This document discusses COPD (chronic obstructive pulmonary disease) and the potential role of telemonitoring in its management. It defines COPD as including asthma, chronic bronchitis, and emphysema. Telemonitoring allows for remote monitoring of COPD patients using devices that transmit health data. It is suggested that telemonitoring may help with earlier detection of exacerbations through reported symptoms. It could also increase disease knowledge and self-care, provide reassurance and support, and reduce hospital admissions. Several studies found telemonitoring improved quality of life and reduced costs, though the evidence base is still developing.

1. COPD Disease not Disorder? Alyn Morice University of Hull HYMS

2. What is COPD? Asthma (eosinophilic bronchitis) Chronic Bronchitis (neutrophilic bronchitis) Emphysema

3. 2010

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5. COPD 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 SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised) PHARMACOLOGICAL TREATMENT Review at each step after one month before escalating treatment SHORTNESS OF BREATH COUGH AND SPUTUM prn short acting β2 agonist MUCOLYTICS THEOPHYLLINE Tiotropium + short acting β2 agonist Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Consider Palliative Care Referral in End Stage Disease

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

8. MDT agrees interventionRESPOND Telephone patient Visit - within identified timescale Emergency Response Step up / Step down Community Beds 2. Alerts 3. Triage 4. Response Protocols for response in place: GP, NCT , specialist services, secondary care

9. Telemonitoring in COPD – How can it work?

10. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; Providing reassurance and support

12. 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

14. Housebound and anxious

15. Frequently uses standby medication

16. Frequent hospital admissions – anxiety rather than healthcare need

18. Patient keeps diary of results and more knowledgeable about condition eg, trends/patterns

19. More proactive about asking for help

21. 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

23. The impact of frequent COPD exacerbations - more frequent attacks increase mortality 1.0 0.8 0.6 0.4 0.2 0 0 10 20 30 40 50 60 n=304 A p<0.0002 Survival probability B p<0.0001 p=0.069 C Time (months) Group A: no exacerbations Group B: 1–2 exacerbations Group C: ≥3 exacerbations Soler-Cataluna JJ, et al. Thorax 2005;60:925–931

24. COPD patients with productive cough More likely to have exacerbations Seemungal TA et al. Am J RespirCrit Care Med 98 More rapid decline in lung function Vestbo J 1996, KannerRA et al. Am J RespirCrit Care Med 01 More likely to die early Prescott E et al. EurRespir J 1995

25. Timing of symptoms: when was each symptom the most troublesome? 40 30 20 10 0 19 Cough (n=1,433) Breathlessness (n=1,769) 50 40 30 20 10 0 48.9 31.0 24.0 22.5 % of patients % of patients 19.5 22.3 18.7 17.3 14.9 10.6 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening 40 30 20 10 0 Phlegm (n=1,551) Chest tightness (n=690) 60 50 40 30 20 10 0 56.7 28.8 25.9 25.4 25.5 % of patients % of patients 26.2 16.7 16.6 16.3 11.8 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening Partridge et al. ERS Vienna 2009

26. HULL AIRWAYS REFLUX QUESTIONNAIRE Name: D.O.B:____________________________ UN: _________________ DATE OF TEST: Please circle the most appropriate response for each question www.issc.info TOTAL SCORE_____________ /70

27. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

28. History of Cough Recording Woolf & Rosenberg,Thorax 1964:19;125

29. Waveforms showing acoustic events – Pre and post filtering unprocessed file processed file

30. Cough counting in exacerbations of COPD Day 1 546 coughs Day 5 162 coughs

31. Futureof telemonitoring in COPD 25