Update on Asthma and COPD

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Update on Asthma and COPD

• Fiona Horwood Diana Hart

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We are both from-
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Our Roles

• Diana Nurse practitioner
• NP since 2006
• Works in community 80
• Fiona respiratory physician
• Based at Middlemore
• Works in multi disciplinary clinics
• Interest in chronic respiratory conditions (COPD)
  and pulmonary rehabilitation

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Aim of this session

• Update on a few topical issues in Asthma and COPD
• Encourage awareness and necessity of
  multidisciplinary and integrated management of
  these chronic conditions
• Specialist
• Nurse NP and CNS
• Physiotherapist
• GP
• PN / DN

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Asthma

• Asthma affects 1in 5 children and 1 in 10 adults
  (Asthma and Respiratory Foundation of New
  Zealand)
• There are still tragic deaths despite
  improvements in knowledge and treatments to
  assist those who have the condition.
• What is new and topical in asthma?

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Inflammometry in asthma

• Symptoms of asthma may be non-specific and may
  cross over with other syndromes
• It can be difficult to treat for a number of
  reasons
• Poor adherence to treatment regime
• Improvement over time may be mistaken for
  response to treatment
• Corticosteroids should be used judiciously
• It makes sense to target asthma therapy to
  underlying inflammation

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Inflammometry

• Eosinophilic airway inflammation reliably
  responds to corticosteroid therapy
• Identifying and treating eosinophilic
  inflammation can allow targeted use of
  corticosteroids
• Induced sputum is the investigation of choice for
  identifying eosinophilic inflammation but its
  availability is limited
• Can use FeNO or serum eosinophilia as proxy

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Vitamin D

• May have an effect on asthma morbidity
• Antiviral (?vit D associated with ?respiratory
  illness)
• ?enhanced steroid responsiveness
• Down regulation of atopy

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Vitamin D

• Currently there is insufficient evidence of a
  causal association between vitamin D status and
  asthma to recommend for or against vitamin D
  supplementation
• But there is consistent evidence from
  observational studies that vitamin D protects
  against asthma exacerbations.
• There is no evidence to support screening for
  vitamin D deficiency
• It would be advisable to screen high risk
  individuals
• Low sun exposure
• Pigmented skins

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Medication Adherence

• Researchers at Henry Ford Hospital in the USA
  have found that one-quarter of severe asthma
  attacks could be prevented if only patients
  consistently took their medication as prescribed.
  
• Moreover, an asthma attack was only significantly
  reduced when patients used at least 75 percent of
  their prescribed dose, according to the study.

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Chronic Obstructive Pulmonary Disease (COPD)

• The Asthma Foundation estimates that 1 in 7 New
  Zealanders aged 45 and over has COPD - more than
  200 000 people, or the population of greater
  Hamilton (in Auckland 90 000)
• Many of these are currently undiagnosed

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COPD

• By 2030 chronic obstructive pulmonary disease is
  estimated to be the third most common cause of
  death worldwide, a leading cause of
  hospitalizations, as well as being one of the
  most expensive chronic diseases.
• However, in comparison to diseases, such as
  diabetes , there is little public awareness of
  COPD and the funding, research and profile is not
  the same as other diseases with a similar burden.

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COPD risk

• According to the first comprehensive estimate of
  lifetime risk for chronic obstructive pulmonary
  disease (COPD) published in a special European
  Respiratory Society issue of The Lancet, one out
  of four individuals aged 35 and over are likely
  to develop COPD at some stage of their lives.
• The discoveries indicate that people have a much
  higher risk of developing COPD than congestive
  heart failure, acute heart attack , and several
  common cancers.
• average woman at 35 years of age is gt3 times more
  likely to develop COPD compared to breast cancer
• average 35 year old man the risk of developing
  COPD is three times higher than prostate cancer

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COPD and CVD

• Despite it being common for individuals to have
  both COPD and cardiovascular disease, it usually
  goes unrecognized by physicians due to
  overlapping clinical manifestations.
• In individuals with heart disease , COPD
  diagnosis can remain unsuspected, however, having
  both of these conditions can lead to a
  considerably worse outlook for the patient.

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COPD and heart disease

• According to a new investigation, individuals who
  suffer with chronic obstructive pulmonary disease
  (COPD) or those with reduced lung function have a
  serious risk of developing cardiovascular
  disease.
• Presented at the European Respiratory Society's
  Annual Congress in Amsterdam 2011, the
  discoveries indicate that because individuals
  with COPD and reduced lung function appear to be
  at a significantly higher risk of developing
  cardiovascular disease, they should be routinely
  screened for it.

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The link between COPD and heart disease

• High troponin, chest pain and ECG changes are
  commonly seen in patients admitted to hospital
  with AECOPD
• Elevated troponin T and NT-BNP levels at the time
  of ECOPD are strong predictors or increased risk
  and poor outcome

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COPD and heart disease

• We need to take hospital presentations with
  AECOPD very seriously and think more broadly
• Major driver of mortality especially in the acute
  period and immediately after.
• Mortality over 5 years increases in direct
  proportion to the frequency of AECOPD
• Exacerbations are associated with important
  outcomes
• ? risk of mortality
• ? health status
• Impaired lung function
• Muscle weakness
• Cardiopulmonary complications

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COPD and heart failure

• Reduced lung function and obstructive airway
  disorders such as chronic obstructive pulmonary
  disease (COPD) increase the risk of heart
  failure, a new study has found.
• For the new study, researchers analyzed data from
  16,000 people in the United States, aged 45 to
  64, who took part in the Atherosclerosis Risk in
  Communities study and were followed for an
  average of 15 years
• The researchers noted that it's common for
  patients with heart failure to have COPD, and
  vice versa. But only recently has prior COPD been
  shown to be a long-term risk factor for heart
  failure.
• European Journal of Heart Failure, news release,
  Feb. 25, 2012

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The impact of co morbidities

• For health professionals, the problem of
  co-morbidities, when a person is suffering from
  more than one condition at the same time, is an
  increasing concern.
• This will only become more of a concern as the
  frequency of co-morbid conditions increases as
  the older population live longer.
• Often individuals are treated by a specialist for
  one particular system eg cardiac, respiratory.
• It will become more important for physicians to
  recognize other symptoms as the frequency of
  co-morbidities increases.

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Pulmonary rehabilitation
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Pulmonary Rehabilitation

• Pulmonary rehabilitation is a structured
  programme of exercise and education for those
  with chronic respiratory disease.
• It is one of the few interventions shown to
  result in sustained improvements in quality of
  life for those with COPD.
• Benefits include
• Improved quality of life
• Less dyspnoea
• Increased exercise capacity
• Reduced hospital admissions
• The Burden of COPD in New Zealand, Asthma and
  Respiratory Foundation of NZ (Inc.) and The
  Thoracic Society of Australia and New Zealand,
  New Zealand Branch Inc., 2003, p8.
  http//www.asthmanz.co.nz/burden_of_asthma_in_nz.p
  hp
• Am. J. Respir. Crit. Care Med., Volume 159,
  Number 5, May 1999, 1666-1682

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Pulmonary rehabilitation

• Controlled studies have also shown a reduction in
  the use of health care resources such as
  admissions after attending a programme.
• Ries, A. L., R. M. Kaplan, T. M. Limberg, and L.
  M. Prewitt. 1995. Effects of pulmonary
  rehabilitation on physiologic and psychosocial
  outcomes in patients with chronic obstructive
  pulmonary disease. Ann. Intern. Med. 122 823-832
  
• Wright, R. W., D. F. Larsen, R. G. Monie, and R.
  A. Aldred. 1983. Benefits of a community hospital
  pulmonary rehabilitation program. Respir. Care
  28 1474-1479
• Agle, D. P., G. L. Baum, E. H. Chester, and M.
  Wendt. 1973. Multidiscipline treatment of chronic
  pulmonary insufficiency. Psychosom. Med. 35
  41-49
• Jensen, P. S.. 1983. Risk, protective factors,
  and supportive interventions in chronic airway
  obstruction. Arch. Gen. Psychiatry 40 1203-1207

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Pulmonary rehabilitation

• Pulmonary rehab should not be considered as the
  last resort
• Catching those early on in their disease can help
  with
• Medication adherence and understanding
• Smoking cessation
• Social interaction and reducing the incidence of
  depression and social isolation
• Self management skills

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Case

• Mr Simmonds
• 68 yr old retired builder
• Severe COPD started home O2-felt it was a death
  sentence.
• Seen in Howick Pulmonary Rehab and after by NP at
  home involving family
• 2 years later still severe COPD but QAL and
  exacerbations much improved

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Multidisciplinary management of COPD

• Historically, the practice of many health
  professionals has been characterized by
  unidisciplinary thinking
• Individualistic and sometimes competitive
  behaviors have emphasized the roles and
  boundaries of each discipline
• Management of a patient with a chronic condition
  requires a multidisciplinary approach

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Multidisciplinary approach to COPD

• Multidisciplinary, collaborative health care
  practice is an effective means to plan,
  coordinate, and implement care.
• Family members and caregivers should be
  participants in this process, although they may
  not be present at all meetings of the
  multidisciplinary team
• Their contribution to the assessment process,
  problem solving, goal and outcome setting is
  vital.

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Multidisciplinary approach to COPD

• Self management is an essential part of chronic
  care, and COPD, management
• Disease knowledge is the most studied outcome of
  chronic disease or self management programmes
• Knowledge is not the only outcome
• Health literacy
• Motivation
• Behavioural changes
• Engagement of patients and families / whanau to
  take an active approach to management

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Multidisciplinary approach to COPD

• Doctors often provide
• Disease knowledge
• Nurses will add
• Advocacy
• Education medications, disease knowledge
• Support psychological, smoking cessation etc
• Exacerbation action plans
• Integrated follow up
• Others physiotherapists, social workers,
  community support workers, cultural support

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Case Example

• 58 Maaori female
• Severe bronchiectasis with multi resistant
  microbiology
• Moved to the area 6 months ago and has had 3
  hospital admissions since
• Seen in clinic twice by chest physician but still
  not making any progress

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Case example

• Seen in clinic in combined appointment with
  physician and CNS
• Discussion
• Advanced care planning
• Action plans
• Acceptability of LTOT
• Pacing herself

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Case example

• Outcome
• CNS home visit in 2 weeks to follow up response
  to antibiotics and further discuss advance care
  planning, advance directive and LTOT
• Physio appointment within 10 days
• Better communication with GP

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To End

• We hope we have given you a topical overview of
  asthma and COPD
• We hope that we have demonstrated the importance
  of multidisciplinary involvement in the
  management of chronic respiratory disease
• We hope to continue to work closely across
  secondary and primary care to offer the best
  possible care to our patients

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