Transcript Obstructive Airways Disease

Obstructive Airways
Disease
Asthma and COPD
Dr H Ahmad VTS 29/04/2009
Definitions:
 Asthma: It's a chronic respiratory condition that
causes the airways to constrict become inflamed
and collect mucus. It can be triggered by natural
allergens, cigarette smoke, pets, exercise or
emotional stress.
 COPD: is characterized by air flow obstruction.
The airflow obstruction is usually progressive,
not fully reversible and doesn't change markedly
over several months. The disease is
predominantly caused by smoking.
Diagnosis of COPD
 It should be considered in patients over the age
of 35 who have a risk factor, generally smoking,
and who present with exertional dyspnoea,
chronic cough, regular sputum production,
frequent winter bronchitis or wheeze. The
presence of airflow obstruction should be
confirmed by performing spirometry.
All health professionals should be competent
in the interpretation of the results
COPD contd.
 Airflow obstruction is defined as a reduced FEV1 and
reduced FEV1/FVC ratio, such that FEV1 is less than
80percent predicted and FEV1/FVC is less than 0.7.
 The airflow obstruction is due to a combination of airway
and parenchymal damage.
 The damage is the result of chronic inflammation that
differs from that seen in asthma and which is usually the
result of tobacco smoke.
 Significant airflow obstruction and lung damage may be
present before the individual is aware of it.
 COPD produces symptoms, disability and impaired
quality of life which may respond to pharmacological and
other therapies that have limited or no impact on airflow
obstruction.
COPD contd:
 Other symptoms
 Weight loss
 Effort tolerance
 Waking at night
 Ankle swelling
 Fatigue
 Occupational hazards
 Chest pain
 Haemoptysis
MRC dyspnoea scale
 Grade 1. Degree of breathlessness except on
strenuous exercise.
 Grade 2. Short of breath when hurrying or
walking up a slight hill.
 Grade 3. Walks slower then contemporaries on
level ground because of breathlessness, or has
to stop for breath when walking at own pace.
 Grade 4. Stops for breath after walking about
100meters or after a few minutes on level
ground.
 Grade 5. Too breathless to leave the house, or
breathless when dressing or undressing.
Investigations of COPD
Spirometry
CXR
FBC
BMI
Additional investigations: serial PEFR,
alpha-1 antitripsin, CT Scan thorax, ECG,
Echocardiogram, pulse oximetry, sputum
culture if sputum persistently purulent.
History
COPD
Asthma
Smoker or ex-smoker
Almost
always
Possibly
Symptoms under age 35
Rare
Common
Chronic productive cough Common
Breathlessness
Night time waking with
sob and wheeze
Significant diurnal or day
to day variability of
symptoms
Uncommon
Persistent/ Variable
Progressive
Uncommon Common
Uncommon Common
Assessment of severity of COPD
 MILD AIRFLOW
OBSTRUCTION
 MODERATE
AIRFLOW
OBSTRUCTION
 SEVERE AIRFLOW
OBSTRUCTION
 FEV1 50-80%
PREDICTED
 FEV1 30-49%
PREDICTED
 FEV1 <30%
PREDICTED
Management of COPD
 Quit smoking
 Short acting bronchodilator – beta-2 agonist or
anticholinergic
 Combination of the above inhalers
 Long acting beta-2-agonists or long acting anticholinergic
 In moderate to severe COPD; if symptoms persist, with at
least two exacerbations requiring oral antibiotics and
steroids, consider a combination of a long-acting beta-2
agonist and inhaled corticosteroid; discontinue if no
benefit after 4 weeks
 If still symptomatic-consider adding Theophylline
 Mucolytics e.g. carbocystiene
Devices to Deliver Medications
 Delivery system used to treat patients with
stable COPD: Several devices are available –
best may be MDI with a spacer.
 Make sure the technique is good with regular
checks.
 Nebuliser therapy should not continue to be
prescribed without proper assessment.
 LTOT: PO2 <7.3KPa or PO2 between 7.3 to
8KPa with secondary polycythaemia, nocturnal
hypoxia i.e. less then 90% SaO2 for more than
30% of time, peripheral oedema or pulmonary
hypertension.
Cor pulmonale
COPD associated with peripheral oedema,
A raised venous pressure, a systolic
parasternal heave and loud second heart
sound.
These patients need to be considered for
LTOT, diuretics, ACE inhibitors, calcium
channel blockers, alpha blockers and
Digoxin
Pulmonary rehabilitation
This should incorporate a programme of
physical training, disease education,
nutritional, psychological and behavioural
intervention.
Other therapies
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Vaccination
Lung surgery
Physiotherapy
Management of anxiety and depression
Nutritional factors
Exercise
Palliative care
Assessment for occupational therapy
Social services
Self-management - Rescue packs etc
Follow up of patients with COPDAT LEAST TWICE A YEAR IN GP PRACTICE
Need spirometry once a year etc.
 Multi-disciplinary team - unique care
Reasons for Referral to Secondary care
Reason
Purpose
There is diagnostic
uncertainty
confirm diagnosis and optimise therapy
Suspected severe COPD
Confirm diagnosis and optimise therapy
The patient requests a
second opinion.
Confirm diagnosis and optimise therapy
Onset of cor pulmonale
Confirm diagnosis and optimise therapy
Assessment for oxygen
therapy
Optimise therapy and measure blood
gases
Assessment for long-term
nebuliser therapy
Optimise therapy and exclude
inappropriate prescriptions
Assessment for oral
corticosteroid therapy
Justify need for long-term treatment or
supervise withdrawal
Bullous lung disease
Identify candidates for surgery
Reasons for Referral to Secondary care contd.
Reason
Purpose
A rapid decline in FEV1
Encourage early intervention
Assessment for pulmonary
rehabilitation
Identify candidate for rehab
Assessment for lung
transplantation
To identify candidates for surgery
Age under 40 or a family
history or alpha-1 antitripsin
deficiency
Consider therapy and screen family
Uncertain diagnosis
Make a diagnosis
Frequent infections
Exclude bronchiectasis
Haemoptysis
To exclude carcinoma
Guide to Therapy
Use short acting bronchodilator prn
(either beta-2-agonist or anticholinergic)
If still symptomatic, try combined therapy with a short-acting
beta-2-agonist and short-acting anticholinergic
If still symptomatic, use a long-acting bronchodilator
(beta-2-agonist or anticholinergic)
In moderate or severe COPD: If still symptomatic,
consider a combination of a long-acting beta-2-agonist and inhale
corticosteroid (discontinue if no benefit after 4 weeks)
If still symptomatic- consider adding theophylline
Consider mucolytic agents if patient complains
of thick, tenacious sputum which is hard to cough up
QOF indicators and points for COPD
No.
Indicator
COPD 1
The practice can produce a register of
patients with COPD
COPD 12 The percentage of all patients with COPD
1st
diagnosed after
April 2008 in whom the
diagnosis has been confirmed by postbronchodilator spirometry
COPD 10 The percentage of patients with COPD with
a record of FEV1 in the previous 15 months
COPD 11 The percentage of patients with COPD
received inhaled treatments in whom there
is a record that inhaler technique has been
checked in the previous 15 months
COPD 8
The percentage of patients with COPD who
have had influenza immunisation in the
preceding 1st September to 31st March
Points Payment
Stages
3
5
40-80%
7
40-70%
7
40-90%
6
40-85%
QOF Indicators and points for Asthma
Indicator
ASTHMA 1. The practice can produce a register of patients with asthma excluding
patients with asthma who have been prescribed no asthma related drugs in the last
twelve months
Pts
Max.
Threshold
7
ASTHMA 2. The percentage of patients age eight and over diagnosed as having
asthma from 1st April 2003 where the diagnosis has been confirmed by spirometry or
peak flow measurement
15
70%
ASTHMA 3. The percentage of patients with asthma between the ages of 14 and 19 in
whom there is a record of smoking status in the previous 15 months
6
70%
ASTHMA 4. The percentage of patients age 20 and over with asthma whose notes
record smoking status in the past 15 months except those who have never smoked
where smoking status should be recorded at least once
6
70%
ASTHMA 5. The percentage of patients with asthma who smoke, and whose notes
contain a record that smoking cessation advice has been offered within last 15
months.
6
70%
ASTHMA 6. The percentage of patients with asthma who have had an asthma review
in the last 15 months
20
70%
ASTHMA 7. The percentage of patients age 16 years and over with asthma who have
had influenza immunisation in the preceding 1st September to 31st March
12
50%
Tasks
1. How would you achieve maximum QOF
points in patients with COPD in your practice?
2. How would you achieve maximum points in
patients with asthma in your practice?
3. How would set up an asthma clinic in your
practice? Include various equipment required
and staff involved in achieving this task
4. How would you audit asthma control in your
patients in your practice? Focus on one or two
criteria. Complete audit cycle