COPD Chronic Obstructive Pulmonary Disease

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COPDChronic Obstructive Pulmonary Disease

• By
• Matthew Hodson
• Respiratory Nurse Specialist COPD
• Westminster Primary Care Trust

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Aim 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

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Definition

• 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

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The Umbrella Disease
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Umbrella 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

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Burden

• 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

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Epidemiology

• 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

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Characteristic

• 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

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Healthy 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
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Damaged 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
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• 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

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• 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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The 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
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Diagnosis

• 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

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Clinical features of Asthma vs. COPD
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Assessment of Severity of COPD
GOLD state that spirometry is the gold standard
for diagnosing COPD, severity is measured by
FEV1.
1 NICE Guidelines 2004
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Impact of Chronic Disease

• Impairment
• Disability
• Handicap

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Management 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)

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Management 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)

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Acute 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

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Annual 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

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Severe COPD

• Smoking cessation
• Oxygen
• Pharmacological Therapy
• Pulmonary Rehabilitation
• Dyspnoea Clinic
• LVRS / Transplantation
• Chronic NIV
• End of Life Care - Palliation

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Natural History
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Look magazine ad from 1951
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Oxygen Therapy

• Long Term Oxygen Therapy (LTOT)
• Short Burst Oxygen Therapy
• Ambulatory Oxygen Therapy

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Benefits 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

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Short 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

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Ambulatory Oxygen Therapy

• Improved exercise tolerance
• Reduced dyspnoea
• Improved quality of life

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Medicines 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

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Long 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
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Xanthines - 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

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Inhaled 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)

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Mycolytics

• 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

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Lung Reduction In Emphysema
Remove hyperinflated areas of lung Improve V/Q
matching Reduce resting length of respiratory
muscles Reduce Dynamic Hyperinflation
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Pulmonary 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

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Pulmonary 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

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Chronic 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

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When 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

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When 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

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MRC DYSPNOEA SCALE
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Consider

• 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
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Dyspnoea - 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
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Dyspnoea 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

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Oxygen 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

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Intractable 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

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Excessive Respiratory Secretions
Pharmacological Management

• Hyoscine Hydrobromide Patches or sub cut.
• Glycopyrronium
• Care must be taken to prevent dry mouth

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Terminal Breathlessness

• Non-pharmacological management
• Touch
• Relaxation
• Environment
• Modelling of behaviour
• Subcutaneous Route may be necessary

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COPD 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

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COPD 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

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Community 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

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Community 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

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And 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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Thank You

• Any Questions?

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Case 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

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COPDChronic Obstructive Pulmonary DiseaseCOPD
Project Nurse End of Life Care

• By
• Matthew Hodson
• Respiratory Nurse Specialist COPD
• Westminster Primary Care Trust

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Definition

• 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

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The Umbrella Disease
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Background

• 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

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The Role

• Project Nurse COPD End of Life
• 6 Month Role
• 2 days a week

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Scope 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.

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Scope 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.

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Outcome 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