alyn morice university of hull hyms
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COPD Disease not Disorder?. Alyn Morice University of Hull HYMS. What is COPD?. Asthma ( eosinophilic bronchitis). Chronic Bronchitis ( neutrophilic bronchitis). Emphysema. 2010. Page 1 of 673!. COPD Treatment Pathway. - PowerPoint PPT PresentationTRANSCRIPT
AHM 2011
Alyn MoriceUniversity of HullHYMS
COPDDisease notDisorder?
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
Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)
SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues
PHARMACOLOGICAL TREATMENT
Review at each step after one month before escalating treatment
THEOPHYLLINE
MUCOLYTICS
prn short acting β2 agonist
Tiotropium + short acting β2 agonist
SHORTNESS OF BREATH
Consider Palliative Care Referral in End Stage Disease
Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol
Tiotropium + combination LABA and inhaled corticosteroid
(Seretide 500 accuhaler or Symbicort 200/6)
COUGH AND SPUTUM
Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss)
Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)
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 low-
quality– Polisena (2010): Telehealth interventions improved QoL and
reduced hospitalisations
Best health, best health care, a health service fit for the East Riding
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
• Risk stratification identifies patient
• MDT agrees intervention
Protocols for response in place:GP, NCT , specialist services,
secondary care
GP’s/NCT
1. Referral for telehealth
intervention
2. Patient registered & unit installed
Patient at risk of deterioration
2. Alerts
3. Triage
4. Response
1. Monitoring
IDENTIFY
REFERMONITOR
RESPOND
Telephone patient Visit - within identified timescale
Emergency Response
Step up / Step down Community Beds
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
Best health, best health care, a health service fit for the East Riding
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
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
self-care– Providing reassurance and support
The impact of frequent COPD exacerbations - more frequent attacks increase mortality
Soler-Cataluna JJ, et al. Thorax 2005;60:925–931
Group A: no exacerbationsGroup B: 1–2 exacerbationsGroup C: ≥3 exacerbations
n=304
Time (months)
p<0.0001
p<0.0002A
B
C
p=0.069
0 10 20 30 40 50 60
1.0
0.8
0.6
0.4
0.2
0
Surv
ival
pro
babi
lity
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 functionVestbo J 1996, Kanner RA et al. Am J Respir Crit Care Med 01
• More likely to die earlyPrescott E et al. Eur Respir J 1995
% o
f pat
ient
s
On Later in the In the In the At night Waking morning afternoon evening
31.0
24.0 22.519.5
10.6
Breathlessness (n=1,769)
28.825.9 25.4 25.5
16.7
Chest tightness (n=690)
40
30
20
10
0
Timing of symptoms: when was each symptom the most troublesome?
19
% o
f pat
ient
s
On Later in the In the In the At night Waking morning afternoon evening
40
30
20
10
0
% o
f pat
ient
s
On Later in the In the In the At night Waking morning afternoon evening
48.9
22.3
14.918.7 17.3
Cough (n=1,433)50
40
30
20
10
0
% o
f pat
ient
s
On Later in the In the In the At night Waking morning afternoon evening
56.7
26.2
16.3 16.611.8
Phlegm (n=1,551)60
50
40
30
20
10
0
Partridge et al. ERS Vienna 2009
HULL AIRWAYS REFLUX QUESTIONNAIREName:D.O.B:____________________________ UN: _________________DATE OF TEST:Please circle the most appropriate response for each question
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 5TOTAL SCORE_____________ /70
www.issc.info
History of Cough Recording
Woolf & Rosenberg,Thorax 1964:19;125
History of Cough Recording
Woolf & Rosenberg,Thorax 1964:19;125
unprocessed file
processed file
Waveforms showing acoustic events – Pre and post filtering
Cough counting in exacerbations of COPD
• Day 1 546 coughs• Day 5 162 coughs
0
10
20
3040
50
60
70
80
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
cough/hour
Future of telemonitoring in COPD
25