AHM 2011 Alyn Morice University of Hull HYMS COPD Disease not Disorder?

AHM 2011

Alyn MoriceUniversity of HullHYMS

COPDDisease notDisorder?

What is COPD?

Asthma (eosinophilic bronchitis)

Emphysema Chronic Bronchitis(neutrophilic bronchitis)

2010

Page 1 of 673!

COPD Treatment PathwayCOPD Treatment Pathway

Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio <70%) Establish severity of disease by FEV1 as % predicted

Management of RISK FACTORS plus EDUCATION plus IMMUNISATION

Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)

SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues

PHARMACOLOGICAL TREATMENT

Review at each step after one month before escalating treatment

THEOPHYLLINE

MUCOLYTICS

prn short acting β2 agonist

Tiotropium + short acting β2 agonist

SHORTNESS OF BREATH

Consider Palliative Care Referral in End Stage Disease

Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol

Tiotropium + combination LABA and inhaled corticosteroid

(Seretide 500 accuhaler or Symbicort 200/6)

COUGH AND SPUTUM

Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss)

Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)

Telemonitoring in COPD – the evidence base• Numerous pilot projects with accompanying evaluation

reports;

– Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions)

– Often methodologically limited (e.g. before-and-after studies; small sample sizes)

• Systematic reviews demonstrate that high-quality evidence base is still immature;

– Bolton (2010): studies included were positive but of a low-quality

– Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations

Best health, best health care, a health service fit for the East Riding

Evaluation…

• Evaluation of first 3 months deployment (24 patients) showed:

- Patient satisfaction generally very good

- 68% reduction in n/e admission costs

- net saving per month

- achievement of £0.5m QIPP saving feasible

• Evaluation by Hull University – full year evaluation due Dec 11

Best health, best health care, a health service fit for the East Riding

The East Riding Model

• Risk stratification identifies patient

• MDT agrees intervention

Protocols for response in place:GP, NCT , specialist services,

secondary care

GP’s/NCT

1. Referral for telehealth

intervention

2. Patient registered & unit installed

Patient at risk of deterioration

2. Alerts

3. Triage

4. Response

1. Monitoring

IDENTIFY

REFERMONITOR

RESPOND

Telephone patient Visit - within identified timescale

Emergency Response

Step up / Step down Community Beds

Telemonitoring in COPD – How can it work?

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can

support COPD patients by;

– Providing reassurance and support

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can

support COPD patients by;

– Increasing knowledge of disease process and enhancing self-care

– Providing reassurance and support

Best health, best health care, a health service fit for the East Riding

Roger• 64 year old with chronic, severe COPD• Housebound and anxious• Frequently uses standby medication• Frequent hospital admissions – anxiety rather

than healthcare need• Distrustful of clinicians due to previous experience

After telehealth:

• Telephone contact to reassure• Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns• More proactive about asking for help• Reduced hospital admissions

Telehealth then...

14

Telemonitoring in COPD – suggested mechanisms of action• It has been suggested that telemonitoring can support COPD

patients by;

– Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms)

– Increasing knowledge of disease process and enhancing self-care

– Providing reassurance and support

The impact of frequent COPD exacerbations - more frequent attacks increase mortality

Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

Group A: no exacerbationsGroup B: 1–2 exacerbationsGroup C: ≥3 exacerbations

n=304

Time (months)

p<0.0001

p<0.0002A

B

C

p=0.069

0 10 20 30 40 50 60

1.0

0.8

0.6

0.4

0.2

0

Su

rviv

al p

rob

abil

ity

COPD patients with productive cough• More likely to have exacerbations

Seemungal TA et al. Am J Respir Crit Care Med 98

• More rapid decline in lung functionVestbo J 1996, Kanner RA et al. Am J Respir Crit Care Med 01

• More likely to die earlyPrescott E et al. Eur Respir J 1995

% o

f p

ati

en

ts

On Later in the In the In the At night Waking morning afternoon evening

31.0

24.022.5

19.5

10.6

Breathlessness (n=1,769)

28.825.9 25.4 25.5

16.7

Chest tightness (n=690)

40

30

20

10

0

Timing of symptoms: when was each symptom the most troublesome?

19

% o

f p

ati

en

ts

On Later in the In the In the At night Waking morning afternoon evening

40

30

20

10

0

% o

f p

ati

en

ts

On Later in the In the In the At night Waking morning afternoon evening

48.9

22.3

14.918.7 17.3

Cough (n=1,433)50

40

30

20

10

0

% o

f p

ati

en

ts

On Later in the In the In the At night Waking morning afternoon evening

56.7

26.2

16.3 16.611.8

Phlegm (n=1,551)60

50

40

30

20

10

0

Partridge et al. ERS Vienna 2009

HULL AIRWAYS REFLUX QUESTIONNAIREName:D.O.B:____________________________ UN: _________________DATE OF TEST:Please circle the most appropriate response for each question

Within the last MONTH, how did the following problems affect you? 0 = no problem and 5 = severe/frequent problem

Hoarseness or a problem with your voice 0 1 2 3 4 5

Clearing your throat 0 1 2 3 4 5

Excess mucus in the throat, or drip down the back of your nose

0 1 2 3 4 5

Retching or vomiting when you cough 0 1 2 3 4 5

Cough on first lying down or bending over 0 1 2 3 4 5

Chest tightness or wheeze when coughing 0 1 2 3 4 5

Heartburn, indigestion, stomach acid coming up (or do you take medications for this, if yes score 5)

0 1 2 3 4 5

A tickle in your throat, or a lump in your throat 0 1 2 3 4 5

Cough with eating (during or straight after meals) 0 1 2 3 4 5

Cough with certain foods 0 1 2 3 4 5

Cough when you get out of bed in the morning 0 1 2 3 4 5

Cough brought on by singing or speaking (for example, on the telephone)

0 1 2 3 4 5

Coughing during the day rather than night 0 1 2 3 4 5

A strange taste in your mouth 0 1 2 3 4 5TOTAL SCORE_____________ /70

www.issc.info

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

History of Cough Recording

Woolf & Rosenberg,Thorax 1964:19;125

unprocessed file

processed file

Waveforms showing acoustic events – Pre and post filtering

Cough counting in exacerbations of COPD

• Day 1 546 coughs• Day 5 162 coughs

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Time hours

cough/

hour

Future of telemonitoring in COPD

25