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COPD Chronic Obstructive Pulmonary Disease

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The cilia beat in a co-ordinated fashion to move mucus out of the airways ... Emerging evidence of enhanced effect of xanthines when combined with corticosteroid ... – PowerPoint PPT presentation

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Title: COPD Chronic Obstructive Pulmonary Disease


1
COPDChronic Obstructive Pulmonary Disease
  • By
  • Matthew Hodson
  • Respiratory Nurse Specialist COPD
  • Westminster Primary Care Trust

2
Aim of Session
  • Understand the epidemiology of COPD
  • Improve knowledge and understanding of COPD and
    its treatments
  • Increase awareness of Oxygen Therapy in COPD
  • Gain an greater insight into when COPD may be
    palliative and exploring options
  • Understand COPD Services in WPCT

3
Definition
  • Chronic obstructive pulmonary disease (COPD)
    is characterised by airflow obstruction. The
    airflow obstruction is usually progressive, not
    fully reversible and does not change markedly
    over several months. 1
  • The disease is predominantly caused by smoking.
  • 1. NICE 2004

4
The Umbrella Disease
5
Umbrella Disease
  • COPD now preferred term for previous diagnosis of
    bronchitis or emphysema, chronic asthma
  • Significant airflow obstruction may be present
    before individual is aware of it
  • May also be related to occupational exposures
    e.g. asbestos

6
Burden
  • Up to 1 in 8 emergency admissions maybe due to
    COPD 1
  • Over one million bed days are contributed to COPD
    1
  • A total of 32,155 deaths in the UK where
    attributed to COPD in 1999 1
  • 1 BTS Consortium 2005

7
Epidemiology
  • COPD is the fourth leading cause of death in the
    USA and Europe. The leading cause of death
    worldwide 1
  • Mortality in females has more than doubled over
    the last 20 years. 1
  • Nearly 900,000 people in England and Wales have a
    diagnosis of COPD 2
  • Morbidity data greatly underestimate the total
    burden of COPD because the disease is usually not
    diagnosed until it is clinically apparent and
    moderately advanced.1
  • COPD is a more costly disease than asthma and,
    depending on country, 5075 of the costs are for
    services associated with exacerbations. 1
  • 1 COPD Audit Commission 2 BTS Consortium 2005

8
Characteristic
  • Changes characteristic of the disease include
  • smooth muscle contraction (bronchoconstriction)
  • mucus hypersecretion
  • ciliary dysfunction
  • pulmonary hyperinflation
  • gas exchange abnormalities
  • pulmonary hypertension
  • cor pulmonale
  • These abnormalities contribute to the
    characteristic symptoms of COPD - chronic cough,
    sputum production and dyspnoea 1
  • 1 Pauwels et al, 2001

9
Healthy Respiratory Mucosa
This electron micrograph shows the respiratory
mucosa in a healthy state The cells are fully
ciliated The cilia beat in a co-ordinated
fashion to move mucus out of the airways
(mucociliary transport)
Scanning electron micrograph showing a sheet of
mucus being moved along by the cilia
10
Damaged Respiratory Mucosa
  • Damage to the cilia and epithelium occur as a
    result of disease processes in COPD. This can
    also occur as a result of bacterial damage
  • This slide shows the result of bacterial
    infection stripping away the cilia from the
    mucosa
  • The damage to the cilia means they are less
    effective in removing mucus from the airways

Scanning electron micrograph showing cilial and
epithelial damage induced by bacteria
11
  • Chronic Bronchitis
  • ? in mucus glands and goblet cells
  • Production of sputum on most days for gt 3 months
    on 2 consecutive years
  • Small airway disease
  • (structural changes in the small airways 2-5mm)
  • gt 50 of bronchioles may be effected before any
    SOB
  • ? airway smooth muscle
  • Inflammatory infiltration resulting in
    structural narrowing and distortion
  • Collagen deposition / fibrosis / mucous plugging

12
  • Emphysema
  • Dilation of alveolar wall
  • ? alveolar capillary network, loss of guy rope
    effect
  • ? lung tissue elasticity
  • Caused by smoking irritation inflammation
    neutrophils and macrophages release neutrophil
    elastase (type of proteases)

Emphysema
Normal Lung
13
(No Transcript)
14
The COPD Patient
  • Generally over 40 years 1
  • A smoker or ex-smoker
  • Presentation with
  • cough
  • excessive sputum production
  • shortness of breath
  • Dyspnoea is the reason most patients seek
    medical attention 3

1. BTS, 1997 3. GOLD, 2003
15
Diagnosis
  • gt35 years
  • Smoker or ex-smoker
  • Spirometry (obstructive pattern)
  • Any symptoms
  • Exertional breathlessness
  • Chronic cough
  • Regular sputum production
  • Frequent winter bronchitis
  • Wheeze
  • no clinical features of asthma

16
Clinical features of Asthma vs. COPD
17
Assessment of Severity of COPD
GOLD state that spirometry is the gold standard
for diagnosing COPD, severity is measured by
FEV1.
1 NICE Guidelines 2004
18
Impact of Chronic Disease
  • Impairment
  • Disability
  • Handicap

19
Management of COPD (Stable)
  • Use short acting bronchodilator PRN
    (beta2-agonist or anti-cholinergic)
  • If still symptomatic try combined therapy with a
    short acting beta2 agonist and a short acting
    anti-cholinergic.
  • If still symptomatic use a long acting
    bronch-dilator (beta2 agonist or
    anti-cholinergic)

20
Management In moderate or severe COPD
  • If still symptomatic consider a trial of a
    combination of a long acting beta2 agonist and
    inhaled corticosteroid. (Discontinue if no
    benefit after 4 6 weeks)
  • If still symptomatic consider adding
    theophylline.
  • Offer pulmonary rehab to all patients who
    consider themselves functionally disabled
    (usually MRC 3 and above)
  • Consider referral for surgery.
  • End of Life Care (need to start these
    conversations ,what the future will hold, discuss
    issues, worries and concerns with patients at an
    earlier stage. Palliative care being part of end
    of life care)

21
Acute exacerbation of COPD
  • Sustained worsening of patients symptoms from
    their usual stable state, which is beyond normal
    day-to-day variations and is acute in onset. 1
  • Symptoms
  • Increased shortness of breath
  • Increased sputum production and/or change in
    colour
  • Increased cough
  • Increased wheeze/tightness
  • Decreased exercise tolerance
  • Increased fatigue
  • Confusion
  • 1 NICE Guidelines 2004

22
Annual Review Primary Care
  • Smoking cessation
  • Spirometry
  • Need for Oxygen Assessment
  • Pharmacological Therapy - inhaler technique
  • Pulmonary Rehabilitation
  • LVRS / Transplantation
  • BMI Need for Dietician Input
  • Referral to other Services
  • MRC Scale
  • Need for Specialist Referral
  • Chronic NIV
  • End of Life Care

23
Severe COPD
  • Smoking cessation
  • Oxygen
  • Pharmacological Therapy
  • Pulmonary Rehabilitation
  • Dyspnoea Clinic
  • LVRS / Transplantation
  • Chronic NIV
  • End of Life Care - Palliation

24
Natural History
25
Look magazine ad from 1951
26
Oxygen Therapy
  • Long Term Oxygen Therapy (LTOT)
  • Short Burst Oxygen Therapy
  • Ambulatory Oxygen Therapy

27
Benefits of LTOT
  • Improved survival
  • Prevention of deterioration of pulmonary
    haemodynamics
  • Reduction in secondary polycythaemia
  • Neuropsychological benefit
  • improved sleep quality
  • Increased renal blood flow
  • reduction in cardiac arrhythmias
  • Reduction in dyspnoea, improved exercise
    tolerance
  • Should be worn for 15 hrs or more a day to gain
    these benefits

28
Short Burst Oxygen Therapy
  • Further research is required
  • Episodic dyspnoea not relieved by other
    treatments
  • Palliative therapy or in emergency situations
  • If improvement in dyspnoea or exercise tolerance
    can be documented

29
Ambulatory Oxygen Therapy
  • Improved exercise tolerance
  • Reduced dyspnoea
  • Improved quality of life

30
Medicines Management
  • Flu and Pneumonia vaccination
  • Bronchodilators
  • Coticosteroids
  • Mucolytics
  • Pharmacotherapy does not modify long-term
    decline, but is used to
  • prevent and control symptoms / improve exercise
    tolerance
  • reduce the frequency and severity of
    exacerbations
  • improve health status

31
Long Acting Inhaled bronchodilators e.g.
Salmeterol / Tiotropium
  • Significant improvement in lung function 1-3
  • better sustained improvement in lung function
    over 12 hours than ipratropium bromide 1
  • Improve shortness of breath day and night 1,3
  • Reduce risk of exacerbations vs. placebo 1
  • Clinically significant improvements in quality of
    life 4,5
  • unlike ipratropium bromide, Salmeterol
    significantly increased the percentage of
    patients showing a clinically relevant
    improvement in health status compared with
    placebo 5

1. Mahler et al, 1999, 2. Mahler et al, 2001, 3.
Boyd et al, 1997, 4. Jones et al, 1997, 5. Cox et
al, 2000
32
Xanthines - e.g. theophylline
  • Less commonly used than other bronchodilators
  • Only modest bronchodilators
  • Side effects within therapeutic range
  • Many drug interactions
  • Smoking can affect the metabolism of theophylline

33
Inhaled Corticosteroids
  • Inhaled steroids now limited to moderate
    symptomatic disease with ?2 exacerbations per
    year to reduce admission rates 1
  • Emerging evidence of enhanced effect of xanthines
    when combined with corticosteroid
  • 1 NICE (2004)

34
Mycolytics
  • Carbocisteine
  • Reduces sputum viscosity to aid expectoration
  • Reduces exacerbations of COPD in those with
    chronic productive cough
  • (caution in peptic ulceration / can cause
    gastrointestinal irritation)
  • Erdotin - Short course during acute exacerbation
  • GOLD guidelines (2007) suggest there is not
    enough evidence to support there use. However,
    there are a group of patients in which it works
    well in

35
Lung Reduction In Emphysema
Remove hyperinflated areas of lung Improve V/Q
matching Reduce resting length of respiratory
muscles Reduce Dynamic Hyperinflation
36
Pulmonary Rehabilitation
  • The goal of PR are to reduce the symptoms,
    disability and handicap to improve functional
    independence in COPD 5
  • Programme incorporates a programme of physical
    training, disease education, nutritional,
    psychological, social and behaviour intervention
    5
  • Provided by a inter professional team, with
    attention to individual goals and needs.
  • Improves exercise tolerance and function /
    reduces dyspnoea / improves QOL 1,2
  • Empowerment for patients to manage their own
    condition recognition of exacerbations.
  • 1 Ries et al. 1995, 2 De Paepe et al. 2000 3,
    Griffiths at al.2000, 4, Troosters et al, 2000 5
    BTS 2001

37
Pulmonary Rehabilitation
  • Introduction
  • Benefits of exercising
  • Anatomy, Physiology and Pathology
  • Medication
  • Chest Clearance techniques
  • Dyspnoea management
  • OT pacing/aids
  • Age Concern Benefits system
  • Exacerbation
  • Nutrition
  • Psychosocial factors - Coping/Anxiety/Panic
  • Breath easy
  • Expert patient
  • What next? Health improvement team

38
Chronic Non-Invasive Ventilation
  • Domiciliary NIV for a highly selected group of
    COPD patients with recurrent admissions requiring
    assisted ventilation is effective at reducing
    admissions and minimizes costs from the
    perspective of the acute hospital 1
  • 1 Tuggey JM, Plant PK, Elliott MW. Thorax. 2003

39
When does COPD become Palliative? (1 of 2)
  • Primary clinical indicators
  • FEV1 lt 30 pred
  • History of gt2 acute exacerbations in last 12
    months
  • Frequent admissions to hospital
  • Progressive shortening of of the intervals
    between admissions
  • Limited improvement following admission 1

40
When does COPD become Palliative? (2 of 2)
  • Supporting clinical Indicators
  • On maximum therapy- no other intervention is
    likely to alter the conditions progression
  • Dependence on oxygen therapy
  • Severe unremitting dyspnoea (MRC Dyspnoea Scale
    grade 5)
  • Severe co morbidities e.g. heart failure,
    diabetes
  • Housebound unable to carry out normal ADL

41
MRC DYSPNOEA SCALE
42
Consider
  • Mortality in severe COPD is between 36 and 50
    at 2 years 1
  • In the last year of life 2
  • 40 had unrelieved breathlessness
  • 68 had low mood unrelieved
  • 51 had unrelieved pain
  • 20 did not know they might die
  • 70 died in hospital (for 25 of whom it was not
    the best place to die)
  • It has been shown that NIV in acute exacerbations
    of COPD reduces mortality and need for ICU 3,4

1 Connors et al AJRCCM 1996 2 Elkington et al
Palliat Med 2005 3 Brochard et al N Engl J Med
1995 4 Plant et al Lancet 2000
43
Dyspnoea - Symptomatic Treatment
  • Opioids
  • Mechanism unclear
  • ? respiratory drive, ?sensation of respiratory
    muscle fatigue, cognitive changes, central
    effect, cough suppressant 2
  • Oral morphine 2.5 4 hourly (dose maybe escalated
    if well tolerated) 1

No evidence to support nebulised morphine
1 Watson et al 2006 2 Jenner 1991
44
Dyspnoea related to Anxiety
  • Benzodiazepines
  • Examples include
  • - Diazepam 2 5mgs BD and PRN
  • - Lorazepam 1 2 mgs p.r.n 1
  • 1 Watson et al 2006

45
Oxygen Therapy
  • Some patients do derive good benefit if not
    already on LTOT
  • But Beware the CO2 retainers
  • Also
  • Risk of psychological dependence
  • Paradoxical restriction to activity
  • Dry mouth / nose
  • Isolation and communication problems
  • Consider open window, fan, cool flannel, heliox

46
Intractable Cough
  • Steam inhalation
  • Nebulisation - (0.9 sodium chloride. Consider
    nebulised bronchodilation and steroid)
  • Oral morphine 2.5 - 5mg, 4 hourly 1
  • 1 Watson et al 2006

47
Excessive Respiratory Secretions
Pharmacological Management
  • Hyoscine Hydrobromide Patches or sub cut.
  • Glycopyrronium
  • Care must be taken to prevent dry mouth

48
Terminal Breathlessness
  • Non-pharmacological management
  • Touch
  • Relaxation
  • Environment
  • Modelling of behaviour
  • Subcutaneous Route may be necessary

49
COPD CNS - Current Role (1 of 2)
  • To provide expert treatment for all COPD patients
    Westminster, in line with the NICE guidelines
  • To provide expert advice and education to
    patients and carers
  • To educate and advise other health care
    professionals on the management of COPD patients
    in both primary and secondary care settings
  • To reduce hospital admissions, length of stay and
    improved use of primary care resources

50
COPD CNS - Current Role (2 of 2)
  • To support GPs and non-respiratory consultants in
    diagnosis and management of COPD patients
  • To continue to develop services for COPD patients
    in both primary and secondary care.
  • Work with Community Matrons and other community
    staff i.e. rapid response nurses in the
    management of exacerbations of COPD
  • Support COPD patients on Long Term Oxygen therapy
  • Proactive Health Screening for COPD

51
Community COPD Service
  • Home Visits COPD Nurse Specialist
  • Education and advice Proactive Management
  • Smoking cessation
  • Review of medication and Inhaler technique
  • Assess Home Situation
  • Long Term Oxygen Assessment / Review
  • Supported discharge from Hospital
  • Exacerbation recognition/management plans
  • Ongoing support and advice Telephone

52
Community COPD Service
  • Community Clinic COPD Nurse Specialist
  • Education and advice Proactive Management
  • Smoking cessation
  • Review of medication and Inhaler technique
  • Long Term Oxygen Assessment / Review
  • Exacerbation recognition/management plans
  • Advice and Support
  • Identification Referral to other agencies

53
And I havent touched on
  • The Management of an COPD Exacerbation
  • Inhaler Technique / Nebulisers
  • Diet Nutrition
  • Anxiety and Depression
  • We will leave that for another day!

54
(No Transcript)
55
Thank You
  • Any Questions?

56
Case Study 1
  • Mrs Jones Age 63
  • Retired Care Worker
  • Heavy smoker, still smoking 2 -3 day
  • Diagnosed with COPD 2 years ago, after spilling a
    bottle of bleach
  • Smokers cough / winter chest infections for
    years
  • Housebound Lives Ground Floor Flat
  • On maximum inhaled therapy including nebuliser
  • Long Term Oxygen
  • Nocte BiPAP
  • Problems
  • - Unable to accept diagnosis of long term
    condition
  • - Depressed and socially isolated
  • - Breathless on minimal exertion
  • - Continues to smoke

57
COPDChronic Obstructive Pulmonary DiseaseCOPD
Project Nurse End of Life Care
  • By
  • Matthew Hodson
  • Respiratory Nurse Specialist COPD
  • Westminster Primary Care Trust

58
Definition
  • Chronic obstructive pulmonary disease (COPD)
    is characterised by airflow obstruction. The
    airflow obstruction is usually progressive, not
    fully reversible and does not change markedly
    over several months. 1
  • The disease is predominantly caused by smoking.
  • 1. NICE 2004

59
The Umbrella Disease
60
Background
  • Mortality in Severe COPD is between 36 50 at 2
    years
  • - High Number of Hospital Admissions
  • Exacerbations
  • Type 2 respiratory failure
  • Non Invasive Ventilation
  • Access to specialist palliative care variable
  • Traditionally on malignant disease into SPC
  • Improving care and patient journey
  • Patient Pathways acute / suspected / stable
    EOL missing

61
The Role
  • Project Nurse COPD End of Life
  • 6 Month Role
  • 2 days a week

62
Scope of Role
  • To understand the current provision of general
    palliative care by GPs, Practice Nurses, DNs and
    Community Matrons to COPD patients and their
    knowledge of this area of care.
  • To assess the current local provision of
    palliative care needs for COPD patients in
    Westminster
  • To understand the potential benefits of
    specialist palliative care to COPD patients.

63
Scope of Role
  • To provide and develop an education opportunity
    for general providers regarding recognising
    palliative needs in COPD patients.
  • To produce a guideline and pathway for
    recognising and managing COPD patients at the end
    of their life, linking in with the overall EOL
    care pathways.

64
Outcome Measures
  • Baseline Audit Completed
  • Improved rates of referral to SPC
  • Care pathway for COPD into SPC
  • Guidelines on criteria for referral
  • Education for Primary Care Staff
  • Evaluation and recommendations for the future
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