COPD

home – hospital -
community

• Dr Chang Yui
• Associate Consultant
• Respiratory Physician
• Department of medicine and Geriatrics
• Princess Margaret Hospital
Case sharing – a typical senanrio
• M/56
• 11 EM and 5 IP admissions in 12 months – all attributed to AECOPD.
• COPD –GOLD stage III.
• Each visit – standard pharmacological treatment – home
• LOS of IP- 1day. – discharge with antibiotics and bronchodilators and a pamphlet
on “how to Manage COPD”
• COPD disease management programs
• Individualized based.
• Post acute care services
Transition from acute to post acute care
• Lived alone
• 2nd floor walk up apartment
• Experiences significant shortness of breath going up and down the stairs.
• Homebound
• No showers as afraid will fall in the shower and therefore has been “washing up”
at the sink.
• Weight loss > 20 pounds over the last year
• No family support;
• Depressed – never spoken to anyone – it just goes with the territory
• Education level – primary Six – not read very well
Discharge plan
• Comprehensive, individualized assessment, evaluating the patient’s true need,
and implementation of an appropriate discharge plan directed at reducing the
potential for readmissions.
What can we do?
Introduction
• Chronic = It’s a long term condition and does not go away
• Obstructive = you airways are narrowed, so its harder to breathe out quickly
• Pulmonary = it affects your lungs
• Disease = It’s a medical condition
• Two of these lung conditions are persistent bronchitis and emphysema, which can also
occur together
• Bronchitis means the airways are inflamed and narrowed. People with bronchitis often
produce sputum, or phlegm.
• Emphysema affects the air sacs at the end of the airways in your lungs.
• They break down and the lungs become baggy and full of holes which trap air.

• These processes narrow the airways. This makes it harder to move air in and out as you
breathe, and your lungs are less able to take in oxygen and get rid of carbon dioxide.
Healthy lung : tissue between the airways acts as packing and
pulls on the airways to keep them open.
COPD : the airways are narrowed
Burden of COPD
• Prevalence
• Morbidity
• Mortality
• Economic burden
• Social burden
Chronic Obstructive Pulmonary Disease
(COPD)
► COPD is currently the fourth leading cause of death in the
world.1

► COPD is projected to be the 3rd leading cause of death by

2020.2

► More than 3 million people died of COPD in 2012

accounting for 6% of all deaths globally.

► Globally, the COPD burden is projected to increase in

coming decades because of continued exposure to COPD
risk factors and aging of the population.

1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic
analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.
2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Economic and Social Burden
Economic burden of COPD

► COPD is associated with significant economic burden.

► COPD exacerbations account for the greatest proportion
of the total COPD burden.

► European Union:
 Direct costs of respiratory disease ~6% of the total
healthcare budget
 COPD accounting for 56% (38.6 billion Euros) of the
cost of respiratory disease.

► USA:
 Direct costs of COPD are $32 billion
 Indirect costs $20.4 billion.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Economic and Social Burden
► Global Burden of Disease (GBD) study

► Disability-Adjusted Life Year (DALY) = sum of years lost

because of premature mortality and years of life lived
with disability, adjusted for the severity of disability.

► COPD is an increasing contributor to disability and

mortality around the world.

► In 2013 COPD was 5th leading cause of DALYs lost.

► In the United States, COPD is the second leading cause of

reduced DALYs, trailing only ischemic heart disease

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Etiology, pathobiology & pathology of COPD leading to
airflow limitation & clinical manifestations

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 FEV1 progression over time

© 2019 Global Initiative for Chronic Obstructive Lung Disease

COPD in HA
• HA: Virtual Registry since 2010
• ~55000 COPD still alive at the end of each year
• ~5100 new cases, ~5100 death cases
COPD incidence and deaths from 2010 to 2015
8000
7000 7000
6300
6000
6000
5500 5100 5100
No. of COPD patients

5000 5500 5500

5300 5200 5200 5100
4000
3000
2000
1000
0
2010 2011 2012 2013 2014 2015
Year
No. of COPD patients new to HA No. of deceased COPD patients

20
COPD in KWC
2016 data No of COPD episodes No of COPD headcounts
admissions to acute hospitals (acute hospitals)

Total 26349 13888

CMC 2360 1037
PMH 2430 1246
YCH 1735 872

• More OAHR
• Older
• Higher Unplanned readmissions
• Higher death rate
COPD in KWC Re: OAH

N o. of
N o. of Episodes U nplanned
2016 A EC O PD adm issions to M G acute hosp N o. of Episodes H eadcount R eadm issions IP D eaths IP D ischarges
A ll A cute H ospital 26349 13888 8437 1191 24819
Total in C M C 2360 1037 966 142 2181
CM C
C M C : A dm it from O A H (Y ) 539 (22.8% ) 223 (21.5% ) 263 (27.2% ) 63 (44.4% ) 476 (21.8% )
Total in PM H 2430 1246 792 139 2182
PM H
PM H : A dm it from O A H (Y ) 338 (13.9% ) 181 (14.5% ) 129 (16.3% ) 48 (34.5% ) 289 (13.2% )
Total in Y C H 1735 872 642 94 1626
YCH
Y C H : A dm it from O A H (Y ) 316 (18.2% ) 167 (19.2% ) 133 (20.7% ) 39 (41.5% ) 276 (17.0% )

OAH
(HA average 16.6% among all OAHR)
• no of headcounts (HA average 16% among all OAHR)
• no of UR (HA average 20.6% among all OAHR)
• % of IP deaths (HA average 31.6% among all OAHR)
Diagnosis and Initial Assessment of COPD

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis and Initial Assessment

© 2019 Global Initiative for Chronic Obstructive Lung Disease

• Symptoms: dyspnoea, chronic cough, sputum production
• Spirometry: Post bronchodilator FEV1/FVC <0.70 – persistent airflow limitation
• Concomitant chronic diseases cardiovascular disease, skeletal muscle
dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung
cancer.
 Spirometry

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Post-bronchodilator FEV1

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Choice of thresholds

► COPD Assessment Test (CATTM)

► Chronic Respiratory Questionnaire (CCQ® )
► St George’s Respiratory Questionnaire (SGRQ)
► Chronic Respiratory Questionnaire (CRQ)
► Modified Medical Research Council (mMRC) questionnaire

© 2019 Global Initiative for Chronic Obstructive Lung Disease

COPD Assessment Test (CATTM)

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Modified MRC dyspnea scale

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 ABCD assessment tool

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Summary

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Prevention and Maintenance Therapy
• Key : smoking cessation
• Pharmacotherapy and nicotine replacement
• Non pharmacologic therapy vs Pharmacologic therapy
• Assessment of inhaler technique
• Vaccinations :Influenzae vaccination
:Pneumococal vaccination PCV13 and PPSV 23
LTOT vs oxygen therapy
NIV – noninvasive ventilation
Surgical / bronchoscopic interventional treatment
Palliative approaches – symptoms relieve and control.
 Treatment of COPD – goal: 2
areas

Improved
exercise
tolerance
Improve Prevent
Reduce disease
health
symptoms progression
status

Reduce
symptoms Reduce
risk
Prevent and Reduce
treat
exacerbation mortality
Manage stable COPD
Non-Pharmacologic Therapy
Non-pharmacologic
Pharmacologic Therapy
Therapy

Beta2-agnosts
Smoking Cessation
Anticholinergics
Physical activity

Pulmonary rehabilitation
Corticosteroids
Inhaled combination
Vaccination:
Flu/Pneumococcal
others
• Smoking cessation is the single most
effective and cost-effective intervention to
reduce the risk developing COPD and stop its
progression (Evidence A)
 Pharmacological therapy

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Pharmacological therapy

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Pharmacological therapy

© 2019 Global Initiative for Chronic Obstructive Lung Disease

LABA inhalers for COPD
DPI diskus Sevevent (salmeterol)

DPI Aerolizer Formoterol

DPI Breezhaler Ombrez (Indacaterol)

SMI Respimat Striverdi (olodaterol)

LAMA inhalers for COPD
DPI handilhaler / SMI respimat Spiriva @ Tiotropium

DIP Breezhaler Seebri @ Glycopyrronium

DPI Genuair Eklika @ Aclidinium

EPI Ellipta Incruse @ Umeclidinium

 Combination LABA + LAMA
Drug Device Dose

Umeclidinium + Vilanterol Ellipta 62.5/25mcg 1 puff once daily

(anoro)
Glycopyrronium + Indacterol Breezhaler 50/110mcg 1 puff once daily
(ultibro)
Tiotropium + Olodaterol Respimat 2.5/2.5mcg 2 puffs once daily
(Spiolto)
Aclidinium + Formoterol Genuair 340/12mcg 1 puff BD
(Duaklir)
ICS + LABA
Triple therapy

Triple therapy with fluticasone furoate, umeclidinium and vilanterol

resulted in a lower rate of moedate or severe COPD exacerbations… It
also resulted in a lower rate of hospitaliszation due to COPD.
Inhalation technique
• Instructions and demonstration of a proper inhalation technique are essential &
needs to be assessed regularly AND re-check at each visit to ensure a correct use
of the inhaler to improve therapeutic outcomes
• Choice of inhaler device has to be individualised and will depend most
importantly on patient’s ability and preference
• Inhaler technique (and adherence) should be evaluated before a treatment is
assessed as insufficient.
Role of ICS in COPD?
• Long term monotherapy with ICS is not recommended.
• Long term treatment with ICS may be considered is association with LABAs for pts
with a history of exacerbations despite appropriate treatement with long acting
bronchodilators.
 FOLLOW-UP pharmacological treatment

► Follow up pharmacological management should be guided by the

principles of first review and assess, then adjust if needed

© 2017 Global Initiative for Chronic Obstructive Lung Disease

© 2019 Global Initiative for Chronic Obstructive Lung Disease
Follow up pharmacological treatment -
dyspnoea
• LAMA can be added to escalate to triple therapy.
• Alternatively switiching from LABA/ICS to LABA/LAMA should be considered if
the original indication for ICS was inappropriate, or there has been a lack of
response to ICS treatment, or if ICS side effects warrant discontinuation.
exacerbations
• Escalation to either LABA/LAMA or LABA/ICS is recommended.
• LABA/ICS may be preferred to patient with a history or findings suggestive of asthma

• Blood eosinophil counts may identify patients with a greater likelihood of a beneficial
response to ICS.
• Patients with one exacerbation /yr, a PBC > 300 eosinophils/UL identifies patients more
likely to respond to LABA/ICS treatment.
• Patients wit > 2 moderate exacerbations /yr or at least one severe exacerbation requiring
hospitalization in the prior year, LABA/ICS treatment can be considered at blood
eosinophil Counts>100cells/ul as ICS effect
© 2017 Global Initiative for Chronic Obstructive Lung Disease
© 2019 Global Initiative for Chronic Obstructive Lung Disease
 • Pulmonary rehabilitation improves dyspnoea, health status
and exercise tolerance in stable patients.
• Pulmonary rehabilitation reduces hospitalization among
patients who have had a recent exacerbation (< 4 weeks from
prior hospitalization)

Pulmonary
rehabilitation
 Education

General
Psychological
exercise
Support
training

Pulmonary
rehabilitation
Components

Nutritional Breathing
advice retraining

Outcome
assessment
Morgan M. Thorax Jan 2017 vol 72 no1
Setting and duration of PRP
• Pulmonary rehabilitation can be delivered on an in-patient, day-patient or home
base.
• For day-patient PRP, the expected duration is 6-8 weeks and the expected
number of supervised sessions is 14 sessions (including 12 training sessions, 1 pre
assessment and 1 post assessment)
• Repeat PRP can be considered in patients who have completed a course of PRP
more than 1 year previously and who gain benefits from the program.
Setting of PRP
• Comprehensive Pulmonary rehabilitation Program
• Maintenance Program
• Refresher Program
• Post-acute exacerbation Pulmonary Rehabilitation Program
• Partial Pulmonary rehabilitation
• Breathing class and education
Education and self management

• Education alone has not been shown to be

effective
• Self management intervention with
communication with a health care professional
improves health status and decreases
hospitalizations and emergency department
visit.
2014 Wolters Kluwer Health 367 - 377
• Total 37 RCTs were identified, with 12 matching the inclusion criteria.
• The corresponding values between QG/TC and no exercise groups were 2.90 (95%
Ci 2.37 -3.43) and 37.77 (95% CI, 35.42 -40.12) m. respectively.

• Conclusions
• This systematic review supports the therapeutic value of QG/TC I patients with
COPD and highlights areas for future research.
• What to measure in PRP?
 Patient satisfaction survey

Program Program default rate

outcome

Program completion rate (% of

patients attended 75%
minimum supervised sessions)
Pulmonary rehabilitation NHS
 Opiates, neuromucular electrical stimulation
(NMES), oxygen and fans blowing air on the
face can relieve breathlessness.

Palliative Nurtitional supplement.

care EOL
and ACP in
COPD
Fatique – self management education,
pulmonary rehabilitation , nutritional
support and mind-body interventions.
Oversea Corporate scholarship Programme –
Pulmonary Rehabilitation
8th October – 2nd November 2018.
Training Institute:
Guy’s and St Thomas’ Hospital; NHS
Foundation Trust.
 Observe Observe COPD care model in a teaching hospital in UK; NHS

Observe the model in UK from hospital to home care –

Observe Palliative care in End stage COPD

Program
objectives Observe the role of outreach LTOT, Ambulatory oxygen (AO)
Observe and Clinic Speciality Nurse clinic.

Observe the importance of different disciplines in weekly

Observe team meeting to provide point of care and fast track care to
the needed patients.
 Physiothera

Referral crit

Pulmonary Well motiva

10m or mor
rehabilitation
programme (1) mMRC >/=3

14 sessions
weeks.
Integrated Respiratory Team (IRT)
Dr Dewar
IRT Lead Clinical (Consultant in OP COPD Nurse
specialist Physio
charge)

Oxygen (PT
COPD (PT) Prehab (PT) +CNS)

Inpatients, Clinics and community

 Recruitment is variable; may be
related to the loose criteria.
Completion
rate of PRP in
NHS UK
Completion rate is around 60%
• THANK YOU