45 and over has COPD - more than 200 000 people, or the population of greater Hamilton (in Auckland 90 000) • Many of these are currently undiagnosed

12. COPD By 2030 chronic obstructive pulmonary disease is estimated to be the third most common cause of death worldwide, a leading cause of hospitalizations, as well as being one of the most expensive chronic diseases. However, in comparison to diseases, such as diabetes , there is little public awareness of COPD and the funding, research and profile is not the same as other diseases with a similar burden.

13. COPD risk • According to the first comprehensive estimate of lifetime risk for chronic obstructive pulmonary disease (COPD) published in a special European Respiratory Society issue of The Lancet, one out of four individuals aged 35 and over are likely to develop COPD at some stage of their lives. • The discoveries indicate that people have a much higher risk of developing COPD than congestive heart failure, acute heart attack , and several common cancers. • average woman at 35 years of age is >3 times more likely to develop COPD compared to breast cancer • average 35 year old man the risk of developing COPD is three times higher than prostate cancer

14. COPD and CVD Despite it being common for individuals to have both COPD and cardiovascular disease, it usually goes unrecognized by physicians due to overlapping clinical manifestations. In individuals with heart disease , COPD diagnosis can remain unsuspected, however, having both of these conditions can lead to a considerably worse outlook for the patient.

15. COPD and heart disease • According to a new investigation, individuals who suffer with chronic obstructive pulmonary disease (COPD) or those with reduced lung function have a serious risk of developing cardiovascular disease. • Presented at the European Respiratory Society's Annual Congress in Amsterdam 2011, the discoveries indicate that because individuals with COPD and reduced lung function appear to be at a significantly higher risk of developing cardiovascular disease, they should be routinely screened for it.

16. The link between COPD and heart disease • High troponin, chest pain and ECG changes are commonly seen in patients admitted to hospital with AECOPD • Elevated troponin T and NT-BNP levels at the time of ECOPD are strong predictors or increased risk and poor outcome

17. COPD and heart disease • We need to take hospital presentations with AECOPD very seriously and think more broadly • Major driver of mortality especially in the acute period and immediately after. • Mortality over 5 years increases in direct proportion to the frequency of AECOPD • Exacerbations are associated with important outcomes • ↑ risk of mortality • ↓ health status • Impaired lung function • Muscle weakness • Cardiopulmonary complications

18. COPD and heart failure • Reduced lung function and obstructive airway disorders such as chronic obstructive pulmonary disease (COPD) increase the risk of heart failure, a new study has found. • For the new study, researchers analyzed data from 16,000 people in the United States, aged 45 to 64, who took part in the Atherosclerosis Risk in Communities study and were followed for an average of 15 years • The researchers noted that it's common for patients with heart failure to have COPD, and vice versa. But only recently has prior COPD been shown to be a long-term risk factor for heart failure. • European Journal of Heart Failure, news release, Feb. 25, 2012

19. The impact of co morbidities • For health professionals, the problem of co-morbidities, when a person is suffering from more than one condition at the same time, is an increasing concern. • This will only become more of a concern as the frequency of co-morbid conditions increases as the older population live longer. • Often individuals are treated by a specialist for one particular system eg cardiac, respiratory. • It will become more important for physicians to recognize other symptoms as the frequency of co-morbidities increases.

20. Pulmonary rehabilitation

21. Pulmonary Rehabilitation • Pulmonary rehabilitation is a structured programme of exercise and education for those with chronic respiratory disease. • It is one of the few interventions shown to result in sustained improvements in quality of life for those with COPD. • Benefits include: • Improved quality of life • Less dyspnoea • Increased exercise capacity • Reduced hospital admissions • The Burden of COPD in New Zealand, Asthma and Respiratory Foundation of NZ (Inc.) and The Thoracic Society of Australia and New Zealand, New Zealand Branch Inc., 2003, p8. http://www.asthmanz.co.nz/burden_of_asthma_in_nz.php • Am. J. Respir. Crit. Care Med., Volume 159, Number 5, May 1999, 1666-1682

22. Pulmonary rehabilitation • Controlled studies have also shown a reduction in the use of health care resources such as admissions after attending a programme. • Ries, A. L., R. M. Kaplan, T. M. Limberg, and L. M. Prewitt. 1995. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann. Intern. Med. 122: 823-832 • Wright, R. W., D. F. Larsen, R. G. Monie, and R. A. Aldred. 1983. Benefits of a community hospital pulmonary rehabilitation program. Respir. Care 28: 1474-1479 • Agle, D. P., G. L. Baum, E. H. Chester, and M. Wendt. 1973. Multidiscipline treatment of chronic pulmonary insufficiency. Psychosom. Med. 35: 41-49 • Jensen, P. S.. 1983. Risk, protective factors, and supportive interventions in chronic airway obstruction. Arch. Gen. Psychiatry 40: 1203-1207

23. Pulmonary rehabilitation • Pulmonary rehab should not be considered as the last resort • Catching those early on in their disease can help with • Medication adherence and understanding • Smoking cessation • Social interaction and reducing the incidence of depression and social isolation • Self management skills

24. Case • Mr Simmonds • 68 yr old retired builder • Severe COPD started home O2-felt it was a death sentence. • Seen in Howick Pulmonary Rehab and after by NP at home involving family • 2 years later still severe COPD but QAL and exacerbations much improved

25. Multidisciplinary management of COPD • Historically, the practice of many health professionals has been characterized by unidisciplinary thinking • Individualistic and sometimes competitive behaviors have emphasized the roles and boundaries of each discipline • Management of a patient with a chronic condition requires a multidisciplinary approach

26. Multidisciplinary approach to COPD • Multidisciplinary, collaborative health care practice is an effective means to plan, coordinate, and implement care. • Family members and caregivers should be participants in this process, although they may not be present at all meetings of the multidisciplinary team • Their contribution to the assessment process, problem solving, goal and outcome setting is vital.

27. Multidisciplinary approach to COPD • Self management is an essential part of chronic care, and COPD, management • Disease knowledge is the most studied outcome of chronic disease or self management programmes • Knowledge is not the only outcome • Health literacy • Motivation • Behavioural changes • Engagement of patients and families / whanau to take an active approach to management

28. Multidisciplinary approach to COPD • Doctors often provide • Disease knowledge • Nurses will add • Advocacy • Education – medications, disease knowledge • Support – psychological, smoking cessation etc • Exacerbation action plans • Integrated follow up • Others – physiotherapists, social workers, community support workers, cultural support

29. Case Example • 58 Maaori female • Severe bronchiectasis with multi resistant microbiology • Moved to the area 6 months ago and has had 3 hospital admissions since • Seen in clinic twice by chest physician but still not making any progress

30. Case example • Seen in clinic in combined appointment with physician and CNS • Discussion • Advanced care planning • Action plans • Acceptability of LTOT • Pacing herself

31. Case example • Outcome • CNS home visit in 2 weeks to follow up response to antibiotics and further discuss advance care planning, advance directive and LTOT • Physio appointment within 10 days • Better communication with GP

32. To End… • We hope we have given you a topical overview of asthma and COPD • We hope that we have demonstrated the importance of multidisciplinary involvement in the management of chronic respiratory disease • We hope to continue to work closely across secondary and primary care to offer the best possible care to our patients