1. Picking up the Clues Bert the breathless patient….. Date of Preparation: Mar 2015 GL/XBR/0315/0356

2. Other causes of breathlessness

3. What could it be? Reproduced with permission from Dr Noel Baxter GP

4. Prevalence of breathlessness activity (coding) as a proportion of the over 40s per practice Reproduced with permission from Dr Noel Baxter GP

5. How do we assess breathlessness and impact on the life of someone living with COPD?

6. MRC Dyspnoea Score GradeDegree of breathlessness related to activities 1Not troubled by breathlessness except on strenuous exercise 2Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level because of breathlessness, or stops for breath when walking at own pace 4Stops for breath after walking about 100m or a few minutes on the level 5Too breathless to leave the house, or breathless when dressing or undressing Fletcher CM (Chairman) (1960). Standardised questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on the aetiology of chronic bronchitis (MRC Breathlessness Score) British Medical Journal 2, 1665

7. Modified MRC (mMRC)

8. Other tools to consider Visual analogue scales Oxygen cost diagram Noseda A, Carpiaux JP, Schmerber J, Yernault J-C (1992). Dyspnoea assessed by visual analogue scale in patients with obstructive lung disease during progressive and high intensity exercise. Thorax 47; 363-368 McGavin CR, Artvinli M, Naoe H, McHardy GJR (1978). Dyspnoea, disability and distance walked: comparison of estimates of exercise performance in respiratory disease. British Medical Journal 2; 241-243

9. Assessing response Able to do more? Less breathless? Able to walk further? Feels better? Sleeps better? Jones PW, Harding G, Berry P, et al (2009). Development and first validation of the COPD Assessment Test. European Respiratory Journal. 34:648-654

10. COPD Assessment Test (CAT) Validated tool Assess impact on health status Different domains Composite score but need to look at individual domain scores Jones PW, Harding G, Berry P, et al (2009). Development and first validation of the COPD Assessment Test. European Respiratory Journal. 34:648-654

11. What other tools are out there? Research or real life?

12. Treatment choices in COPD https://www.nice.org.uk/guidance/cg101 Bronchodilators are the mainstay of treatment for COPD Even if reversibility tests are negative patients can be less breathless and feel better.

13. Bronchodilators FEV 1 RV FEV 1 RV Total lung capacity FVC Pre-bronchodilator Post-bronchodilator Booker R, 2006 ©Education for Health.

14. Why use bronchodilators? The optimal drug and dose needs to be determined individually after therapeutic trial Measure response by improvements in disability and ‘well-being’. https://www.nice.org.uk/guidance/cg101

15. IMPRESS breathlessness algorithm https://www.networks.nhs.uk/nhs-networks/impress-improving-and- integrating-respiratory/news/impress-breathlessness-resources

16. Signposting to services already commissioned Reproduced with permission from Dr Noel Baxter GP

17. Prioritising psychological/dietary/activity interventions Reproduced with permission from Dr Noel Baxter GP