Current management of COPD
and when to refer?
Dr Maxine Hardinge
Consultant Respiratory Medicine
Oxford University Hospitals NHS Foundation Trust
• Aims of treatment – reducing risk and reducing
symptoms
• Inhaled therapy – new Oxfordshire guidance
• Severe COPD – home oxygen therapy, palliative
measures, surgical interventions
• Out-patient referrals - who to refer and who is
being referred?
GOLD 2014: Treatment goals for stable COPD
•
Relieve symptoms
•
Improve exercise tolerance
•
Improve health status
REDUCE
SYMPTOMS
AND
•
Prevent disease progression
•
Prevent and treat exacerbations
•
Reduce mortality
COPD, chronic obstructive pulmonary disease;
GOLD, Global initiative for chronic Obstructive Lung Disease
Date of preparation: February 2015; ULT0046
REDUCE
RISK
Reference:
GOLD. COPD guidelines 2014. Available at http://www.goldcopd.org (Accessed December 2014)
3
NICE 2010: Use of inhaled therapies
Who should be treated with LABA/ICS or LABA/LAMA?
Offer
Consider
* SABAs (as required) may continue at all stages
“Value” in COPD
Triple
Therapy
£35,000£187,000/
QALY
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in “at risk”
population
London respiratory team, NHS London
Getting the basics right
•
•
•
•
•
•
•
Diagnosis – quality assured spirometry
Vaccination
Smoking cessation
Physical activity – pulmonary rehabilitation
Diet
Self management
Depression/ anxiety
Smoking cessation – a treatment for
COPD
Stopping smoking is only intervention in COPD that can
– reduce all four core symptoms (cough, wheeze,
breathlessness and chest pain)1 and simultaneously
– slow the decline in lung function 1
– reduce COPD readmissions 2
– mortality 3
1 Scanlon PD et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary
disease. The Lung Health Study. Am J Respir Crit Care Med 2000;161:381-90.
2 Borglykke A et al. The effectiveness of smoking cessation groups offered to hospitalised patients with
symptoms of exacerbations of chronic obstructive pulmonary disease (COPD). Clin Respir J 2008;2:158-65.
3 Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic
Obstructive Lung Disease (GOLD); 2010 http://www.goldcopd.org/.
Smoking cessation data (PHE)
• Smoking prevalence in Oxfordshire in 2013 was 14.7% (12% in 2010)
• Numbers setting a quit date
– 2013/14: 6065
– 2014/15: 3319
• Percentage of successful 4 week quitters self-report
– 2013/14: 60%
– 2014/15: 58%
• Percentage of successful 4 week quitters CO monitor validated
– 2013/14: 46%
– 2014/15: 43%
• Cost per quitter 2013/14 £181.1
NICE 2010: Pulmonary rehabilitation
Offer to all appropriate people with COPD
• those who consider themselves functionally disabled
by COPD (usually MRC grade 3 and above)
• including those who have had a recent
hospitalisation for an exacerbation – early post
discharge pulmonary rehabilitation
Oxon PR outcomes
Percentage of
patients achieving
exercise tolerance
MICD by MRC grade
Percentage of
patients achieving
quality of life MICD
by MRC grade
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
% achieving MICD on ISWT
MRC 3
MRC 4
MRC 5
% achieving MICD on SGRQ
MRC 3
MRC 4
MRC 5
Pulmonary rehabilitation programme
• 45% of patients invited to assessment attend
• Of those 77.23% who started the course
managed to complete it (starter to completion
rate has improved considerably from the
previous years: 2011-12: 59.5%, 2012-13:
64.6% and 2013-14: 66.66%)
• Therefore, just over 30% of all the referrals we
receive complete course
Self management
• Need to take a variety of approaches tailored
to individual
Pharmacological management
•
•
•
•
•
•
Bronchodilators – single or dual
Role of ICS
Theophyllines
Mucolytics
Long term oral steroids
Macrolides - azithromycin
Severe COPD – additional treatments
• Home oxygen
therapy
– Long term
oxygen
therapy
– Ambulatory
oxygen
therapy
• Surgical
interventions
– Lung volume
reduction by
endobronchial
valves or
surgery
– Bullectomy
– Transplantation
End of Life Care in COPD:
• Severe AFO FEV1 < 30%
predicted
• Respiratory failure
• BMI < 19
• Housebound or MRC
grade 5
• 2 or more admissions in
previous year
• Required NIV for AECOPD
• “Surprise question”
• Symptom relief
– Fan therapy
– Breathing control/pacing
advice
– Dietary advice
– Depression/anxiety
– Morphine
– Benzodiazepines
– Home oxygen therapy if
resting O2 sats< = 92%
• Advance care planning
• Support for carers
NICE 1.1.8 Referral for specialist
advice (2004, 2010)
• should be made when clinically indicated
• may be appropriate at all stages and not solely
in most severely disabled patients
Referrals for specialist advice
• Diagnostic uncertainty:
– Is it all COPD? Symptoms disproportionate to lung function
deficit
– Is it asthma or COPD?
• Assessment for additional treatments;
– oxygen therapy, pulmonary rehabilitation, transplantation,
nebulisers, long term steroids or antibiotics
• Advice about management of recurrent exacerbations
• Advice about management of breathlessness
• Significant disease in young person:
– Alpha 1 antitrypsin deficiency
– cannabis
Who is being referred?
• 69 year old woman
• COPD diagnosed following
hospital admission Sept
2015
• Fostair and salbutamol.
Tried Carbocisteine twice –
rash both times.
• O2 sats 95%
• ‘extremely SOB and afraid
to out. Please advise on
breathlessness’
• What is her spirometry?
• Why tried carbocisteine if
problem is breathlessness?
• Why isn’t she on a LAMA?
• Has she done PR?
• Is she still smoking?
• Is her CXR normal?
• FEV1 0.7L (51% pred), FVC
1.1L (64%)
• Thoracic kyphoscoliosis
• CXR normal
Who is being referred?
•
•
•
•
•
•
63 yr old woman
COPD breathlessness grade 4
Continues to smoke
On maximal therapy
Requires frequent courses of oral
steroids
O2 sats 93%
•
•
•
•
•
•
•
•
•
•
•
•
What is her spirometry?
Has she has a CXR or Hb recently?
If recurrent exacerbations what’s
growing in her sputum?
Is she eosinophilic and would long
term low dose steroids be
appropriate?
Has she been to PR?
What's been tried for her smoking?
O2 sats 90-91%
No CXR or Fbc since 2010
Dry powder inhalers – try MDI/ mist
Declined PR or smoking advice
Sputum culture ? PSA
Discussion about smoking –
prognosis and oxygen
Summary
• Treatments as risk reduction and symptom
treatment
• New inhaler guidance
• Smoking cessation is a treatment for COPD
• Championing exercise and PR
• Tailoring self-management
• Referrals – overview of COPD severity and
problem which needs addressing