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Www.pspbc.ca Shared System of Care COPD/Heart Failure Learning Session 2.

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Presentation on theme: "Www.pspbc.ca Shared System of Care COPD/Heart Failure Learning Session 2."— Presentation transcript:

1 Shared System of Care COPD/Heart Failure Learning Session 2

2 Agenda Introduction (35) Patient Voice (15) Medication (60, 40 didactic and 20 discussion) MOA Breakout Break (15) PSM Support COPD and AECOPD Management (30, 20 didactic, 10 questions) Heart Zones and other PSM tools (30, 20 didactic, 10 questions) Smoking cessation (10, 5 didactic, 5 questions) Sharing the care with the specialist and the referral process Planning for Action Period 2 (15)

3 Patient Voice (10 minutes)

4 COPD Medications (15 minutes)

5 5 Comprehensive Management of COPD

6 6 Classification of Disease Severity in COPD

7 7 Goals   Symptoms   Exacerbations   Exercise  Beta - agonists  Anticholinergics  Short vs. long-acting  Inhaled corticosteroids  Combination therapies  Antibiotics  Oral prednisone- for AECOPD  PDE4 inhibitors  Oxygen  Pulmonary rehabilitation  Smoking cessation Treatment of stable COPD

8 8 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

9 9 Short-acting Bronchodilators

10 10 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

11 11 Stepwise increased therapy Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

12 12 Mild Increasing Disability and Lung Function Impairment Infrequent AECOPD (< 1/year) Frequent AECOPD (> 1/year) LAAC or LABA+ SABA prn LAAC + LABA +SABA prn LAAC + ICS/LABA* + SABA prn LAAC + ICS/LABA + SABA prn persistent disability LAAC + SABA prn or LABA + SABA prn persistent disability LAAC + ICS/LABA + SABA prn +/- Theophylline persistent disability Moderate Severe persistent disability * Inhaled corticosteroid/long-acting beta 2 -agonist (ICS/LABA) combination with the lower ICS dose i.e. SALM/FP 50/250 µg twice daily O’Donnell DE, et al. Can Respir J 2007 Optimal Pharmacotherapy in COPD

13 13 Comprehensive management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

14 14  Spirometry essential as screening tool in subjects at risk  Beware false positive/false negative results with COPD 6.  Treatment:  Mild: Short acting BD’s  Moderate: Long acting BD’s (single or comb)  Severe: Combination BD’s + ICS +Pulmonary Rehabilitation.  All: education, vaccinations and smoking cessation. Summary

15 15  Dyspnea out of proportion to spirometry  Young age of onset  Remote smoking history and disease severity not consistent with smoking history  Rapid deterioration (symptoms or FEV1)  History of exacerbations  Concern re multiple co morbidities Stable COPD: Who should be referred?

16 16  79yo woman severe SOB  PHx: overweight (BMI 32), diet controlled DM2, & HTN  Allergy: mild seasonal allergies - rhinorrhea  Smoking: 40 pack. years - quit 20 y ago.  Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post BD change.  Next step? Case #1

17 17  Explore possibility of heart failure/ischemic heart disease/if acute onset consider PE.  Could this patient have asthma?  Exam patient and rule out heart failure.  Unclear re CHF and COPD: BNP  Request spirometry with reversibility.  If COPD categorize severity.  If non obstructive pattern: detailed lung function including lung volumes + DLCO  Chest x-ray.  Echocardiogram  Stress test Case #1

18 18  Spirometry with post bronchodilator assessment showed a 12% improvement consistent with the diagnosis of asthma.  Echocardiogram: Normal  Stress test: No ischemic changes Case #1

19 19 Diagnosis:  Adult onset asthma with likely added de-conditioning and obesity,  Initiate low dose inhaled corticosteroids and short acting bronchodilators PRN  Advise re immunizations  Provide education about inhaler use and refer for education  Provide a written action plan Key learning points:  Asthma can occur late in life and can occur independently or in association with COPD  Important to identify co-existence of asthma in COPD as it will effect adjunct therapies such as beta blockers.  If asthma is a consideration request reversibility initially Case #1

20 20  68yo man progressive SOB with a history of a recent exacerbation requirng a vist to the ED and a course of prednisone and antibiotics.  PHx: HTN on metoprolol and ramipril.  Allergy: no seasonal or environmental allergies  Smoking: 55 pack years - quit 5 y ago.  Spirometry: 3 years ago: FEV1 53% pred,  FEV1/FVC ratio. No post BD improvement  Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H PRN with increasing use in the last few weeks.  Next step? Case #2

21 21  Clinically this patient has deteriorated with a recent exacerbation.  What would you do next? Case #2

22 22  You repeat the spirometry and the FEV1 is now 45% of predicted.  This patient has severe COPD and a history of exacerbation and therefore would qualify for the use of tiotropium and the addition of a LABA  Need to consider emerging evidence of increased risk of pneumonia associated with fluticasone. Case #2

23 23 Larsson et al, J Intern Med 2013 Patient Flow Patients who met the inclusion criteria identified within the study period n= Patients with a record of fixed ICS/LABA therapy (Index date) n=9893 FLU/SAL cohort n=2734 BUD/FORM cohort n=2734 Linked data from 76 centres throughout Sweden Matched populations

24 24  The exacerbation rate was 26.6% lower with BUD/FORM vs. FLU/SAL  The number needed to treat with BUD/FORM vs. FLU/SAL to prevent one exacerbation per patient-year was 3.4 Larsson et al, J Intern Med 2013 COPD Exacerbations RR = 0.74 (CI: 0.69, 0.79) p<.0001 RR, rate ratio BUD/Form Flutic/salmeterol

25 25 Stepwise increased therapy Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)myr

26 26  Question: What reliever medication would you recommend for this patient?  Key learning point: ipratropium should not be used as a rescue medication because of the use of tiotropium and the patient should be prescribed salbutamol on a PRN basis. Case #2

27 27  60yo woman progressive SOB  PHx: COPD  Allergy: Seasonal allergies years ago  Smoking: 25 pack years - quit 10 y ago.  Spirometry: 3 years ago: FEV1 54% pred,  FEV1/FVC ratio.  Meds: salbutamol and ipratropium bromide PRN and now needing them up to five times daily.  Next step? Case #3

28 28  Repeat spirometry and FEV1 unchanged.  Next steps? Case #3

29 29  Add tiotropium bromide, stop ipratropium bromide and continue salbutamol PRN.  Six weeks later patient reports some improvement but still short of breath and has developed peripheral edema?  What are your concerns now and what would you do? Case #3

30 30  Clinically there is evidence of congestive heart failure and you start a diuretic and get an ECHO.  The ECHO shows a reduced EF of 35% predicted. Key learning point:  HF and severe COPD often co-exist and treatment strategies need to take account of this Case #3

31 31 Questions

32 32 Management of severe COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

33 33  Maximize inhaled therapy: › Combined ICS/ long acting beta-agonists › Long acting anti cholinergic  Additional considerations: › Ensure patient is adherent and taking inhalers correctly if unable to use spacer and deliver medication correctly consider nebulized Rx. › Refer to pulmonary rehabilitation. › If having frequent exacerbations consider a trial of roflumilast. › Azithromax a consideration but important caveats: see next slide. › Ensure no untreated co morbidities such as CHF and GERD Severe COPD

34 34  Continuous (Grade A evidence)  Resting ABG pO2 < 55 mmHg  Resting ABG pO mmHg › Cor pulmonale › Hct > 56%  Intermittent (Grade B evidence)  Exertion: sO2 1 min  Nocturnal sO2 30% night Long term O2 therapy indications

35 35 Continuous home O2 minimum 20h /day

36 36  Important to note most patients can effectively use inhaler device and a spacer but nebuilizer:  Beneficial in extremes of age  Coordination not required  Breath-hold not required  Note because of the size of aerosol particles the use of a nebulizer does not lead to increased deposition into the lung. Nebulizer treatment in severe COPD

37 37 Chronic oral prednisone therapy in COPD

38 38  There is no evidence base for the regular use of oral prednisone in COPD.  In one RCT of prednisone for ARCOPD one group who were left on prednisone had increased side effects.  For patients who have frequent AECOPD and continue to exacerbate despise all the measures outlined above then an N-of- 1 trial of alternate day OCS can be considered.  Bone density and osteoporosis risk should be regularly reassessed. Chronic oral prednisone therapy in COPD

39 39  Patients with moderate-severe COPD (FEV1 2/year ) exacerbations.  Patients should be advised re the risk of GI side effects. Roflumilast: indication:

40 40  Apart from azithromax there is no evidence that chronic antibiotic therapy is effective in COPD.  For exacerbation: rotating antibiotics between classes are recommended  A significant minority of COPD patients have co existing bronchiectasis and in the presence of significant sputum volume and purulence assessment for atypical TB infection and gram negative pathogens such as Pseudomonas should be completed. Other antibiotics for severe COPD

41 41 Heart Failure (15 min)

42 42 ACE/ARB % Region/ year

43 43 Region/ year Beta Blocker %

44 44 Evidence Based HF Therapies in BC

45 45 Principle of HF Management  Therapeutic Goals  1. prompt resolution of congestive symptoms  2. initiate patient self management related to lifestyle and medication compliance  3. initiate/enhance therapies direct to underlying disease process  limit recurrent hospitalizations  improve mortality  4. prevent adverse events related to administered therapies

46 46 Heart Failure Therapies TherapyAgentReduction in 1° Endpoint Self Management23% PharmacologicalACE-I8% - 26% Beta Blocker23% - 65% MRA35% ARB15% DeviceICD23% - 31% CRT24% - 36%

47 47 Contemporary Management of HF  Pharmacological Therapies  (1) Beta Blockers  (2) Inhibition of the RAAS  ACE-inhibitors (ACEi)  Angiotensin Receptor Blockers (ARB)  Mineralocorticoid Receptors Antagonists (MRA)  Device Therapies  (1) ICD  (2) Cardiac Resynchronization Therapy (CRT)

48 48 Beta-Blockers Reduce Mortality and Decrease the Risk of Hospitalization

49 49 Impact of ACE Inhibitors on Mortality in HF

50 50 Benefits of ACE Inhibitors Persist

51 51 Spironolactone: EF<30 & Advanced Symptoms 10% ARR

52 52 Combining Therapies Improves Outcomes

53 53 Cumulative risk reduction if all three therapies are used: 63% Absolute risk reduction: 22%, NNT = 5 Fonarow GC. Rev Cardiovasc Med. 2003;4:8–17. Relative risk2-yr Mortality None  ---35% ACE Inhibitor  23%27% MRA (Spironolactone)  30%19% Carvedilol  25%19% Cumulative Impact of Heart Failure Therapies: All Cause Mortality

54 54 RAFT  1798 patients with:  NYHA class II or III heart failure,  LVEF  30% intrinsic  QRS > 120 msec  Randomized to ICD alone or an ICD plus CRT  Primary outcome was death from any cause or hospitalization for heart failure  Follow up - mean of 40 months

55 55 RAFT

56 56 NEJM 1996

57 57 Important Therapeutic Considerations in HF Patients  Smoking cessation  Cardiac rehab  Action plans for acute decompensation  Addressing co-morbidities  COPD  CKD  Immunizations  Symptom management  End of life care some synergies and therapeutic overlap

58 Break

59 Patient Self-Management Generating an Action Plan COPD and AECOPD Management Patient Education Materials Smoking Cessation

60 60

61 61

62

63 COPD and AECOPD Management (30 minutes, 20 didactic + 10 questions)

64 64  72 year old male seen by me in clinic Jan 2012 with moderate COPD  Quit smoking 4 years ago  Comorbid illnesses including: CHF, Afib, AVR, CABG complicated by sternal infection, obesity, asbestos related pleural disease.  Recurrent admissions for AECOPD and CHF (‘dirty’ x-ray). 90 days in hospital this past year.  Discharged post AECOPD Oct 23. Readmitted Monday pm in distress. Case

65 65  Had seen GP in community 1 week prior started on higher dose prednisone, PO antibiotics  Requiring high flow oxygen, BiPAP  Increased work of breathing  Uncontrolled Afib post ventolin and atrovent nebulizer  HR  I’m consulted as on for ICU…. Case continued

66 66 Clinical course of COPD

67 67  Burden of illness  Under diagnosis and role of targeted screening  The role of spirometry in diagnosis and staging  Staging by symptoms and by FEV1 Last time…

68 68 Goals of COPD care Preventing/ managing exacerbations Relieving symptoms Improving quality of life

69 69 5 point “PRIME” Plan: 1.Prevent further damage to your lungs 2.Relieve your symptoms › optimize drug therapy › work on mental outlook and coping mechanisms 3.Improve your general health and physical activity level 4.Manage COPD flare-ups with an “Action Plan” 5.Establish your COPD team › family, friends, physician, healthcare professionals, COPD educator A “Personal Management Plan” for COPD

70 70 Stepped approach to care Individuals at Risk Smokers Environmental Exposure All Patients: Exercise Rehabilitation Smoking Cessation Healthy Lifestyle Patient Education Increasing severity of COPD

71 71  An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”  Acute Exacerbations are THE LEADING CAUSE* of deaths, hospitalization and ER visits among COPD patients.  COPD and CHF and #1 and #2 for most common reason for medical admission to BC hospitals Acute exacerbations (AECOPD) or lung attacks

72 72  22-43% of patients hospitalized with AECOPD die within 1 year (Eriksen et a., 2003; Groenewegen et al., 2003)  In-hospital mortality for AECOPD is 7.8%-11.0%  There is increasing mortality with increased number of AECOPD.  A number of interventions can reduce the risk of AECOPD: › Long acting bronchodilator – tiotropium › LABA / ICS combo inhalers › Roflumilast (but not systematically assessed inpatients on triple therapy) › Education and Rehabilitation (AECOPD recognized earlier and treated before become severe) Acute exacerbations (AECOPD) or lung attacks

73 73 AECOPD frequency: mortality

74 74 Time course of AECOPD recovery

75 75 Benefits of COPD self management education

76 76  Patient education, including smoking cessation program  Prevention of exacerbations, vaccinations  Initiation of bronchodilator therapy  Encouragement of regular physical exercise  Close follow-up and disease monitoring Can Respir J 2008;15(Suppl A):1A-8A. Management of symptomatic: mild COPD

77 77  Patient education, including smoking cessation program  Prevention of exacerbations, vaccinations  2 long acting bronchodilators and add in ICS if chronic bronchitis or recurrent AECOPD  Encouragement of regular physical exercise  Close follow-up and disease monitoring Can Respir J 2008;15(Suppl A):1A-8A. Management of symptomatic: mild COPD

78 78  Consider oxygen  Mobility assistance  Consider roflumilast  Consider co-morbidities again  Initiate advanced care planning, maybe DNR form  Consider palliative help with dyspnea Management of severe COPD

79 79 Increasing disability & lung function impairment Mild Infrequent AECOPD (< 1/year) Frequent AECOPD (> 1/year) LAAC + ICS/LABA + SABA prn SABD prn persistent dyspnea LAAC + SABD prn or LABA + SABD prn LAAC + ICS/LABA + SABA prn +/- Theophylline persistent dyspnea Moderate Severe LAAC or LABA+ SABA prn LAAC + LABA +SABA prn LAAC + ICS/LABA + SABA prn persistent dyspnea Can Respir J 2008;15(Suppl A):1A-8A.

80 80  Smoking Cessation  Vaccinations  Self-Management Education with Case Manager and written Action Plan  Regular long-acting bronchodilator therapy  Regular inhaled ICS/LABA therapy in moderate-severe COPD and > 1 episode per year of AECOPD necessitating therapy  Appropriate treatment of episodes of AECOPD Can Respir J 2008;15(Suppl A):1A-8A. AECOPD: Prevention Strategies

81 81  Reducing AECOPD or lung attacks is key to › Patient survival › Patient QOL › Patient lung function › Keeping patients at home  How can we achieve this? › Medications › Vaccination › Smoking cessation/pulmonary rehabilitation. › Education / self management Take Home Points:

82 82 Nishimura K, et al. Chest 2002; 121: 1434: 40 Survival in COPD – Relationship to Lung Function and Disability

83 83  BODE index helps guide prognosis: › BMI › Obstruction (degree of ) › Dyspnea (severity of) › Exercise tolerance (or lack thereof)  Points add up to answer the Q: Am I going to survive for 4 years? › 0-2 Points: 80% › 3-4 Points: 67% › 5-6 Points: 57% › 7-10 Points: 18% Prognosis

84 84  FEV1 % Predicted After Bronchodilator >=65% (0 points) 50-64% (1 point) 36-49% (2 points) <=35% (3 points)  6 Minute Walk Distance >=350 Meters (0 points) Meters (1 point) Meters (2 points) <=149 Meters (3 points)  MRC Dyspnea Scale (5 is worst) MRC 1: Dyspneic on strenuous exercise (0 points) MRC 2: Dyspneic on walking a slight hill (0 points) MRC 3: Dyspneic on walking on the level; must stop occasionally due to SOB (1 point) MRC 4: Must stop for SOB after walking 100 yards or after a few minutes (2 points) MRC 5: Cannot leave house; SOB on dressing/undressing (3 points)  Body Mass Index  >21 (0 points) <=21 (1 point)

85 85 Prognosis - Survival by BODE Index

86 86 Domiciliary oxygen (≥ 15 hours/day to achieve SaO 2 ≥ 90%) improves survival in stable COPD patients with severe hypoxemia (PaO 2 ≤ 55 mmHg) or when the PaO 2 ≤ 60 mmHg in the presence of ankle edema, cor pulmonale or hemacrit ≥ 56%) Can Respir J 2008; 15(Suppl A):1 A-8A Long Term Oxygen Therapy: Survival

87 87

88 88  COPD care isn’t rocket science/brain surgery - you can do it!  First screen for COPD, then assess severity  Make a treatment plan (include an Action Plan for attacks)  Recruit help to enact the plan (build the team).  Promote advance care planning and when appropriate palliative components.  Summary

89 89 Heart Failure 101 Patient Education Resources

90 90 Heart Zones Patient Education Resources

91 91 Daily weight Patient Education Resources

92 92 Sodium Restriction Patient Education Resources

93 93 Fluid Restriction Patient Education Resources

94 94 Activity Patient Education Resources

95 95 Clinical Care Algorithms

96 96

97 97

98 98

99 99 PATIENT RESOURCES MEDICATIONS SODIUM FLUID EXERCISE EXACERBATION PLAN HF 101 A Comprehensive List of Patient and Provider Resources PROVIDER RESOURCES REFERRAL FORMS PATIENT ASSESMENT FORMS CARE MAPS & TX ALGORITHMS MEDICATION TITRATION PATIENT SYMPTOM STATUS VISIT SNAP SHOT

100 100 BC’s Heart Failure Website

101 101 Smoking Cessation 101

102 102 Progress in British Columbia Progress in BC BC sues tobacco companies Prevention program in schools BC Quitline Govt funding to $6.5M

103 103 Intention to Quit

104 104 Physicians discussing quitting Physicians Discussing Quitting

105 105 Effect of Physician intervention Effect of Intervention

106 106 What can Physicians do?

107 107 Strategies to help your patients quit Strategies  Complete Personal Risk Assessment for Rx for Health  Brief advice to quit smoking  Refer to behavioural support (like QuitNow)  Recommend patients call for NRT  Order Buproprion or Varenicline (prescription)

108 108 What is QuitNow?  Behavioural quit smoking support  Provincially Funded  Managed by the BC Lung Association  Evidence-based  Free, confidential, 24/7

109 109 Fax Referral Forms

110 110 Online Referral online

111 111 Indications for Referral to a HFC Heart Function Clinic Referral Form Referral Resources

112 112 Patient History/Assessment Heart Failure Patient Questionnair e

113 113 A Guide to HF Patient Assessment Patient Assessment Tool

114 114 Snapshot of Patient Visit

115 Referral and Consult Process

116

117

118 Planning for Action Period 2


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