Transcript LS 2 - COPD/HF

Shared System of Care
COPD/Heart Failure
Learning Session 2
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
3
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
6
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
$1,540.18
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
$160.00
7
Agenda
•
Introduction (35)
•
Patient Voice (15)
•
Medication (60, 40 didactic and 20 discussion)
•
MOA Breakout
•
Break (15)
•
PSM Support
•
COPD and AECOPD Management (30, 20 didactic, 10 questions)
•
Heart Zones and other PSM tools (30, 20 didactic, 10 questions)
•
Smoking cessation (10, 5 didactic, 5 questions)
•
Sharing the care with the specialist and the referral process
•
Planning for Action Period 2 (15)
Patient Voice
(10 minutes)
COPD Medications
(15 minutes)
Comprehensive Management of COPD
11
Classification of Disease Severity in COPD
12
Treatment of stable COPD
Goals
 Symptoms
 Exacerbations
 Exercise











Beta - agonists
Anticholinergics
Short vs. long-acting
Inhaled corticosteroids
Combination therapies
Antibiotics
Oral prednisone- for AECOPD
PDE4 inhibitors
Oxygen
Pulmonary rehabilitation
Smoking cessation
13
Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
14
Short-acting Bronchodilators
15
Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
16
Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
Stepwise increased therapy
17
Optimal Pharmacotherapy in COPD
Increasing Disability and Lung Function Impairment
Mild
Moderate
SABA prn
Severe
Infrequent AECOPD
Frequent AECOPD
(< 1/year)
(> 1/year)
LAAC or LABA+ SABA prn
LAAC + ICS/LABA +
SABA prn
persistent disability
persistent
disability
LAAC + LABA +
SABA prn
LAAC + SABA prn
or
LABA + SABA prn
persistent disability
persistent disability
LAAC + ICS/LABA* + SABA prn
LAAC + ICS/LABA +
SABA prn +/- Theophylline
* Inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower ICS dose i.e. SALM/FP 50/250 µg twice daily
O’Donnell DE, et al. Can Respir J 2007
18
Comprehensive management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
19
Summary
 Spirometry essential as screening tool in subjects at risk
 Beware false positive/false negative results with COPD 6.
 Treatment:
 Mild: Short acting BD’s
 Moderate: Long acting BD’s (single or comb)
 Severe: Combination BD’s + ICS +Pulmonary Rehabilitation.
 All: education, vaccinations and smoking cessation.
20
Stable COPD: Who should be referred?
 Dyspnea out of proportion to spirometry
 Young age of onset
 Remote smoking history and disease severity not consistent with
smoking history
 Rapid deterioration (symptoms or FEV1)
 History of exacerbations
 Concern re multiple co morbidities
21
Case #1
 79yo woman severe SOB
 PHx: overweight (BMI 32), diet controlled DM2, & HTN
 Allergy: mild seasonal allergies - rhinorrhea
 Smoking: 40 pack. years - quit 20 y ago.
 Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post
BD change.
 Next step?
22
Case #1
 Explore possibility of heart failure/ischemic heart disease/if acute
onset consider PE.
 Could this patient have asthma?
 Exam patient and rule out heart failure.
 Unclear re CHF and COPD: BNP
 Request spirometry with reversibility.
 If COPD categorize severity.
 If non obstructive pattern: detailed lung function including lung
volumes + DLCO
 Chest x-ray.
 Echocardiogram
 Stress test
23
Case #1
 Spirometry with post bronchodilator assessment showed a 12%
improvement consistent with the diagnosis of asthma.
 Echocardiogram: Normal
 Stress test: No ischemic changes
24
Case #1
Diagnosis:
 Adult onset asthma with likely added de-conditioning and obesity,
 Initiate low dose inhaled corticosteroids and short acting bronchodilators PRN
 Advise re immunizations
 Provide education about inhaler use and refer for education
 Provide a written action plan
Key learning points:
 Asthma can occur late in life and can occur independently or in association with
COPD
 Important to identify co-existence of asthma in COPD as it will effect adjunct
therapies such as beta blockers.
 If asthma is a consideration request reversibility initially
25
Case #2
 68yo man progressive SOB with a history of a recent
exacerbation requirng a vist to the ED and a course of prednisone
and antibiotics.
 PHx: HTN on metoprolol and ramipril.
 Allergy: no seasonal or environmental allergies
 Smoking: 55 pack years - quit 5 y ago.
 Spirometry: 3 years ago: FEV1 53% pred, FEV1/FVC ratio. No
post BD improvement
 Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H PRN
with increasing use in the last few weeks.
 Next step?
26
Case #2
 Clinically this patient has deteriorated with a recent exacerbation.
 What would you do next?
27
Case #2
 You repeat the spirometry and the FEV1 is now 45% of
predicted.
 This patient has severe COPD and a history of exacerbation and
therefore would qualify for the use of tiotropium and the addition
of a LABA
 Need to consider emerging evidence of increased risk of
pneumonia associated with fluticasone.
28
Patient Flow
Linked data from 76 centres throughout Sweden
Patients who met the inclusion criteria identified within the study
period n=21 361
Patients with a record of fixed ICS/LABA therapy
(Index date) n=9893
Matched
populations
BUD/FORM cohort
n=2734
FLU/SAL cohort
n=2734
Larsson et al, J Intern Med 2013
29
COPD Exacerbations
 The exacerbation rate was 26.6% lower with BUD/FORM vs.
FLU/SAL
 The number needed to treat with BUD/FORM vs. FLU/SAL to
prevent one exacerbation per patient-year was 3.4
Exacerbation rate
1.2
1.0
0.8
RR = 0.74 (CI: 0.69, 0.79)
p<.0001
1.09
Flutic/salmeterol
0.80
BUD/Form
0.6
0.4
0.2
0.0
RR, rate ratio
BUD/FORM (n=2734)
FLU/SAL (n=2734)
Larsson et al, J Intern Med 2013
30
Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)myr
Stepwise increased therapy
31
Case #2
 Question: What reliever medication would you recommend for this
patient?
 Key learning point: ipratropium should not be used as a rescue
medication because of the use of tiotropium and the patient
should be prescribed salbutamol on a PRN basis.
32
Case #3
 60yo woman progressive SOB
 PHx: COPD
 Allergy: Seasonal allergies years ago
 Smoking: 25 pack years - quit 10 y ago.
 Spirometry: 3 years ago: FEV1 54% pred, FEV1/FVC ratio.
 Meds: salbutamol and ipratropium bromide PRN and now
needing them up to five times daily.
 Next step?
33
Case #3
 Repeat spirometry and FEV1 unchanged.
 Next steps?
34
Case #3
 Add tiotropium bromide, stop ipratropium bromide and continue
salbutamol PRN.
 Six weeks later patient reports some improvement but still short of
breath and has developed peripheral edema?
 What are your concerns now and what would you do?
35
Case #3
 Clinically there is evidence of congestive heart failure and you
start a diuretic and get an ECHO.
 The ECHO shows a reduced EF of 35% predicted.
Key learning point:
 HF and severe COPD often co-exist and treatment strategies
need to take account of this
36
Questions
37
Management of severe COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
38
Severe COPD
 Maximize inhaled therapy:
› Combined ICS/ long acting beta-agonists
› Long acting anti cholinergic
 Additional considerations:
› Ensure patient is adherent and taking inhalers correctly if unable to use
spacer and deliver medication correctly consider nebulized Rx.
› Refer to pulmonary rehabilitation.
› If having frequent exacerbations consider a trial of roflumilast.
› Azithromax a consideration but important caveats: see next slide.
› Ensure no untreated co morbidities such as CHF and GERD
39
Long term O2 therapy indications
 Continuous (Grade A evidence)
 Resting ABG pO2 < 55 mmHg
 Resting ABG pO2 55-60 mmHg
› Cor pulmonale
› Hct > 56%
 Intermittent (Grade B evidence)
 Exertion: sO2 <87% for > 1 min
 Nocturnal sO2 <88% for > 30% night
40
Continuous home O2 minimum 20h /day
41
Nebulizer treatment in severe COPD
 Important to note most patients can effectively use inhaler device
and a spacer but nebuilizer:
 Beneficial in extremes of age
 Coordination not required
 Breath-hold not required
 Note because of the size of aerosol particles the use of a
nebulizer does not lead to increased deposition into the lung.
42
Chronic oral prednisone therapy in COPD
43
Chronic oral prednisone therapy in COPD
 There is no evidence base for the regular use of oral prednisone
in COPD.
 In one RCT of prednisone for ARCOPD one group who were left
on prednisone had increased side effects.
 For patients who have frequent AECOPD and continue to
exacerbate despise all the measures outlined above then an N-of1 trial of alternate day OCS can be considered.
 Bone density and osteoporosis risk should be regularly
reassessed.
44
Roflumilast: indication:
 Patients with moderate-severe COPD (FEV1 < 50%) ± chronic
bronchitis with frequent ( > 2/year ) exacerbations.
 Patients should be advised re the risk of GI side effects.
45
Other antibiotics for severe COPD
 Apart from azithromax there is no evidence that chronic antibiotic
therapy is effective in COPD.
 For exacerbation: rotating antibiotics between classes are
recommended
 A significant minority of COPD patients have co existing
bronchiectasis and in the presence of significant sputum volume
and purulence assessment for atypical TB infection and gram
negative pathogens such as Pseudomonas should be completed.
46
Heart Failure (15 min)
47
2005/06
2006/07
2007/08
2008/09
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
ACE/ARB %
68%
66%
64%
62%
60%
58%
56%
2009/10
Region/ year
48
2005/06
2006/07
2007/08
2008/09
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Northern
Vancouver Island
Vancouver Costal
Fraser
Interior
Beta Blocker %
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2009/10
Region/ year
49
Evidence Based HF Therapies in BC
100
90
80
70
60
ACE/ARB
BB
50
40
30
20
10
0
All Ages
Age < 85
50
Principle of HF Management
 Therapeutic Goals
 1. prompt resolution of congestive symptoms
 2. initiate patient self management related to lifestyle and
medication compliance
 3. initiate/enhance therapies direct to underlying
disease process
 limit recurrent hospitalizations
 improve mortality
 4. prevent adverse events related to administered
therapies
51
Heart Failure Therapies
Therapy
Agent
Self Management
Pharmacological
Device
Reduction in 1° Endpoint
23%
ACE-I
8% - 26%
Beta Blocker
23% - 65%
MRA
35%
ARB
15%
ICD
23% - 31%
CRT
24% - 36%
52
Contemporary Management of HF
 Pharmacological Therapies
 (1) Beta Blockers
 (2) Inhibition of the RAAS
 ACE-inhibitors (ACEi)
 Angiotensin Receptor Blockers (ARB)
 Mineralocorticoid Receptors Antagonists (MRA)
 Device Therapies
 (1) ICD
 (2) Cardiac Resynchronization Therapy (CRT)
53
Beta-Blockers Reduce Mortality and Decrease the
Risk of Hospitalization
54
Impact of ACE Inhibitors on Mortality in HF
55
Benefits of ACE Inhibitors Persist
56
Spironolactone: EF<30 & Advanced Symptoms
10%
ARR
57
Combining Therapies Improves Outcomes
58
Cumulative Impact of Heart Failure Therapies: All
Cause Mortality
Relative risk
2-yr Mortality
None

---
35%
ACE Inhibitor

23%
27%
MRA (Spironolactone)

30%
19%
Carvedilol

25%
19%
Cumulative risk reduction if all three therapies are used: 63%
Absolute risk reduction: 22%, NNT = 5
Fonarow GC. Rev Cardiovasc Med. 2003;4:8–17.
59
RAFT
 1798 patients with:
 NYHA class II or III heart failure,
 LVEF  30% intrinsic
 QRS > 120 msec
 Randomized to ICD alone or an ICD plus CRT
 Primary outcome was death from any cause or hospitalization
for heart failure
 Follow up - mean of 40 months
60
RAFT
61
NEJM 1996
62
Important Therapeutic Considerations
in HF Patients
 Smoking cessation
 Cardiac rehab
 Action plans for acute decompensation
 Addressing co-morbidities
 COPD
 CKD
some synergies and therapeutic overlap
 Immunizations
 Symptom management
 End of life care
63
Break
Patient Self-Management
Generating an Action Plan
COPD and AECOPD Management
Patient Education Materials
Smoking Cessation
66
67
COPD and AECOPD Management
(30 minutes, 20 didactic + 10 questions)
Case
 72 year old male seen by me in clinic Jan 2012 with moderate
COPD
 Quit smoking 4 years ago
 Comorbid illnesses including: CHF, Afib, AVR, CABG complicated
by sternal infection, obesity, asbestos related pleural disease.
 Recurrent admissions for AECOPD and CHF (‘dirty’ x-ray). 90
days in hospital this past year.
 Discharged post AECOPD Oct 23. Readmitted Monday pm in
distress.
70
Case continued
 Had seen GP in community 1 week prior started on higher dose
prednisone, PO antibiotics
 Requiring high flow oxygen, BiPAP
 Increased work of breathing
 Uncontrolled Afib post ventolin and atrovent nebulizer
 HR 140-160.
 I’m consulted as on for ICU….
71
Clinical course of COPD
72
Last time…




Burden of illness
Under diagnosis and role of targeted screening
The role of spirometry in diagnosis and staging
Staging by symptoms and by FEV1
73
Goals of COPD care
Relieving
symptoms
Improving
quality of life
Preventing/
managing
exacerbations
74
A “Personal Management Plan” for COPD
5 point “PRIME” Plan:
1. Prevent further damage to your lungs
2. Relieve your symptoms
› optimize drug therapy
› work on mental outlook and coping mechanisms
3. Improve your general health and physical activity level
4. Manage COPD flare-ups with an “Action Plan”
5. Establish your COPD team
› family, friends, physician, healthcare professionals, COPD
educator
75
Stepped approach to care
End of Life Care
Individuals at Risk
•
Smokers
•
Environmental Exposure
Surgery
Oxygen
Theophyline (in certain patients)
All Patients:
•
Exercise Rehabilitation
•
Smoking Cessation
•
Healthy Lifestyle
•
Patient Education
Inhaled corticosteroids (with ‘LABA’)
Referral for Pulmonary Rehabilitation
Initial referral to Pulmologist, Respirologist or Other Specialist
Additional therapy: long acting bronchodilators
First line therapy: Short-acting beta2 – Agonists and Anticholinergics
Care Plan & Exacerbation Plans Created & Shared
Influenza & Pneumococcal Immunizations in GP Office
Smoking Cessation Education & Self Management Exercise & Lifestyle
Referral for Diagnostic Spirometry
Case Finding Spirometry by Primary Care Physician
Increasing severity of COPD
76
Acute exacerbations (AECOPD) or lung attacks
 An event in the natural course of the disease characterized by a
change in the patient’s baseline dyspnea, cough, and/or sputum
that is beyond normal day-to-day variations, is acute in onset, and
may warrant a change in regular medication in a patient with
underlying COPD.”
 Acute Exacerbations are THE LEADING CAUSE* of deaths,
hospitalization and ER visits among COPD patients.
 COPD and CHF and #1 and #2 for most common reason for
medical admission to BC hospitals
77
Acute exacerbations (AECOPD) or lung attacks
 22-43% of patients hospitalized with AECOPD die within 1 year
(Eriksen et a., 2003; Groenewegen et al., 2003)
 In-hospital mortality for AECOPD is 7.8%-11.0%
 There is increasing mortality with increased number of AECOPD.
 A number of interventions can reduce the risk of AECOPD:
› Long acting bronchodilator – tiotropium
› LABA / ICS combo inhalers
› Roflumilast (but not systematically assessed inpatients on
triple therapy)
› Education and Rehabilitation (AECOPD recognized earlier and
treated before become severe)
78
AECOPD frequency: mortality
79
Time course of AECOPD recovery
80
Benefits of COPD self management education
81
Management of symptomatic: mild COPD





Patient education, including smoking cessation program
Prevention of exacerbations, vaccinations
Initiation of bronchodilator therapy
Encouragement of regular physical exercise
Close follow-up and disease monitoring
Can Respir J 2008;15(Suppl A):1A-8A.
82
Management of symptomatic: mild COPD
 Patient education, including smoking cessation program
 Prevention of exacerbations, vaccinations
 2 long acting bronchodilators and add in ICS if chronic bronchitis
or recurrent AECOPD
 Encouragement of regular physical exercise
 Close follow-up and disease monitoring
Can Respir J 2008;15(Suppl A):1A-8A.
83
Management of severe COPD






Consider oxygen
Mobility assistance
Consider roflumilast
Consider co-morbidities again
Initiate advanced care planning, maybe DNR form
Consider palliative help with dyspnea
84
Increasing disability & lung function impairment
Mild
SABD prn
Moderate
Infrequent AECOPD
Frequent AECOPD
(< 1/year)
(> 1/year)
LAAC or LABA+ SABA prn
LAAC + ICS/LABA +
SABA prn
persistent dyspnea
persistent dyspnea
LAAC + LABA +
SABA prn
LAAC + SABD prn
or
LABA + SABD prn
Can Respir J 2008;15(Suppl A):1A-8A.
Severe
persistent dyspnea
persistent dyspnea
LAAC + ICS/LABA + SABA prn
LAAC + ICS/LABA +
SABA prn +/- Theophylline
85
AECOPD: Prevention Strategies
 Smoking Cessation
 Vaccinations
 Self-Management Education with Case Manager and written
Action Plan
 Regular long-acting bronchodilator therapy
 Regular inhaled ICS/LABA therapy in moderate-severe COPD
and > 1 episode per year of AECOPD necessitating therapy
 Appropriate treatment of episodes of AECOPD
Can Respir J 2008;15(Suppl A):1A-8A.
86
Take Home Points:
 Reducing AECOPD or lung attacks is key to
› Patient survival
› Patient QOL
› Patient lung function
› Keeping patients at home
 How can we achieve this?
› Medications
› Vaccination
› Smoking cessation/pulmonary rehabilitation.
› Education / self management
87
Survival in COPD – Relationship to Lung Function
and Disability
Nishimura K, et al. Chest 2002; 121: 1434: 40
88
Prognosis
 BODE index helps guide prognosis:
› BMI
› Obstruction (degree of )
› Dyspnea (severity of)
› Exercise tolerance (or lack thereof)
 Points add up to answer the Q: Am I going to survive for 4 years?
› 0-2 Points: 80%
› 3-4 Points: 67%
› 5-6 Points: 57%
› 7-10 Points: 18%
89
 FEV1 % Predicted After Bronchodilator
>=65% (0 points)
50-64% (1 point)
36-49% (2 points)
<=35% (3 points)
 6 Minute Walk Distance
>=350 Meters (0 points)
250-349 Meters (1 point)
150-249 Meters (2 points)
<=149 Meters (3 points)
 MRC Dyspnea Scale (5 is worst)
MRC 1: Dyspneic on strenuous exercise (0 points)
MRC 2: Dyspneic on walking a slight hill (0 points)
MRC 3: Dyspneic on walking on the level; must stop occasionally due to SOB (1 point)
MRC 4: Must stop for SOB after walking 100 yards or after a few minutes (2 points)
MRC 5: Cannot leave house; SOB on dressing/undressing (3 points)
 Body Mass Index
 >21 (0 points)
<=21 (1 point)
90
Prognosis - Survival by BODE Index
91
Long Term Oxygen Therapy: Survival
Domiciliary oxygen (≥ 15 hours/day to achieve SaO2 ≥ 90%)
improves survival in stable COPD patients with severe hypoxemia
(PaO2 ≤ 55 mmHg) or when the PaO2 ≤ 60 mmHg in the presence of
ankle edema, cor pulmonale or hemacrit ≥ 56%)
Can Respir J 2008; 15(Suppl A):1 A-8A
92
93
Summary
 COPD care isn’t rocket science/brain surgery - you can do it!
 First screen for COPD, then assess severity
 Make a treatment plan (include an Action Plan for attacks)
 Recruit help to enact the plan (build the team).
 Promote advance care planning and when appropriate palliative
components.
 http://www.advancecareplanning.ca/
94
Patient Education Resources
Heart
Failure
101
95
Patient Education Resources
Heart Zones
96
Patient Education Resources
Daily
weight
97
Patient Education Resources
Sodium
Restriction
98
Patient Education Resources
Fluid
Restriction
99
Patient Education Resources
Activity
100
Clinical Care Algorithms
101
102
103
104
A Comprehensive List of Patient and Provider
Resources
PATIENT RESOURCES
PROVIDER RESOURCES
MEDICATIONS
REFERRAL FORMS
SODIUM
PATIENT ASSESMENT FORMS
FLUID
CARE MAPS & TX ALGORITHMS
EXERCISE
MEDICATION TITRATION
EXACERBATION PLAN
PATIENT SYMPTOM STATUS
HF 101
VISIT SNAP SHOT
105
BC’s Heart Failure Website www.bcheartfailure.ca
106
Smoking Cessation
107
107
Progress in British Columbia
BC sues
tobacco
companies
Percentage Smoking Prevalence in BC, 1999-2011
25
Govt funding to $6.5M
QuitNow
20
19-24
projects
1st Quit
Contest
NRT
access
15
10
5
0
BC Quitline
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
BC
Prevention program in
schools
Progress in BC
108
Intention to Quit
Intention to Quit
109
Physicians discussing quitting
Physicians Discussing Quitting
110
Effect of Physician intervention
Effect of Intervention
111
What can Physicians do?
What can Physicians do?
112
Strategies to help your patients quit
Complete Personal Risk Assessment for Rx for Health
Brief advice to quit smoking
Refer to behavioural support (like QuitNow)
Recommend patients call 8-1-1 for NRT
Order Buproprion or Varenicline (prescription)
Strategies
113
What is QuitNow?
Behavioural quit smoking support
Provincially Funded
Managed by the BC Lung Association
Evidence-based
Free, confidential, 24/7
What is QuitNow?
114
Fax Referral Forms
115
[email protected]
Online Referral
116
Referral Resources
Indications for
Referral
to a HFC
Heart
Function
Clinic
Referral
Form
117
Patient History/Assessment
Heart Failure
Patient
Questionnaire
118
A Guide to HF Patient Assessment
Patient Assessment
Tool
119
Snapshot of Patient
Visit
120
Referral and Consult Process
Planning for Action Period 2