Transcript Update on Asthma and COPD - The Goodfellow Symposium 2012

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
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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
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Update on a few topical issues in Asthma and
COPD
Encourage awareness and necessity of
multidisciplinary and integrated management of
these chronic conditions
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Specialist
Nurse – NP and CNS
Physiotherapist
GP
PN / DN
Asthma
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Asthma affects 1in 5 children and 1 in 10 adults
(Asthma and Respiratory Foundation of New
Zealand)
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There are still tragic deaths despite
improvements in knowledge and treatments to
assist those who have the condition.
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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
reasons
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 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
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Eosinophilic airway inflammation reliably
responds to corticosteroid therapy
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Identifying and treating eosinophilic inflammation
can allow targeted use of corticosteroids
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Induced sputum is the investigation of choice for
identifying eosinophilic inflammation but its
availability is limited
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Can use FeNO or serum eosinophilia as proxy
Vitamin D
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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
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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
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Low sun exposure
Pigmented skins
Medication Adherence
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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.
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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)
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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)
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Many of these are currently undiagnosed
COPD
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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.
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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
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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.
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The discoveries indicate that people have a much higher
risk of developing COPD than congestive heart failure,
acute heart attack , and several common cancers.
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average woman at 35 years of age is >3 times more likely to
develop COPD compared to breast cancer
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average 35 year old man the risk of developing COPD is three
times higher than prostate cancer
COPD and CVD
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Despite it being common for individuals to have both
COPD and cardiovascular disease, it usually goes
unrecognized by physicians due to overlapping clinical
manifestations.
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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
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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.
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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
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High troponin, chest pain and ECG
changes are commonly seen in patients
admitted to hospital with AECOPD
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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
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We need to take hospital presentations with
AECOPD very seriously and think more broadly
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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
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↑ risk of mortality
↓ health status
Impaired lung function
Muscle weakness
Cardiopulmonary complications
COPD and heart failure
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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.
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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
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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.
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European Journal of Heart Failure, news release, Feb. 25, 2012
The impact of co morbidities
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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.
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This will only become more of a concern as the
frequency of co-morbid conditions increases as the older
population live longer.
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Often individuals are treated by a specialist for one
particular system eg cardiac, respiratory.
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It will become more important for physicians to recognize
other symptoms as the frequency of co-morbidities
increases.
Pulmonary rehabilitation
Pulmonary Rehabilitation
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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:
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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.php
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.
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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
Pulmonary rehabilitation
Pulmonary rehab should not be
considered as the last resort
 Catching those early on in their disease
can help with
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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
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Historically, the practice of many health professionals
has been characterized by unidisciplinary thinking
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Individualistic and sometimes competitive behaviors
have emphasized the roles and boundaries of each
discipline
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Management of a patient with a chronic condition
requires a multidisciplinary approach
Multidisciplinary approach to COPD
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Multidisciplinary, collaborative health care practice is an
effective means to plan, coordinate, and implement care.
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Family members and caregivers should be participants
in this process, although they may not be present at all
meetings of the multidisciplinary team
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Their contribution to the assessment process, problem
solving, goal and outcome setting is vital.
Multidisciplinary approach to COPD
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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
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Health literacy
Motivation
Behavioural changes
Engagement of patients and families / whanau to take an
active approach to management
Multidisciplinary approach to COPD
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Doctors often provide
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Nurses will add
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Disease knowledge
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
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
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Seen in clinic in combined appointment
with physician and CNS
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Discussion
Advanced care planning
 Action plans
 Acceptability of LTOT
 Pacing herself
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Case example
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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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