1. AHM 2011 Alyn Morice University of Hull HYMS COPD Disease not Disorder?

2. What is COPD? Asthma (eosinophilic bronchitis) Emphysema Chronic Bronchitis (neutrophilic bronchitis)

3. 2010

4. Page 1 of 673!

5. COPD Treatment Pathway Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV 1 /FEV ratio <70%) Establish severity of disease by FEV 1 as % predicted Management of RISK FACTORS plus EDUCATION plus IMMUNISATION Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised) SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues PHARMACOLOGICAL TREATMENT Review at each step after one month before escalating treatment THEOPHYLLINETHEOPHYLLINE MUCOLYTICSMUCOLYTICS prn short acting β 2 agonist Tiotropium + short acting β 2 agonist SHORTNESS OF BREATH Consider Palliative Care Referral in End Stage Disease Tiotropium + long acting β 2 agonist (LABA)* *salmeterol, eformoterol or indercaterol Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) COUGH AND SPUTUM Roflumilast + Tiotropium + short acting β 2 agonist (  Weight loss) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)

6. Telemonitoring in COPD – the evidence base Numerous pilot projects with accompanying evaluation reports; – Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions) – Often methodologically limited (e.g. before-and-after studies; small sample sizes) Systematic reviews demonstrate that high-quality evidence base is still immature; – Bolton (2010): studies included were positive but of a low- quality – Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations

7. Best health, best health care, a health service fit for the East Riding Evaluation… Evaluation of first 3 months deployment (24 patients) showed: -Patient satisfaction generally very good -68% reduction in n/e admission costs -net saving per month -achievement of £0.5m QIPP saving feasible Evaluation by Hull University – full year evaluation due Dec 11

8. Best health, best health care, a health service fit for the East Riding The East Riding Model Risk stratification identifies patient MDT agrees intervention Protocols for response in place: GP, NCT, specialist services, secondary care GP’s/NCT 1. Referral for telehealth intervention 2. Patient registered & unit installed Patient at risk of deterioration 2. Alerts 3. Triage 4. Response 1. Monitoring IDENTIFY REFER MONITOR RESPOND Telephone patient Visit - within identified timescale Emergency Response Step up / Step down Community Beds

9. Telemonitoring in COPD – How can it work?

10. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; – Providing reassurance and support

12. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; – Increasing knowledge of disease process and enhancing self-care – Providing reassurance and support

13. Best health, best health care, a health service fit for the East Riding Roger 64 year old with chronic, severe COPD Housebound and anxious Frequently uses standby medication Frequent hospital admissions – anxiety rather than healthcare need Distrustful of clinicians due to previous experience After telehealth: Telephone contact to reassure Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns More proactive about asking for help Reduced hospital admissions

14. Telehealth then... 14

15. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; – Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms) – Increasing knowledge of disease process and enhancing self- care – Providing reassurance and support

17. The impact of frequent COPD exacerbations - more frequent attacks increase mortality Soler-Cataluna JJ, et al. Thorax 2005;60:925–931 Group A: no exacerbations Group B: 1–2 exacerbations Group C: ≥3 exacerbations n=304 Time (months) p<0.0001 p<0.0002 A B C p=0.069 0102030405060 1.0 0.8 0.6 0.4 0.2 0 Survival probability

18. COPD patients with productive cough More likely to have exacerbations More likely to have exacerbations Seemungal TA et al. Am J Respir Crit Care Med 98 More rapid decline in lung function More rapid decline in lung function Vestbo J 1996, Kanner RA et al. Am J Respir Crit Care Med 01 More likely to die early More likely to die early Prescott E et al. Eur Respir J 1995

19. % of patients On Later in the In the In the At night Waking morning afternoon evening 31.0 24.0 22.5 19.5 10.6 Breathlessness (n=1,769) 28.8 25.9 25.4 25.5 16.7 Chest tightness (n=690) 40 30 20 10 0 Timing of symptoms: when was each symptom the most troublesome? 19 % of patients On Later in the In the In the At night Waking morning afternoon evening 40 30 20 10 0 % of patients On Later in the In the In the At night Waking morning afternoon evening 48.9 22.3 14.9 18.7 17.3 Cough (n=1,433) 50 40 30 20 10 0 % of patients On Later in the In the In the At night Waking morning afternoon evening 56.7 26.2 16.3 16.6 11.8 Phlegm (n=1,551) 60 50 40 30 20 10 0 Partridge et al. ERS Vienna 2009

20. HULL AIRWAYS REFLUX QUESTIONNAIRE Name: D.O.B:____________________________ UN: _________________ DATE OF TEST: Please circle the most appropriate response for each question Within the last MONTH, how did the following problems affect you? 0 = no problem and 5 = severe/frequent problem Hoarseness or a problem with your voice012345 Clearing your throat012345 Excess mucus in the throat, or drip down the back of your nose 012345 Retching or vomiting when you cough012345 Cough on first lying down or bending over012345 Chest tightness or wheeze when coughing012345 Heartburn, indigestion, stomach acid coming up (or do you take medications for this, if yes score 5) 012345 A tickle in your throat, or a lump in your throat012345 Cough with eating (during or straight after meals)012345 Cough with certain foods012345 Cough when you get out of bed in the morning012345 Cough brought on by singing or speaking (for example, on the telephone) 012345 Coughing during the day rather than night012345 A strange taste in your mouth012345 TOTAL SCORE_____________ /70 www.issc.info

21. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

22. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

23. unprocessed file processed file Waveforms showing acoustic events – Pre and post filtering

24. Cough counting in exacerbations of COPD Day 1 546 coughs Day 5 162 coughs

25. Future of telemonitoring in COPD 25