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Copd Pallative Care

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    • 1. COPD Chronic Obstructive Pulmonary Disease By Matthew Hodson Respiratory Nurse Specialist COPD Westminster Primary Care Trust
    • 2. 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
    • 3. 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
    • 4. The Umbrella Disease
    • 5. 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
    • 6. 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
    • 7. 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, 50–75% of the costs are for services associated with exacerbations. 1
      • 1 COPD Audit Commission 2 BTS Consortium 2005
    • 8. 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
    • 9. 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
    • 10. 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
    • 11.
      • Chronic Bronchitis
      • ↑ in mucus glands and goblet cells
      • Production of sputum on most days for > 3 months on 2 consecutive years
      • Small airway disease
      • (structural changes in the small airways 2-5mm)
      • > 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
    • 13.  
    • 14. 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
    • 15. Diagnosis
      • >35 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
    • 16. Clinical features of Asthma vs. COPD
    • 17. Assessment of Severity of COPD 1 NICE Guidelines 2004 GOLD state that spirometry is the gold standard for diagnosing COPD, severity is measured by FEV1. <30% Severe 30-49% Moderate 50-80% Mild FEV1 % predicted 1 Severity of airflow obstruction
    • 18. Impact of Chronic Disease
      • Impairment
      • Disability
      • Handicap
    • 19. 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)
    • 20. 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)
    • 21. 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
    • 22. 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
    • 23. Severe COPD
      • Smoking cessation
      • Oxygen
      • Pharmacological Therapy
      • Pulmonary Rehabilitation
      • Dyspnoea Clinic
      • LVRS / Transplantation
      • Chronic NIV
      • End of Life Care - Palliation
    • 24. Natural History
    • 25. Look magazine ad from 1951
    • 26. Oxygen Therapy
      • Long Term Oxygen Therapy (LTOT)
      • Short Burst Oxygen Therapy
      • Ambulatory Oxygen Therapy
    • 27. 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
    • 28. 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
    • 29. Ambulatory Oxygen Therapy
      • Improved exercise tolerance
      • Reduced dyspnoea
      • Improved quality of life
    • 30. 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
    • 31. 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
    • 32. 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
    • 33. 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)
    • 34. 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
    • 35. Lung Reduction In Emphysema
      • Remove hyperinflated areas of lung :
        • Improve V/Q matching
        • Reduce resting length of respiratory muscles
        • Reduce Dynamic Hyperinflation
                 
    • 36. 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
    • 37. 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
    • 38. 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
    • 39. When does COPD become Palliative? (1 of 2)
      • Primary clinical indicators
      • FEV1 < 30% pred
      • History of >2 acute exacerbations in last 12 months
      • Frequent admissions to hospital
      • Progressive shortening of of the intervals between admissions
      • Limited improvement following admission 1
    • 40. 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
    • 41. MRC DYSPNOEA SCALE
    • 42. 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
    • 43. 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
    • 44. 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
    • 45. 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
    • 46. 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
    • 47. Excessive Respiratory Secretions – Pharmacological Management
      • Hyoscine Hydrobromide – Patches or sub cut.
      • Glycopyrronium
      • Care must be taken to prevent dry mouth
    • 48. Terminal Breathlessness
        • Non-pharmacological management
            • Touch
            • Relaxation
            • Environment
            • Modelling of behaviour
        • Subcutaneous Route may be necessary
    • 49. 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
    • 50. 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
    • 51. 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
    • 52. 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
    • 53. And I haven’t touched on…
      • The Management of an COPD Exacerbation
      • Inhaler Technique / Nebulisers
      • Diet & Nutrition
      • Anxiety and Depression
      • We will leave that for another day…!
    • 54.  
    • 55. Thank – You Any Questions ?
    • 56. 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
    • 57. COPD Chronic Obstructive Pulmonary Disease COPD Project Nurse – End of Life Care By Matthew Hodson Respiratory Nurse Specialist COPD Westminster Primary Care Trust
    • 58. 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
    • 59. The Umbrella Disease
    • 60. 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
    • 61. The Role
      • Project Nurse COPD – End of Life
      • 6 Month Role
      • 2 days a week
    • 62. 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.
    • 63. 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.
    • 64. Outcome Measures
      • Baseline Audit Completed
      • Improved rate’s 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

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