1. COPD The Why, The How, and The Where
Jo Congleton
Consultant in Integrated Respiratory Care

2. COPD Why How Where Why has the CCG commissioned a LCS for COPD?
To Diagnose
To Manage
Where
To get help

3. Prevalence of COPD
WHO Global Burden of Disease 5th Cause of Death in 2002
BOLD programme Global 10.5% Adults aged >30yrs
QOF B+H CCG 1.3% of total population
EPHO Predicted for B+H CCG 3.6% of population

4. QoF Registered COPD in B+H CCG
EHPO Predicted 9,998
PMA Majority of COPD deaths on QoF register
Exception rate 37% vs 14%
Current exception rate 11%

5. National COPD Audit Primary Care
National COPD Audit Programme Data from 48,029 COPD registered patients in Wales

6. High Quality COPD Annual Reviews
COPD, not on Register
Not COPD and on QoF Register
COPD and on QoF register

7. AECOPD admissions at BSUH
Slight upward trend of no. of admissions
Low length of stay (downward trend)
High 30 day re-admission rate (trend static for all cause, upward for COPD related)
Low in hospital mortality (downward trend)

8. The How: GUIDELINES
NICE 2010
GOLD 2017
ATS/ERS Exacerbations 2017

9. COPD Definition GOLD 2017
COPD is a common, preventable and treatable disease that is characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases

10. Diagnosing COPD AND Typical Symptoms
Spirometry
Post-bronchodilator FEV1/FVC < 70%
Exposure to risk factors (significant smoking history)
Typical Symptoms
(dyspnoea, cough, sputum, production)
AND

11. this is how we understand COPD now-the airflow obstruction can occur 3 ways: in the larger airways, the smaller airways (fibrosis-most important site of airflow obstruction in COPD) and due to loss of elastic recoil causing pressure dependant airflow obstruction in emphysema and the three components can vary in their extent.  In addition emphysema causes destruction of the alveolar-capillary interface, and this affects gas exchange.

13. Evolution of COPD

14. TTrash Can

15. Normal flow-volume curve
Obstructive disorder:
Severe obstructive disorder:

16. Airflow obstruction: severity
FEV1:FVC ratio < 70% (i.e. < ¾ of lung volume expired in 1 second)
Graded by FEV1 % predicted:
Mild <100% predicted
Moderate <80% predicted
Severe <50% predicted
Very severe <30% predicted

17. Symptoms: MRC dyspnoea grade CAT score

18. Many patients have features of asthma and COPD
Does my patient have asthma or COPD? or What is this Asthma COPD Overlap Syndrome? (ACOS)
Many patients have features of asthma and COPD
Older age group
Childhood asthma
Significant smoking history

19. Aims of Management Reduce Symptoms Reduce Risk of Exacerbations
Prolonging life

20. Management Reducing Symptoms Reducing Risk of Exacerbations
Bronchodilators PR
Reducing Risk of Exacerbations
LABA/ICS
Prolonging life
Smoking Cessation
LTOT
(Reducing exacerbations)

21. The Value Pyramid Triple Therapy £35,000-£187,000 LABA £8,000/QALY
LAMA
£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
This is why we should always ensure best value from our management! The value pyramid was devised by the London Respiratory Programme and we find  it a useful way of demonstrating value from various interventions. Note the big step up in cost per QALY (Quality Adjusted Life Year) at the peak of the pyramid (triple therapy, i.e LABA and ICS in combination plus LAMA). It is therefore lf evident that interventions lower down the pyramid should be addressed before considering prescribing ‘at the peak.’ 21 21

23. Exacerbations Symptoms
High risk, less symptoms
High risk, more symptoms
Low risk, less symptoms
Low risk, more symptoms
Exacerbator
2 or more per year
Non-exacerbator
0 /1 per year
MRC < 3
CAT < 10
MRC 3 or more
CAT 10 or more
MRC 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

24. Exacerbations Symptoms
High risk, less symptoms
LAMA
LABA/LAMA
High risk, more symptoms
LABA/LAMA (LABA/ICS)
(Triple therapy)
Low risk, less symptoms
prn SABA or SAMA
(LAMA or LABA)
Low risk, more symptoms
LAMA or LABA
(LAMA /LABA)
Exacerbator
2 or more per year
Non-exacerbator
0 /1 per year
MRC < 3
CAT < 10
MRC 3 or more\
CAT > 10
MRC 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

25. Inhaled Therapy B agonists Anti-Muscarinics Inhaled Corticosteroids
SABA
LABA
Anti-Muscarinics
SAMA
LAMA
Inhaled Corticosteroids
ICS
Low dose/ Medium dose /high dose

26. Metered Dose Inhalers (MDI’s)
Evohaler
Metered Dose Inhalers (MDI’s)
Autohaler
Easi-breathe
Breath Actuated MDI’s
MDI’s with dose counters
Respimat

27. Dry Powder Inhalers Novolizer Ellipta Genuair Accuhaler Forspiro
NEXThaler
Breezhaler
Handihaler
Zonda
Spiromax
Inhaler & caps
Easyhaler
Turbohaler
Twisthaler

28. Devices
MDI
Slow and Steady
Dry Powder
Fast and Deep

29. The correct inhaler device….
…Is the one that the patient is able to use and will use
There is no place for an ICS containing mdi without concurrent use of a spacing device

30. Long Acting Muscarinics
Eklira ▼
Genuair (Aclidinium)
Incruse ▼
Ellipta (Umeclidinium)
Braltus
Zonda (Tiotropium)
Spiriva (Tiotropium)
Seebri ▼ Breezhaler (Glycopyrronium)
Respimat
Handihaler

31. Formulary LAMAs Eklira ▼ Genuair (Aclidinium) Braltus
Zonda (Tiotropium)
Spiriva (Tiotropium)
Respimat
Handihaler

32. Long acting bronchodilators and long acting muscarinics
LAMA/LABAs
Spiolto Respimat ®▼
(Oldaterol/ Tiotropium)
Anoro Ellipta ® ▼
(Vilanterol & Umeclidinium)
Duaklir Genuair ® ▼
(Formoterol & Aclidinium)
Ultibro Breezhaler ®▼
(Indacaterol & Glycopyrronium)

33. Formulary LABA/LAMAS Spiolto Respimat ®▼ (Oldaterol/ Tiotropium) SOON
Duaklir Genuair ® ▼
(Formoterol & Aclidinium)
Ultibro Breezhaler ®▼
(Indacaterol & Glycopyrronium)

34. ICS + COPD Only effect is on exacerbation rate
Only positive trials are when used in combination with LABA (LABA/ICS)
Only effect is on exacerbation rate
Balance with increase in pneumonia
New (GOLD) guidelines defer adding ICS (LABA/ICS)
If using ICS keep steroid burden as low as possible

35. Time to 1st pneumonia NNT 44 patients with FP/SV for 3 years to prevent one exacerbation of COPD NNH 16 patients to induce one pneumonia
Probability (%)
Time to first event (weeks)
SCO study

36. Long Acting Bronchodilators and Inhaled Corticosteroids
Seretide Accuhaler ® (Salmeterol & Fluticasone propionate)
Relvar Ellipta ®▼ – (vilanterol & Fluticasone Furoate)
AirFluSal Forspiro ® (Salmeterol & Fluticasone propionate)
MDI
NEXThaler
Symbicort Turbohaler ®
(Formoterol & Budesonide)
DuoResp Spiromax ® (Formoterol & Budesonide)
Fostair ® – (Formoterol & Beclometasone)

37. Formulary LABA/ICS
Seretide Accuhaler ® (Salmeterol & Fluticasone propionate)
AirFluSal Forspiro ® (Salmeterol & Fluticasone propionate)
MDI
NEXThaler
Symbicort Turbohaler ®
(Formoterol & Budesonide)
DuoResp Spiromax ® (Formoterol & Budesonide)
Fostair ® – (Formoterol & Beclometasone)

38. Asthma COPD Overlap Syndrome (ACOS) Management
Older age group
Childhood asthma
Significant smoking history
Main therapeutic difference is to use LAMA earlier (than if pure asthma)
And to use lower doses of ICS (than if pure COPD)

39. Tips for prescribing in COPD
Always check inhaler technique
Remember non-pharmacological interventions (PR)
Inhaled corticosteroids only for:
co-existent asthma
frequent exacerbations despite other measures
If use ICS, aim for low steroid burden
Always include a spacer for mdi prescription
Only make one change at a time
Check inhaler technique again!

40. Where: To get help Secondary Care
Management of severe exacerbations (IP)
COPD discharge bundle
Diagnostic clarification (OPA), assess for additional conditions (ILD, pulmonary hypertension)
Assess for referral for home NIV
Assess for LVRS / Lung Transplant referral

41. Integrated Respiratory Service Brighton and Hove Locality
Brighton General Hospital
Dyke Building
Elm Grove
Brighton, BN2 3EW
Mon-Fri 8am-8pm
Sat/Sun/BH 8.30am-4.30pm

42. Referrals Patients accepted: COPD Asthma – chronic asthmatic patients
ILD
Bronchiectasis
Referral time frame:
URGENT within 24 hours – must speak to IRS rapid clinician prior to referral and be reasonable request for visit.
ROUTINE within 2-4 weeks
Referrals cannot be processed until the team have received:
Up to date medical history and drug history
Confirmation of diagnosis (Spirometry, PEF diary, CT scan)
Lone worker risk specified

43. Diagnostic confirmation of disease
COPD
Spirometry must include trace and be reproducible to be accurately interpreted.
If CT shows emphysema will accept onto service pending spirometry from PN
If the hospital refer we will expect the spirometry to be done by them.
If any difficulties with obtaining reproducibility please call IRS to discuss
Asthma
Spirometry if obstructive with reversibility
PEF diary
If long standing diagnosis but no diagnostic test available as confirmation of disease to refer to secondary care to confirm
Bronchiectasis and ILD
CT Scan

44. IRS Multidisciplinary Team
The patient
Respiratory Nurses
Physios
Oxygen practitioners
Occupational therapist
CBT therapist
Respiratory rehab assistant
Consultant
BSUH COPD Nurse

45. Purpose of referral
Airway clearance – physios will develop individual regimes with/without adjuncts
Review inhaler medications – nebs not given to patients who are able to use inhalers
Rapid response – after initial assessment patients can self refer if difficulty with their breathing. Patient will be contacted within 2 hours and triaged over the phone.
Anxiety – CBT and OT

46. Pulmonary Rehabilitation
Benefits - ↑exercise capacity, dyspnoea, health status, psychological wellbeing, muscle strength. ↓exacerbations
Inclusions/exclusions – able to walk 100m, cardiac stable, pain/functional/cognition issues
Waiting list – Aim to enroll and start PR within 13 weeks of referral
Pre assessment – walk test in clinic, check obs and meds, questionnaires
Content – individualised CV and resistance work, education
Duration – twice weekly for 6 weeks
Venues:
Salvation Army, Brighton
Tuesday and Friday afternoon 2pm-4pm
Portslade Town Hall
Monday and Thursday Morning 10am-12pm

47. Oxygen therapy Referrals
LTOT: Spo2 ≤92% at rest and not within 5-8 weeks of exacerbation, SpO2 ≤94% with secondary conditions PH, RSHF, Polycythaemia (to provide Blood Test)
Ambulatory: Never urgent referral
Palliative: If GP/pall care seen. GP to Px oxygen on Part A and refer in. SpO2 ≤ 92%
Risk assessment vital
What information would you like in Oxygen clinic letters?

48. End of life care
Identifying patients: gold standard framework (recurrent admission, LTOT, MRC 4/5, RSHF, NIV, Low BMI, >6 weeks steroids in last 6/12)
Breathlessness Mx – oromorph (side effects)/fan therapy
Anxiety Mx – lorazepam
Cough Mx - Simple linctus-codeine linctus-oramorph-methadone 2-4mg nocte (long half life)
IBIS – upload ACP, inform paramedic crew re: DNAR and situation. Reduce unecessary hospital admissions
DNAR – clinician will contact GP to do following discussion