Practice Support Program in
COPD: South Okanagan Project
COPD CARE Algorithm
South Okanagan, Interior Health
Patricia Rattee RRT, CRE
Shannon Walker MD, FRCPC Respirology
Why did we do this project?
 COPD is under-diagnosed.
 COPD is a chronic progressive respiratory disease for
which guidelines recommend a chronic disease
management approach through a multi-disciplinary team
and patient self-management endpoints.
 GPs may not have the time nor skills to promote selfmanagement disciplines to their patients with COPD.
 Tools currently exist for AECOPD discharge planning but
not for early identification or management of the COPD
outpatient.
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What do we hope to achieve?
 To promote early diagnosis of COPD in the community with
a case finding approach and registry
 To improve the care pathway of patients with COPD or
suspected COPD through the GPs office
 Develop relationships and care plans amongst family
physicians, patients, specialists and acute care /
community services
 To promote and encourage optimal management of COPD
patients according to national Canadian Thoracic Society
COPD guidelines
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5 step OFFICE APPROACH
VISIT 1: Patient Registry
Burden of COPD
Identification of Persons at Risk
VISIT 2: Screening of Persons at Risk
Smoking cessation
COPD-6 or Spirometry
VISIT 3: Confirmation
Spirometry interpretation
Assessment of level of disability
VISIT 4: Management
CTS guidelines for pharmacologic and non-pharmacologic treatment,
ACTION PLAN
VISIT 5+: Continuing Care
Follow up, Rehab, Co-morbidities, End of Life
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Visit 1: Identification
 BE AWARE OF THE BURDEN OF COPD in Canada and
world-wide
 WHO IS AT RISK?
› Formulate a patient registry
› Identify smokers and ex-smokers in the practice
› Have smoking cessation tools and contacts at hand
› Bring patient at risk back for screening
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Visit 2: Screening
 To screen for COPD, airflow obstruction not fully
responsive to BD needs to be demonstrated
 Physical exam, Xray, nor smoking history alone confirms
the diagnosis
 COPD-6 is useful office tool for screening in suspected
patients
 Differentiate from other airway diseases, and other causes
of SOBOE
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Visit 3: Confirmation of COPD and
Assessment of Severity
 Does spirometry confirm fixed airflow obstruction postbronchodilator?
 Is the patient still smoking?
 How severe is the FEV1?
 How severe are symptoms and/or disability?
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What constitutes “Severity”?
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Lung function
Level of symptomatology
Level of disability
Co-morbidities
Exacerbations and hospitalizations
Systemic effects
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Visit 4: Management of COPD
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Do they have COPD?
Are they still smoking?*
Do they have symptoms?
Have they had an exacerbation in the past year?
Answers to the above determines the starting point for
the management of COPD…
CTS management guidelines
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
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Optimal Pharmacotherapy
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Visit 5+: Continuing COPD Care and Tools
Prevention and Treatment of AECOPD
Management of progressive symptoms
Compliance and Medication Side-effects
Pulmonary Rehab
Respiratory Education
Patient Self-management and Action Plans
Re-assessment of lung function
Management of Co-morbidities
End of Life Care
COPD CARE PROGRAM
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Questions ???
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