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Update on Asthma and COPD


Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann. Intern. – PowerPoint PPT presentation

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Title: Update on Asthma and COPD

Update on Asthma and COPD
  • Fiona Horwood Diana Hart

We are both from-
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

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

  • Asthma affects 1in 5 children and 1 in 10 adults
    (Asthma and Respiratory Foundation of New
  • 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?

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
  • 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

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

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

Vitamin D
  • Currently there is insufficient evidence of a
    causal association between vitamin D status and
    asthma to recommend for or against vitamin D
  • 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
  • Low sun exposure
  • Pigmented skins

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.

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

  • 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.

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

  • 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.

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
  • 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.

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

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
  • ? risk of mortality
  • ? health status
  • Impaired lung function
  • Muscle weakness
  • Cardiopulmonary complications

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
  • European Journal of Heart Failure, news release,
    Feb. 25, 2012

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.

Pulmonary rehabilitation
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.
  • Am. J. Respir. Crit. Care Med., Volume 159,
    Number 5, May 1999, 1666-1682

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
  • Jensen, P. S.. 1983. Risk, protective factors,
    and supportive interventions in chronic airway
    obstruction. Arch. Gen. Psychiatry 40 1203-1207

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

  • Mr Simmonds
  • 68 yr old retired builder
  • Severe COPD started home O2-felt it was a death
  • 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

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

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

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

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

Case Example
  • 58 Maaori female
  • Severe bronchiectasis with multi resistant
  • 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

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

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

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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