COPD
Disease not
Disorder?
Alyn Morice
University of Hull
HYMS
AHM 2011
What is COPD?
Asthma (eosinophilic bronchitis)
Emphysema
Chronic Bronchitis
(neutrophilic bronchitis)
2010
Page 1 of 673!
COPD Treatment Pathway
Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio
<70%) Establish severity of disease by FEV1 as % predicted
Management of RISK FACTORS plus EDUCATION plus IMMUNISATION
SMOKING CESSATION
Lifestyle Advice
Diet/Exercise
Influenza vax (annual)
Pneumococcal vax.
Psychological Issues
Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)
PHARMACOLOGICAL TREATMENT
Review at each step after one month before
escalating treatment
SHORTNESS
OF BREATH
prn short acting β2 agonist
COUGH AND
SPUTUM
Tiotropium + short acting β2 agonist
Tiotropium + long acting β2 agonist (LABA)*
*salmeterol, eformoterol or indercaterol
Tiotropium + combination LABA and inhaled corticosteroid
(Seretide 500 accuhaler or Symbicort 200/6)
Roflumilast + Tiotropium + short acting β2 agonist
( Weight loss)
Tiotropium + combination LABA and inhaled
corticosteroid
(Seretide 500 accuhaler or Symbicort 200/6)
Consider Palliative Care Referral in End Stage Disease
M
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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 lowquality
– Polisena (2010): Telehealth interventions improved QoL and
reduced hospitalisations
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
Best health, best health care, a health service fit for the East Riding
The East Riding Model
IDENTIFY
GP’s/NCT
Patient at risk
of deterioration
•
•
Risk
stratification
identifies
patient
MDT agrees
intervention
REFER
1. Referral for
telehealth
intervention
2. Patient
registered &
unit installed
MONITOR
RESPOND
1. Monitoring
Telephone patient
2. Alerts
3. Triage
4. Response
Visit - within identified
timescale
Emergency Response
Step up / Step down
Community Beds
Protocols for response in place:
GP, NCT , specialist services,
secondary care
Best health, best health care, a health service fit for the East Riding
Telemonitoring in COPD – How can it work?
Telemonitoring in COPD – suggested mechanisms
of action
• It has been suggested that telemonitoring can support COPD
patients by;
– Providing reassurance and support
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
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
Best health, best health care, a health service fit for the East Riding
Telehealth then...
14
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 selfcare
– Providing reassurance and support
The impact of frequent COPD exacerbations
- more frequent attacks increase mortality
Survival probability
1.0
n=304
0.8
A
p<0.0002
0.6
B
p=0.069
0.4
p<0.0001
C
0.2
0
0
10
20
30
40
Time (months)
Soler-Cataluna JJ, et al. Thorax 2005;60:925–931
50
60
Group A: no exacerbations
Group B: 1–2 exacerbations
Group C: ≥3 exacerbations
COPD patients with productive
cough
• More likely to have exacerbations
Seemungal TA et al. Am J Respir Crit Care Med 98
• 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
Prescott E et al. Eur Respir J 1995
Timing of symptoms:
when was each symptom the most troublesome?
30
50
Breathlessness (n=1,769)
31.0
24.0
20
22.5
19.5
10
10.6
% of patients
% of patients
40
Cough (n=1,433)
40
30
20
22.3
18.7
17.3
In the
evening
At night
14.9
10
0
0
On
Later in the In the
Waking morning afternoon
40
In the
evening
On
Later in the In the
Waking morning afternoon
At night
60
Chest tightness (n=690)
30
28.8
25.9
25.4
25.5
20
16.7
10
% of patients
50
% of patients
48.9
40
30
20
10
0
Phlegm (n=1,551)
56.7
26.2
16.3
16.6
11.8
0
On
Later in the In the
Waking morning afternoon
Partridge et al. ERS Vienna 2009
In the
evening
At night
On
Later in the In the
Waking morning afternoon
In the
evening
At night
19
HULL AIRWAYS REFLUX QUESTIONNAIRE
Name:
D.O.B:____________________________ UN: _________________
DATE OF TEST:
Please circle the most appropriate response for each question
www.issc.info
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 voice
0
1
2
3
4
5
Clearing your throat
0
1
2
3
4
5
Excess mucus in the throat, or drip down the back of
your nose
0
1
2
3
4
5
Retching or vomiting when you cough
0
1
2
3
4
5
Cough on first lying down or bending over
0
1
2
3
4
5
Chest tightness or wheeze when coughing
0
1
2
3
4
5
Heartburn, indigestion, stomach acid coming up (or
do you take medications for this, if yes score 5)
0
1
2
3
4
5
A tickle in your throat, or a lump in your throat
0
1
2
3
4
5
Cough with eating (during or straight after meals)
0
1
2
3
4
5
Cough with certain foods
0
1
2
3
4
5
Cough when you get out of bed in the morning
0
1
2
3
4
5
Cough brought on by singing or speaking (for
example, on the telephone)
0
1
2
3
4
5
Coughing during the day rather than night
0
1
2
3
4
5
A strange taste in your mouth
0
1
2
3
4 TOTAL
5 SCORE_____________ /70
History of Cough Recording
Woolf & Rosenberg,Thorax 1964:19;125
History of Cough Recording
Woolf & Rosenberg,Thorax 1964:19;125
Waveforms showing acoustic events – Pre and post filtering
unprocessed
file
processed
file
Cough counting in exacerbations of COPD
•Day 1 546 coughs
•Day 5 162 coughs
80
70
cough/hour
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time hours
Future of telemonitoring in COPD
25