Title: COPD Chronic Obstructive Pulmonary Disease
1COPDChronic Obstructive Pulmonary Disease
- By
- Matthew Hodson
- Respiratory Nurse Specialist COPD
- Westminster Primary Care Trust
2Aim of Session
- Understand the epidemiology of COPD
- Improve knowledge and understanding of COPD and
its treatments - Increase awareness of Oxygen Therapy in COPD
- Gain an greater insight into when COPD may be
palliative and exploring options - Understand COPD Services in WPCT
3Definition
- Chronic obstructive pulmonary disease (COPD)
is characterised by airflow obstruction. The
airflow obstruction is usually progressive, not
fully reversible and does not change markedly
over several months. 1 - The disease is predominantly caused by smoking.
- 1. NICE 2004
4The Umbrella Disease
5Umbrella Disease
- COPD now preferred term for previous diagnosis of
bronchitis or emphysema, chronic asthma - Significant airflow obstruction may be present
before individual is aware of it - May also be related to occupational exposures
e.g. asbestos
6Burden
- Up to 1 in 8 emergency admissions maybe due to
COPD 1 - Over one million bed days are contributed to COPD
1 - A total of 32,155 deaths in the UK where
attributed to COPD in 1999 1 - 1 BTS Consortium 2005
7Epidemiology
- COPD is the fourth leading cause of death in the
USA and Europe. The leading cause of death
worldwide 1 - Mortality in females has more than doubled over
the last 20 years. 1 - Nearly 900,000 people in England and Wales have a
diagnosis of COPD 2 - Morbidity data greatly underestimate the total
burden of COPD because the disease is usually not
diagnosed until it is clinically apparent and
moderately advanced.1 - COPD is a more costly disease than asthma and,
depending on country, 5075 of the costs are for
services associated with exacerbations. 1 - 1 COPD Audit Commission 2 BTS Consortium 2005
8Characteristic
- Changes characteristic of the disease include
- smooth muscle contraction (bronchoconstriction)
- mucus hypersecretion
- ciliary dysfunction
- pulmonary hyperinflation
- gas exchange abnormalities
- pulmonary hypertension
- cor pulmonale
- These abnormalities contribute to the
characteristic symptoms of COPD - chronic cough,
sputum production and dyspnoea 1 - 1 Pauwels et al, 2001
9Healthy Respiratory Mucosa
This electron micrograph shows the respiratory
mucosa in a healthy state The cells are fully
ciliated The cilia beat in a co-ordinated
fashion to move mucus out of the airways
(mucociliary transport)
Scanning electron micrograph showing a sheet of
mucus being moved along by the cilia
10Damaged Respiratory Mucosa
- Damage to the cilia and epithelium occur as a
result of disease processes in COPD. This can
also occur as a result of bacterial damage - This slide shows the result of bacterial
infection stripping away the cilia from the
mucosa - The damage to the cilia means they are less
effective in removing mucus from the airways
Scanning electron micrograph showing cilial and
epithelial damage induced by bacteria
11- Chronic Bronchitis
- ? in mucus glands and goblet cells
- Production of sputum on most days for gt 3 months
on 2 consecutive years
- Small airway disease
- (structural changes in the small airways 2-5mm)
- gt 50 of bronchioles may be effected before any
SOB - ? airway smooth muscle
- Inflammatory infiltration resulting in
structural narrowing and distortion - Collagen deposition / fibrosis / mucous plugging
12- Emphysema
- Dilation of alveolar wall
- ? alveolar capillary network, loss of guy rope
effect - ? lung tissue elasticity
- Caused by smoking irritation inflammation
neutrophils and macrophages release neutrophil
elastase (type of proteases)
Emphysema
Normal Lung
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14The COPD Patient
- Generally over 40 years 1
- A smoker or ex-smoker
- Presentation with
- cough
- excessive sputum production
- shortness of breath
- Dyspnoea is the reason most patients seek
medical attention 3
1. BTS, 1997 3. GOLD, 2003
15Diagnosis
- gt35 years
- Smoker or ex-smoker
- Spirometry (obstructive pattern)
- Any symptoms
- Exertional breathlessness
- Chronic cough
- Regular sputum production
- Frequent winter bronchitis
- Wheeze
- no clinical features of asthma
16Clinical features of Asthma vs. COPD
17Assessment of Severity of COPD
GOLD state that spirometry is the gold standard
for diagnosing COPD, severity is measured by
FEV1.
1 NICE Guidelines 2004
18Impact of Chronic Disease
- Impairment
- Disability
- Handicap
19Management of COPD (Stable)
- Use short acting bronchodilator PRN
(beta2-agonist or anti-cholinergic) - If still symptomatic try combined therapy with a
short acting beta2 agonist and a short acting
anti-cholinergic. - If still symptomatic use a long acting
bronch-dilator (beta2 agonist or
anti-cholinergic)
20Management In moderate or severe COPD
- If still symptomatic consider a trial of a
combination of a long acting beta2 agonist and
inhaled corticosteroid. (Discontinue if no
benefit after 4 6 weeks) - If still symptomatic consider adding
theophylline. - Offer pulmonary rehab to all patients who
consider themselves functionally disabled
(usually MRC 3 and above) - Consider referral for surgery.
- End of Life Care (need to start these
conversations ,what the future will hold, discuss
issues, worries and concerns with patients at an
earlier stage. Palliative care being part of end
of life care)
21Acute exacerbation of COPD
- Sustained worsening of patients symptoms from
their usual stable state, which is beyond normal
day-to-day variations and is acute in onset. 1 - Symptoms
- Increased shortness of breath
- Increased sputum production and/or change in
colour - Increased cough
- Increased wheeze/tightness
- Decreased exercise tolerance
- Increased fatigue
- Confusion
- 1 NICE Guidelines 2004
22Annual Review Primary Care
- Smoking cessation
- Spirometry
- Need for Oxygen Assessment
- Pharmacological Therapy - inhaler technique
- Pulmonary Rehabilitation
- LVRS / Transplantation
- BMI Need for Dietician Input
- Referral to other Services
- MRC Scale
- Need for Specialist Referral
- Chronic NIV
- End of Life Care
23Severe COPD
- Smoking cessation
- Oxygen
- Pharmacological Therapy
- Pulmonary Rehabilitation
- Dyspnoea Clinic
- LVRS / Transplantation
- Chronic NIV
- End of Life Care - Palliation
24Natural History
25Look magazine ad from 1951
26Oxygen Therapy
- Long Term Oxygen Therapy (LTOT)
- Short Burst Oxygen Therapy
- Ambulatory Oxygen Therapy
27Benefits of LTOT
- Improved survival
- Prevention of deterioration of pulmonary
haemodynamics - Reduction in secondary polycythaemia
- Neuropsychological benefit
- improved sleep quality
- Increased renal blood flow
- reduction in cardiac arrhythmias
- Reduction in dyspnoea, improved exercise
tolerance - Should be worn for 15 hrs or more a day to gain
these benefits
28Short Burst Oxygen Therapy
- Further research is required
- Episodic dyspnoea not relieved by other
treatments - Palliative therapy or in emergency situations
- If improvement in dyspnoea or exercise tolerance
can be documented
29Ambulatory Oxygen Therapy
- Improved exercise tolerance
- Reduced dyspnoea
- Improved quality of life
30Medicines Management
- Flu and Pneumonia vaccination
- Bronchodilators
- Coticosteroids
- Mucolytics
- Pharmacotherapy does not modify long-term
decline, but is used to - prevent and control symptoms / improve exercise
tolerance - reduce the frequency and severity of
exacerbations - improve health status
31Long Acting Inhaled bronchodilators e.g.
Salmeterol / Tiotropium
- Significant improvement in lung function 1-3
- better sustained improvement in lung function
over 12 hours than ipratropium bromide 1 - Improve shortness of breath day and night 1,3
- Reduce risk of exacerbations vs. placebo 1
- Clinically significant improvements in quality of
life 4,5 - unlike ipratropium bromide, Salmeterol
significantly increased the percentage of
patients showing a clinically relevant
improvement in health status compared with
placebo 5
1. Mahler et al, 1999, 2. Mahler et al, 2001, 3.
Boyd et al, 1997, 4. Jones et al, 1997, 5. Cox et
al, 2000
32Xanthines - e.g. theophylline
- Less commonly used than other bronchodilators
- Only modest bronchodilators
- Side effects within therapeutic range
- Many drug interactions
- Smoking can affect the metabolism of theophylline
33Inhaled Corticosteroids
- Inhaled steroids now limited to moderate
symptomatic disease with ?2 exacerbations per
year to reduce admission rates 1 - Emerging evidence of enhanced effect of xanthines
when combined with corticosteroid - 1 NICE (2004)
34Mycolytics
- Carbocisteine
- Reduces sputum viscosity to aid expectoration
- Reduces exacerbations of COPD in those with
chronic productive cough - (caution in peptic ulceration / can cause
gastrointestinal irritation) - Erdotin - Short course during acute exacerbation
- GOLD guidelines (2007) suggest there is not
enough evidence to support there use. However,
there are a group of patients in which it works
well in
35Lung Reduction In Emphysema
Remove hyperinflated areas of lung Improve V/Q
matching Reduce resting length of respiratory
muscles Reduce Dynamic Hyperinflation
36Pulmonary Rehabilitation
- The goal of PR are to reduce the symptoms,
disability and handicap to improve functional
independence in COPD 5 - Programme incorporates a programme of physical
training, disease education, nutritional,
psychological, social and behaviour intervention
5 - Provided by a inter professional team, with
attention to individual goals and needs. - Improves exercise tolerance and function /
reduces dyspnoea / improves QOL 1,2 - Empowerment for patients to manage their own
condition recognition of exacerbations. - 1 Ries et al. 1995, 2 De Paepe et al. 2000 3,
Griffiths at al.2000, 4, Troosters et al, 2000 5
BTS 2001
37Pulmonary Rehabilitation
- Introduction
- Benefits of exercising
- Anatomy, Physiology and Pathology
- Medication
- Chest Clearance techniques
- Dyspnoea management
- OT pacing/aids
- Age Concern Benefits system
- Exacerbation
- Nutrition
- Psychosocial factors - Coping/Anxiety/Panic
- Breath easy
- Expert patient
- What next? Health improvement team
38Chronic Non-Invasive Ventilation
- Domiciliary NIV for a highly selected group of
COPD patients with recurrent admissions requiring
assisted ventilation is effective at reducing
admissions and minimizes costs from the
perspective of the acute hospital 1 - 1 Tuggey JM, Plant PK, Elliott MW. Thorax. 2003
39When does COPD become Palliative? (1 of 2)
- Primary clinical indicators
- FEV1 lt 30 pred
- History of gt2 acute exacerbations in last 12
months - Frequent admissions to hospital
- Progressive shortening of of the intervals
between admissions - Limited improvement following admission 1
40When does COPD become Palliative? (2 of 2)
- Supporting clinical Indicators
- On maximum therapy- no other intervention is
likely to alter the conditions progression - Dependence on oxygen therapy
- Severe unremitting dyspnoea (MRC Dyspnoea Scale
grade 5) - Severe co morbidities e.g. heart failure,
diabetes - Housebound unable to carry out normal ADL
41MRC DYSPNOEA SCALE
42Consider
- Mortality in severe COPD is between 36 and 50
at 2 years 1 - In the last year of life 2
- 40 had unrelieved breathlessness
- 68 had low mood unrelieved
- 51 had unrelieved pain
- 20 did not know they might die
- 70 died in hospital (for 25 of whom it was not
the best place to die) - It has been shown that NIV in acute exacerbations
of COPD reduces mortality and need for ICU 3,4
1 Connors et al AJRCCM 1996 2 Elkington et al
Palliat Med 2005 3 Brochard et al N Engl J Med
1995 4 Plant et al Lancet 2000
43Dyspnoea - Symptomatic Treatment
- Opioids
- Mechanism unclear
- ? respiratory drive, ?sensation of respiratory
muscle fatigue, cognitive changes, central
effect, cough suppressant 2
- Oral morphine 2.5 4 hourly (dose maybe escalated
if well tolerated) 1
No evidence to support nebulised morphine
1 Watson et al 2006 2 Jenner 1991
44Dyspnoea related to Anxiety
- Benzodiazepines
- Examples include
- - Diazepam 2 5mgs BD and PRN
- - Lorazepam 1 2 mgs p.r.n 1
-
- 1 Watson et al 2006
45Oxygen Therapy
- Some patients do derive good benefit if not
already on LTOT - But Beware the CO2 retainers
- Also
- Risk of psychological dependence
- Paradoxical restriction to activity
- Dry mouth / nose
- Isolation and communication problems
- Consider open window, fan, cool flannel, heliox
46Intractable Cough
- Steam inhalation
- Nebulisation - (0.9 sodium chloride. Consider
nebulised bronchodilation and steroid) - Oral morphine 2.5 - 5mg, 4 hourly 1
- 1 Watson et al 2006
47Excessive Respiratory Secretions
Pharmacological Management
- Hyoscine Hydrobromide Patches or sub cut.
- Glycopyrronium
- Care must be taken to prevent dry mouth
48Terminal Breathlessness
- Non-pharmacological management
- Touch
- Relaxation
- Environment
- Modelling of behaviour
- Subcutaneous Route may be necessary
-
49COPD CNS - Current Role (1 of 2)
- To provide expert treatment for all COPD patients
Westminster, in line with the NICE guidelines - To provide expert advice and education to
patients and carers - To educate and advise other health care
professionals on the management of COPD patients
in both primary and secondary care settings - To reduce hospital admissions, length of stay and
improved use of primary care resources
50COPD CNS - Current Role (2 of 2)
- To support GPs and non-respiratory consultants in
diagnosis and management of COPD patients - To continue to develop services for COPD patients
in both primary and secondary care. - Work with Community Matrons and other community
staff i.e. rapid response nurses in the
management of exacerbations of COPD - Support COPD patients on Long Term Oxygen therapy
- Proactive Health Screening for COPD
51Community COPD Service
- Home Visits COPD Nurse Specialist
- Education and advice Proactive Management
- Smoking cessation
- Review of medication and Inhaler technique
- Assess Home Situation
- Long Term Oxygen Assessment / Review
- Supported discharge from Hospital
- Exacerbation recognition/management plans
- Ongoing support and advice Telephone
52Community COPD Service
- Community Clinic COPD Nurse Specialist
- Education and advice Proactive Management
- Smoking cessation
- Review of medication and Inhaler technique
- Long Term Oxygen Assessment / Review
- Exacerbation recognition/management plans
- Advice and Support
- Identification Referral to other agencies
53And I havent touched on
- The Management of an COPD Exacerbation
- Inhaler Technique / Nebulisers
- Diet Nutrition
- Anxiety and Depression
- We will leave that for another day!
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55Thank You
56Case Study 1
- Mrs Jones Age 63
- Retired Care Worker
- Heavy smoker, still smoking 2 -3 day
- Diagnosed with COPD 2 years ago, after spilling a
bottle of bleach - Smokers cough / winter chest infections for
years - Housebound Lives Ground Floor Flat
- On maximum inhaled therapy including nebuliser
- Long Term Oxygen
- Nocte BiPAP
- Problems
- - Unable to accept diagnosis of long term
condition - - Depressed and socially isolated
- - Breathless on minimal exertion
- - Continues to smoke
57COPDChronic Obstructive Pulmonary DiseaseCOPD
Project Nurse End of Life Care
- By
- Matthew Hodson
- Respiratory Nurse Specialist COPD
- Westminster Primary Care Trust
58Definition
- Chronic obstructive pulmonary disease (COPD)
is characterised by airflow obstruction. The
airflow obstruction is usually progressive, not
fully reversible and does not change markedly
over several months. 1 - The disease is predominantly caused by smoking.
- 1. NICE 2004
59The Umbrella Disease
60Background
- Mortality in Severe COPD is between 36 50 at 2
years - - High Number of Hospital Admissions
- Exacerbations
- Type 2 respiratory failure
- Non Invasive Ventilation
- Access to specialist palliative care variable
- Traditionally on malignant disease into SPC
- Improving care and patient journey
- Patient Pathways acute / suspected / stable
EOL missing
61The Role
- Project Nurse COPD End of Life
- 6 Month Role
- 2 days a week
62Scope of Role
- To understand the current provision of general
palliative care by GPs, Practice Nurses, DNs and
Community Matrons to COPD patients and their
knowledge of this area of care. - To assess the current local provision of
palliative care needs for COPD patients in
Westminster - To understand the potential benefits of
specialist palliative care to COPD patients.
63Scope of Role
- To provide and develop an education opportunity
for general providers regarding recognising
palliative needs in COPD patients. - To produce a guideline and pathway for
recognising and managing COPD patients at the end
of their life, linking in with the overall EOL
care pathways.
64Outcome Measures
- Baseline Audit Completed
- Improved rates of referral to SPC
- Care pathway for COPD into SPC
- Guidelines on criteria for referral
- Education for Primary Care Staff
- Evaluation and recommendations for the future