1. Jacqui Carrett Respiratory Clinical Lead
COPD Update
Jacqui Carrett
Respiratory Clinical Lead

2. Aim of the session Overview of COPD
Look at the COPD Assessment Tool - CAT score
GOLD classification of patients
Spirometry update
Leave the session with at least one piece of information that you did not know at the start of the session!

3. 2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011
COPD
COPD is the only major cause of death which in increasing in the UK1
There are over 30,000 deaths from COPD annually in the UK – which equates to one person dying from COPD every 20 minutes in England1
Death rates from COPD are almost double the EU average 1
15% of those admitted to hospital with COPD die within 3 months and around 25% die within a year1
1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.
2. Chronic Obstructive Pulmonary Disease: Costing Report NICE 2011

4. COPD is projected to be the third biggest killer by 2020
26/11/ :46
COPD is projected to be the third biggest killer by 2020
1990
2020
Ischemic heart disease
CVD disease
Lower respiratory infection
Diarrhoeal disease
Perinatal disorders
COPD
Tuberculosis
Measles
Road traffic accident
Lung cancer
Ischemic heart disease
CVD disease
Lower respiratory infection
Diarrhoeal disease
Perinatal disorders
COPD
Tuberculosis
Measles
Road traffic accident
Lung cancer
3rd
6th
Stomach cancer
HIV
Suicide
Notes:
As part of the Global Burden of Disease Study, Murray and Lopez1 projected future mortality rates based on the most common causes of death in The top 10 most important causes of death are presented in this slide. The majority of these leading causes of deaths are projected to remain stable or decline.
Notably, COPD is expected to rise from the sixth biggest killer in 1990 to the third in Of the top 10 leading causes of death in 1990, only deaths caused by COPD, lung cancer and road traffic accidents are projected to rise.
Reference
Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349:1498–504.
Murray & Lopez 1997 4

5. COPD
Cost – COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS 1
80% of people with COPD have at least one other long-term condition. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and / or an anxiety disorder 1
24 million working days are lost each year from COPD with 3.8 billion lost through reduced productivity1
1.An Outcome Strategy for COPD and Asthma: NHS Companion Document 2012.

6. COPD Under diagnosis – estimated to be 2 million un-diagnosed
COPD is characterised by accelerated decline in lung function
Patients are not normally aware of a problem until half their lung function is lost

7. Drivers
Local and national guidelines / priorities – Locality commissioning framework
NICE quality standards for COPD – (updated 2016)
NICE clinical guidelines for COPD
NHS outcomes framework – 2016/2017
GOLD – Global strategy (2017 Report)

8. So…… what is COPD
Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterised by persistent airflow limitation, that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients. Although COPD affects the lungs, it also produces significant systemic consequences

9. Defining COPD
Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation previously diagnosed as having chronic bronchitis and emphysema

10. Risk factors Smoking – accounts for 90% cases
Alpha 1 antitrypsin deficiency – 1% cases
Increasing age
Gender
Occupation – coal mining, cotton processing, dusty occupations
Outdoor and indoor air pollution – e.g. burning of wood and other biomass fuels
Airway hyper-responsiveness
Lower socio-economic status
Low birth weight

11. Presenting features of COPD
Over 35 years age
Smoker or ex-smoker
Breathlessness on exertion
Chronic cough
Regular sputum production – common but not universal
Recurrent chest infections

12. Clinical features differentiating COPD and Asthma

13. Inflammation in Asthma V COPD
Although Asthma and COPD are both associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells involved in the two diseases, which in turn account for differences in symptoms and response to treatment
Asthma – eosinophils
COPD - Neutrophils

14. Diagnosis
There is no single diagnostic test and very often there are no physical signs

15. Diagnosis Take a full history
Confirmed by SPIROMETRY – this measures lung function
FEV1 - forced expiratory volume in 1 second
FVC – forced vital capacity
EVC – relaxed vital capacity
FEV1 FVC ratio – less than 70% demonstrates airflow obstruction
Mild disease – FEV1 > 80% predicted
Moderate disease – FEV1 – 50-79% predicted
Severe disease - FEV1 – 30-49% predicted
Very Severe disease – FEV1 less than 30%

16. New National Spirometry register
By 31st March 2021 All practitioners to be certified & listed on the register
Phased implementation of this requirement from 1st April this year (2017)
The National Register will be maintained by the ARTP - Association for Respiratory Technology & Physiology

17. 3 Certificates
1. Foundation: those who have been assessed as competent to perform safe, accurate and reliable spirometry tests without interpretation
2. Interpretation only: Those who have been assessed as competent in interpretation only (ie those with no responsibility / requirement to perform spirometry but who do have a requirement to interpret accurately the results of spirometry)
3.Full: those who have been assessed as competent to perform and interpret spirometry in terms of the physiological changes.

18. Foundation – performing tests
A professional portfolio is required relating to all aspects of preparation for, & performance of spirometry. This comprises compilation or creation of protocols, cleaning & calibration logs that ensure safety of the patient, checking for contraindications & preparation of the equipment to ensure accuracy etc.
This will include 10 patient tests.
Applicants will also complete a practical assessment of competence where spirometry is performed & observed by an ARTP approved assessor.

19. Full Certificate – performing tests and interpretation
Assessment at Full level includes both an observed practical assessment of competence and submission of a professional portfolio as required at Foundation level.
The 10 spirometry tests will cover a range of scenarios (obstruction, restriction & reversibility) & within this, these will then be interpreted within the context of the history of the patient described.
There will also be a written assignment.

20. Interpretation Only – interpreting tests without performing
Some prior knowledge of spirometry interpretation is advisable
There is no observed practical assessment at this level
A portfolio of 10 tracings that the individual has interpreted is required
Plus a written assignment.

21. Experienced Practitioner Scheme
Those with significant experience can apply to be confirmed as competent by having their skills assessed against ARTP standards. The Experienced Practitioner Scheme enables them to undertake an assessment of competence without attending any training
To achieve certificate of competence at either Foundation or Full levels – individuals must undertake an observed assessment of competence at their workplace, Portfolio requirements are assessed at the same time
For the full level, there is also an interpretation Viva and a written assignment.
Interpretation only level - A portfolio of 10 tracings plus interpretation is required – there is no written assignment

22. Re-certification Required on a 3-yearly basis
An observed assessment of competence
Plus submission of a comprehensive portfolio (continued calibration, quality assurance, infection control, evidence of quality spirometric measurements)
Where interpretation is required, an analysis of 5 traces provided by ARPT to review for technical quality & interpretation.

23. Treatment Smoking cessation
Bronchodilators are the mainstay of COPD treatment – short acting and long acting – B2 and anticholinergic
Combination inhalers – LABA+LAMA, LABA+ICS
Steroid inhaler now only recommended in patients who experience > 2 or > 1 exacerbation leading to hospital admission and high symptom scores or those with a history of Asthma-COPD overlap
Mucolytics
Pulmonary rehab
oxygen

25. CAT – COPD Assessment Tool
8 questions
Score ranges from 0 – 5
0 = no symptoms 5 = more symptoms
Helps guide your consultation to what are the most important symptoms for the patient
Helps monitor any response to changes
Change of 2 points is clinically significant

26. MRC DYSPNOEA SCALE
GRADE
Degree of breathlessness related to activities 1
Not troubled by breathlessness except on strenuous exercise 2
Short of breath when hurrying or walking up a slight hill 3
Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4
Stops for breath after walking about 100 m or after a few minutes on the level 5
Too breathless to leave the house, or breathless when dressing or undressing

27. Oxygen therapy
Indicated if resting sats < 92% and on maximal inhaled therapy
Refer to the Integrated Community Respiratory Service (ICRS)
Referral form
Either fax : or send via –
Not an emergency service

28. Other factors
Breathlessness, fatigue and anxiety occur more commonly in COPD patients than those with advanced cancer, heart disease or renal disease
Need to screen COPD patents for anxiety and depression
People with COPD frequently have other co-existing diseases or co-morbidities
Cardiovascular mortality in COPD – for every 10% decrease in FEV1 cardiovascular mortality increases by 28% and non-fatal coronary events increase by 20%

29. Any questions?