COPD<br />Disease not<br />Disorder?<br />Alyn Morice<br />University of Hull<br />HYMS<br />
What is COPD?<br />Asthma (eosinophilic  bronchitis)<br />Chronic Bronchitis<br />(neutrophilic bronchitis)<br />Emphysema...
2010<br />
Page 1 of  673!<br />
COPD Treatment Pathway<br />Establish diagnosis of COPD in at risk population with history, examination and spirometry (FE...
Telemonitoring in COPD – the evidence base<br />Numerous pilot projects with accompanying evaluation reports;<br />Often e...
Evaluation…<br /><ul><li>Evaluation of first 3 months deployment (24 patients) showed:</li></ul>	-	Patient satisfaction ge...
 MDT agrees intervention</li></ul>RESPOND<br />  Telephone patient<br />  Visit - within identified <br />     timescale <...
Telemonitoring in COPD – How can it work?<br />
Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD pa...
Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD pa...
Roger<br /><ul><li>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</li></ul>After telehealth:<br /><ul><li>	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</li></li></ul><li>Telehealth then...<br />14<br />
Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD pa...
The impact of frequent COPD exacerbations - more frequent attacks increase mortality<br />1.0<br />0.8<br />0.6<br />0.4<b...
COPD patients with productive cough<br />More likely to have exacerbations<br />Seemungal TA et al. Am J RespirCrit Care M...
Timing of symptoms: when was each symptom the most troublesome?<br />40<br />30<br />20<br />10<br />0<br />19<br />Cough ...
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Alyn morice hull wsdan 30 june 2011

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  • Here we can see two acoustic waveforms. The x-axis is time (covering approx 55 mins) and the y-axis is relative decibels of acoustic events. The upper waveform is from an unprocessed and unfiltered file and the lower waveform is that same file after undergoing the Hull filtering process. We can clearly notice the huge reduction in non-cough acoustic events prior to cough quantification.
  • Alyn morice hull wsdan 30 june 2011

    1. 1. COPD<br />Disease not<br />Disorder?<br />Alyn Morice<br />University of Hull<br />HYMS<br />
    2. 2. What is COPD?<br />Asthma (eosinophilic bronchitis)<br />Chronic Bronchitis<br />(neutrophilic bronchitis)<br />Emphysema<br />
    3. 3. 2010<br />
    4. 4. Page 1 of 673!<br />
    5. 5. COPD Treatment Pathway<br />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<br />Management of RISK FACTORS plus EDUCATION plus IMMUNISATION<br />SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues<br />Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised)<br />PHARMACOLOGICAL TREATMENT<br />Review at each step after one month before escalating treatment<br />SHORTNESS OF BREATH<br />COUGH AND SPUTUM<br />prn short acting β2 agonist<br />MUCOLYTICS<br />THEOPHYLLINE<br />Tiotropium + short acting β2 agonist<br />Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol<br />Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss)<br />Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)<br />Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6)<br />Consider Palliative Care Referral in End Stage Disease<br />
    6. 6. Telemonitoring in COPD – the evidence base<br />Numerous pilot projects with accompanying evaluation reports;<br />Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions)<br />Often methodologically limited (e.g. before-and-after studies; small sample sizes)<br />Systematic reviews demonstrate that high-quality evidence base is still immature;<br />Bolton (2010): studies included were positive but of a low-quality<br />Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations<br />
    7. 7. Evaluation…<br /><ul><li>Evaluation of first 3 months deployment (24 patients) showed:</li></ul> - Patient satisfaction generally very good<br /> - 68% reduction in n/e admission costs<br /> - net saving per month<br /> - achievement of £0.5m QIPP saving feasible<br /><ul><li> Evaluation by Hull University – full year evaluation due Dec 11</li></li></ul><li>The East Riding Model<br />IDENTIFY<br />GP’s/NCT<br />Patient at risk <br />of deterioration<br />REFER<br />MONITOR<br />1. Referral for telehealth<br /> intervention<br />2. Patient registered & unit installed<br />1. Monitoring<br /><ul><li> Risk stratification identifies patient
    8. 8. MDT agrees intervention</li></ul>RESPOND<br /> Telephone patient<br /> Visit - within identified <br /> timescale <br /> Emergency Response<br /> Step up / Step down<br /> Community Beds<br />2. Alerts<br />3. Triage<br />4. Response<br />Protocols for response in place:<br />GP, NCT , specialist services, secondary care<br />
    9. 9. Telemonitoring in COPD – How can it work?<br />
    10. 10. Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD patients by;<br />Providing reassurance and support<br />
    11. 11.
    12. 12. Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD patients by;<br />Increasing knowledge of disease process and enhancing self-care<br />Providing reassurance and support<br />
    13. 13. Roger<br /><ul><li>64 year old with chronic, severe COPD
    14. 14. Housebound and anxious
    15. 15. Frequently uses standby medication
    16. 16. Frequent hospital admissions – anxiety rather than healthcare need
    17. 17. Distrustful of clinicians due to previous experience</li></ul>After telehealth:<br /><ul><li> Telephone contact to reassure
    18. 18. Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns
    19. 19. More proactive about asking for help
    20. 20. Reduced hospital admissions</li></li></ul><li>Telehealth then...<br />14<br />
    21. 21. Telemonitoring in COPD – suggested mechanisms of action<br />It has been suggested that telemonitoring can support COPD patients by;<br />Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms)<br />Increasing knowledge of disease process and enhancing self-care<br />Providing reassurance and support<br />
    22. 22.
    23. 23. The impact of frequent COPD exacerbations - more frequent attacks increase mortality<br />1.0<br />0.8<br />0.6<br />0.4<br />0.2<br />0<br />0<br />10<br />20<br />30<br />40<br />50<br />60<br />n=304<br />A<br />p<0.0002<br />Survival probability<br />B<br />p<0.0001<br />p=0.069<br />C<br />Time (months)<br />Group A: no exacerbations<br />Group B: 1–2 exacerbations<br />Group C: ≥3 exacerbations<br />Soler-Cataluna JJ, et al. Thorax 2005;60:925–931<br />
    24. 24. COPD patients with productive cough<br />More likely to have exacerbations<br />Seemungal TA et al. Am J RespirCrit Care Med 98<br />More rapid decline in lung function<br />Vestbo J 1996, KannerRA et al. Am J RespirCrit Care Med 01<br />More likely to die early<br />Prescott E et al. EurRespir J 1995<br />
    25. 25. Timing of symptoms: when was each symptom the most troublesome?<br />40<br />30<br />20<br />10<br />0<br />19<br />Cough (n=1,433)<br />Breathlessness (n=1,769)<br />50<br />40<br />30<br />20<br />10<br />0<br />48.9<br />31.0<br />24.0<br />22.5<br />% of patients<br />% of patients<br />19.5<br />22.3<br />18.7<br />17.3<br />14.9<br />10.6<br /> On Later in the In the In the At night Waking morning afternoon evening<br /> On Later in the In the In the At night Waking morning afternoon evening<br />40<br />30<br />20<br />10<br />0<br />Phlegm (n=1,551)<br />Chest tightness (n=690)<br />60<br />50<br />40<br />30<br />20<br />10<br />0<br />56.7<br />28.8<br />25.9<br />25.4<br />25.5<br />% of patients<br />% of patients<br />26.2<br />16.7<br />16.6<br />16.3<br />11.8<br /> On Later in the In the In the At night Waking morning afternoon evening<br /> On Later in the In the In the At night Waking morning afternoon evening<br />Partridge et al. ERS Vienna 2009<br />
    26. 26. HULL AIRWAYS REFLUX QUESTIONNAIRE<br />Name: <br />D.O.B:____________________________ UN: _________________<br />DATE OF TEST: <br />Please circle the most appropriate response for each question<br />www.issc.info<br /> TOTAL SCORE_____________ /70<br />
    27. 27. History of Cough Recording<br />Woolf & Rosenberg,Thorax 1964:19;125<br />
    28. 28. History of Cough Recording<br />Woolf & Rosenberg,Thorax 1964:19;125<br />
    29. 29. Waveforms showing acoustic events – Pre and post filtering<br />unprocessed file<br />processed<br /> file<br />
    30. 30. Cough counting in exacerbations of COPD<br />Day 1 546 coughs<br />Day 5 162 coughs<br />
    31. 31. Futureof telemonitoring in COPD<br />25<br />

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