Obstructive Airways Disease

1. Obstructive Airways Disease Asthma and COPD

2. Definitions: • Asthma: It's a chronic respiratory condition that causes the airways to constrict become inflamed and collect mucus. It can be triggered by natural allergens, cigarette smoke, pets, exercise or emotional stress. • COPD: is characterized by air flow obstruction. The airflow obstruction is usually progressive, not fully reversible and doesn't change markedly over several months. The disease is predominantly caused by smoking.

3. Diagnosis of COPD • It should be considered in patients over the age of 35 who have a risk factor, generally smoking, and who present with exertional dyspnoea, chronic cough, regular sputum production, frequent winter bronchitis or wheeze. The presence of airflow obstruction should be confirmed by performing spirometry. All health professionals should be competent in the interpretation of the results

4. COPD contd. • Airflow obstruction is defined as a reduced FEV1 and reduced FEV1/FVC ratio, such that post bronchodilator FEV1 is less than 80% predicted and post bronchodilator FEV1/FVC is less than 0.7. • The airflow obstruction is due to a combination of airway and parenchymal damage. • The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. • Significant airflow obstruction and lung damage may be present before the individual is aware of it. • COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on airflow obstruction.

5. COPD contd: • Other symptoms • Weight loss • Effort tolerance • Waking at night • Ankle swelling • Fatigue • Occupational hazards • Chest pain • Haemoptysis

6. MRC dyspnoea scale • Grade 1. Dyspnoea on strenuous exercise. • Grade 2. Short of breath when hurrying or walking up a slight hill. • Grade 3. Walks slower then contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. • Grade 4. Stops for breath after walking about 100meters or after a few minutes on level ground. • Grade 5. Too breathless to leave the house, or breathless when dressing or undressing.

7. Investigations of COPD • Spirometry • CXR • FBC • BMI • Additional investigations: serial PEFR, alpha-1 antitripsin, CT Scan Thorax,ECG, • Echocardiogram, pulse oximetry, sputum culture if sputum persistently purulent.

9. MILD AIRFLOW OBSTRUCTION MODERATE AIRFLOW OBSTRUCTION SEVERE AIRFLOW OBSTRUCTION FEV1 50-80% PREDICTED FEV1 30-49% PREDICTED FEV1 <30% PREDICTED Assessment of severity of COPD

10. Management of COPD • Quit smoking • Short acting bronchodilator- beta 2 agonist or anticholenergic • Combination of the above inhalers • Long acting beta-2-agonists or long acting anticholinergic • In moderate to severe COPD; if symptoms persist, with at least two exacerbations requiring oral antibiotics and steroids, consider a combination of a long-acting beta-2-agonist and inhaled corticosteroid; discontinue if no benefit after 4 weeks • If still symptomatic-consider adding Theophylline • Mucolytics e.g. carbocystiene

11. Devices to Deliver Medications • Delivery system used to treat patients with stable COPD: Several devices are available –best may be MDI with a spacer. • Make sure the technique is good with regular checks. • Nebuliser therapy should not continue to be prescribed without proper assessment. • LTOT: PO2 <7.3KPa or PO2 between 7.3 to 8KPa with secondary polycythaemia, nocturnal hypoxia i.e. less then 90% SaO2 for more than 30% of time, peripheral oedema or pulmonary hypertension.

12. Corpulmonale • COPD associated with peripheral oedema, A raised venous pressure, a systolic parasternal heave and loud second heart sound. These patients need to be considered for LTOT, diuretics, ACE inhibitors, calcium channel blockers, alpha blockers and Digoxin

13. Pulmonary rehabilitation • This should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention.

14. Other therapies • Vaccination • Lung surgery • Physiotherapy • Management of anxiety and depression • Nutritional factors • Exercise • Palliative care • Assessment for occupational therapy • Social services • Self-management –Rescue packs etc • Follow up of patients with COPD- AT LEAST TWICE A YEAR IN GP PRACTICE Need spirometry once a year etc. • Multi-disciplinary team- Unique care

15. Reasons for Referral to Secondary care

16. Reasons for Referral to Secondary care contd.

17. Guide to Therapy Use short acting bronchodilator prn (either beta-2-agonist or anticolinergic) If still symptomatic, try combined therapy with a short-acting beta-2-agonist and short-acting anticolinergic If still symptomatic, use a long-acting bronchodilator (beta-2-agonist or anticolinergic) In moderate or severe COPD: If still symptomatic, consider a combination of a long-acting beta-2-agonist and inhale corticosteroid (discontinue if no benefit after 4 weeks) If still symptomatic- consider adding theophylline Consider mucolytic agents if patient complains of thick, tenacious sputum which is hard to cough up

23. Clinical management tips • Advise your patient to stop smoking because this will reduce the progression of COPD • Consider referring your patient for pulmonary rehabilitation if they are becoming disabled by their COPD and they have a Medical Research Council dyspnoea score of 3 or more • Prescribe bronchodilators if your patient had symptoms, rather than basing your decision on an improvement in lung function. You should therefore be judging whether treatment has been successful according to symptom relief • Start high dose combination inhaled corticosteroid/ long acting beta2 agonist inhalers in patients with an FEV1 ≤50% predicted and two or more exacerbations a year • For example, you can give either budesonide/ formeterol 400/12 one puff twice daily or fluticasone/ salmeterol 500/50 one puff twice daily. The benefit is about a 25% reduction in exacerbations • Be aware that aresponse to a course of oral steroids does not help you to predict which patients will benefit • Refer patients with an oxygen saturation of <92% for assessment to see whether they would benefit from long term oxygen therapy • You should consider this in patients who have an FEV1 <30% of predicted, polycythaemia, peripheral oedema, or signs of right heart failure • Long term oxygen therapy must be given over a minimum of 15 hours each day to correct chronic hypoxia • Be aware of the impact on carers of patients with severe COPD • Consider the palliative care needs of patients with severe COPD, especially those who have been admitted to hospital with respiratory failure • Be aware that your patient can stop taking oral steroids abruptly, provided they have not taken them for more than three weeks in total • Consider carrying out bone densitometry on patients with FEV1<50%. Irrespective of inhaled corticosteroid use there is a high risk of osteoporosis in this group

24. Assess symptoms/ problems of a patient with COPD and manage as described below:

25. How can I put this into practice? Ideas for audit towards appraisal/ revalidation are: • Number of patients with COPD who have an exacerbation in the last year who have a personalised action plan • Number of patients with FEV1 of 50% and 2 or more exacerbations who are on ICS/IABA combination therapy • Number of patients with MRC dyspnoea score of 3 (excluding housebound) who have ever been referred for pulmonary rehabilitation • Number of patients with FEV1<50% who have had a record of pulse oximetry being carried out in the last year

26. Possible ways of identifying patients with COPD for inclusion on a practice palliative care register • Hospital admission for a severe exacerbation of COPD • Being housebound due to COPD • Having an FEV1 of 30% or less • Being on long term oxygen therapy • Having depression or a poor quality of life • Other parameters such as a low body mass index (<20) and comorbidities (especially heart failure) • GPs and nurses asking themselves the question: “Would I be surprised if my patient were to die in the next twelve months?” This could be considered during routine consultations or on reviewing the register. If the answer is “No, I would not be surprised” the palliative or anticipatory care approach may be indicated

27. Tasks • How would you achieve maximum QOF points in patients with COPD in your practice? • How would you achieve maximum points in patients with asthma in your practice? • How would set up an asthma clinic in your practice? Include various equipment required and staff involved in achieving this task • How would you audit asthma control in your patients in your practice? Focus on one or two criteria. Complete audit cycle

28. QOF Indicators and points for Asthma

29. QOF indicators and points for COPD