COPDChronic Obstructive Pulmonary Disease

By Matthew Hodson Respiratory Nurse Specialist COPDWestminster Primary Care Trust

Aim of Session

Understand the epidemiology of COPDUnderstand the epidemiology of COPD Improve knowledge and understanding of Improve knowledge and understanding of

COPD and its treatmentsCOPD and its treatments Increase awareness of Oxygen Therapy in Increase awareness of Oxygen Therapy in

COPDCOPD Gain an greater insight into when COPD Gain an greater insight into when COPD

may be palliative and exploring optionsmay be palliative and exploring options Understand COPD Services in WPCT Understand COPD Services in WPCT

Definition Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease

(COPD) is characterised by airflow (COPD) is characterised by airflow obstruction. The airflow obstruction is obstruction. The airflow obstruction is

usually progressive, not fully reversible usually progressive, not fully reversible and does not change markedly over and does not change markedly over

several months. several months. 11

The disease is predominantly caused by smoking.The disease is predominantly caused by smoking.

1. NICE 20041. NICE 2004

COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma

Emphysema

Airwayobstruction

Chronic severe asthma

Chronicbronchitis

COPD(shaded area)

COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma

Emphysema

Airwayobstruction

Chronic severe asthma

Chronicbronchitis

COPD(shaded area)

The Umbrella Disease

Umbrella Disease

COPD now preferred term for previous COPD now preferred term for previous diagnosis of bronchitis or emphysema, diagnosis of bronchitis or emphysema, chronic asthma chronic asthma

Significant airflow obstruction may be Significant airflow obstruction may be present before individual is aware of itpresent before individual is aware of it

May also be related to occupational May also be related to occupational exposures e.g. asbestosexposures e.g. asbestos

Burden

Up to 1 in 8 emergency admissions Up to 1 in 8 emergency admissions maybe due to COPDmaybe due to COPD 11

Over one million bed days are Over one million bed days are contributed to COPDcontributed to COPD 11

A total of 32,155 deaths in the UK where A total of 32,155 deaths in the UK where attributed to COPD in 1999attributed to COPD in 1999 11

1 BTS Consortium 20051 BTS Consortium 2005

Epidemiology

COPD is the fourth leading cause of death in the USA and Europe. COPD is the fourth leading cause of death in the USA and Europe. The leading cause of death worldwide The leading cause of death worldwide 11

Mortality in females has more than doubled over the last 20 years. Mortality in females has more than doubled over the last 20 years. 11

Nearly 900,000 people in England and Wales have a Nearly 900,000 people in England and Wales have a diagnosis of COPD diagnosis of COPD 22

Morbidity data greatly underestimate the total burden of COPD Morbidity data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically because the disease is usually not diagnosed until it is clinically apparent and moderately advancedapparent and moderately advanced..11

COPD is a more costly disease than asthma and, depending on COPD is a more costly disease than asthma and, depending on country, 50–75% of the costs are for services associated with country, 50–75% of the costs are for services associated with exacerbations. exacerbations. 11

1 COPD Audit Commission 2 BTS Consortium 20051 COPD Audit Commission 2 BTS Consortium 2005

Characteristic

Changes characteristic of the disease include:Changes characteristic of the disease include: smooth muscle contraction (bronchoconstriction)smooth muscle contraction (bronchoconstriction) mucus hypersecretionmucus hypersecretion ciliary dysfunctionciliary dysfunction pulmonary hyperinflationpulmonary hyperinflation gas exchange abnormalitiesgas exchange abnormalities pulmonary hypertension pulmonary hypertension cor pulmonalecor pulmonale

These abnormalities contribute to the characteristic These abnormalities contribute to the characteristic symptoms of COPD - chronic cough, sputum production and symptoms of COPD - chronic cough, sputum production and dyspnoea dyspnoea 11

1 Pauwels et al, 2001

Healthy Respiratory MucosaThis electron micrograph This electron micrograph shows the respiratory mucosa shows the respiratory mucosa in a healthy statein a healthy state

The cells are fully ciliated The cells are fully ciliated

The cilia beat in a co-ordinated The cilia beat in a co-ordinated fashion to move mucus out of fashion to move mucus out of the airways (mucociliary the airways (mucociliary transport) transport)

Scanning electron micrograph showing a sheet Scanning electron micrograph showing a sheet of mucus being moved along by the ciliaof mucus being moved along by the cilia

Damaged Respiratory Mucosa Damage to the cilia and Damage to the cilia and

epithelium occur as a result of epithelium occur as a result of disease processes in COPD. disease processes in COPD. This can also occur as a result of This can also occur as a result of bacterial damage bacterial damage

This slide shows the result of This slide shows the result of bacterial infection stripping away bacterial infection stripping away the cilia from the mucosathe cilia from the mucosa

The damage to the cilia means The damage to the cilia means they are less effective in they are less effective in removing mucus from the removing mucus from the airwaysairways

Scanning electron micrograph showing cilial and Scanning electron micrograph showing cilial and epithelial damage induced by bacteriaepithelial damage induced by bacteria

Chronic Bronchitis– ↑ ↑ in mucus glands and goblet cellsin mucus glands and goblet cells– Production of sputum on most days for > 3 months on 2 Production of sputum on most days for > 3 months on 2

consecutive yearsconsecutive years

Small airway disease (structural changes in the small airways 2-5mm)(structural changes in the small airways 2-5mm)

> 50% of bronchioles may be effected > 50% of bronchioles may be effected before any SOB before any SOB

–↑ ↑ airway smooth muscleairway smooth muscle

– Inflammatory infiltration resulting in Inflammatory infiltration resulting in structural narrowing and distortionstructural narrowing and distortion

Collagen deposition / fibrosis / mucous Collagen deposition / fibrosis / mucous pluggingplugging

Emphysema•Dilation of alveolar wallDilation of alveolar wall

•↓ ↓ alveolar capillary network, loss of guy rope effectalveolar capillary network, loss of guy rope effect

•↓ ↓ lung tissue elasticitylung tissue elasticity

•Caused by smoking Caused by smoking »» irritation irritation »» inflammation inflammation »» neutrophils and macrophages neutrophils and macrophages »» release neutrophil release neutrophil elastase (type of proteases)elastase (type of proteases)

EmphysemaNormal Lung

The COPD Patient

Generally over 40 years Generally over 40 years 11

A smoker or ex-smokerA smoker or ex-smoker

Presentation with:Presentation with: coughcough excessive sputum excessive sputum

productionproduction shortness of breathshortness of breath

Dyspnoea is the reason Dyspnoea is the reason most patients seek most patients seek medical attention medical attention 33

1. BTS, 1997; 3. GOLD, 2003

Diagnosis

>35 years>35 years Smoker or ex-smokerSmoker or ex-smoker Spirometry (obstructive pattern) Spirometry (obstructive pattern) Any symptoms :Any symptoms :

Exertional breathlessnessExertional breathlessness Chronic coughChronic cough Regular sputum productionRegular sputum production Frequent “winter bronchitis”Frequent “winter bronchitis” WheezeWheeze + no clinical features of asthma+ no clinical features of asthma

Clinical features of Asthma vs. COPD

Assessment of Severity of COPD

Severity of airflow Severity of airflow obstructionobstruction

FEV1 % predicted FEV1 % predicted 11

MildMild 50-80%50-80%

ModerateModerate 30-49%30-49%

SevereSevere <30%<30%

1 NICE Guidelines 2004

GOLD state that spirometry is the gold standard for diagnosing GOLD state that spirometry is the gold standard for diagnosing COPD, severity is measured by FEV1. COPD, severity is measured by FEV1.

Impact of Chronic Disease

ImpairmentImpairment

DisabilityDisability

HandicapHandicap

Management of COPD (Stable)

Use short acting bronchodilator PRN Use short acting bronchodilator PRN (beta2-agonist or anti-cholinergic)(beta2-agonist or anti-cholinergic)

If still symptomatic try combined therapy If still symptomatic try combined therapy with a short acting beta2 agonist and a with a short acting beta2 agonist and a short acting anti-cholinergic.short acting anti-cholinergic.

If still symptomatic use a long acting If still symptomatic use a long acting bronch-dilator (beta2 agonist or anti-bronch-dilator (beta2 agonist or anti-cholinergic)cholinergic)

Management In moderate or severe COPD

If still symptomatic consider a trial of a combination of a long If still symptomatic consider a trial of a combination of a long acting beta2 agonist and inhaled corticosteroid. acting beta2 agonist and inhaled corticosteroid. ((Discontinue if no benefit after 4 – 6 Discontinue if no benefit after 4 – 6 weeks)weeks)

If still symptomatic consider adding theophylline.If still symptomatic consider adding theophylline.

Offer pulmonary rehab to all patients who consider themselves Offer pulmonary rehab to all patients who consider themselves functionally disabled (usually MRC 3 and above)functionally disabled (usually MRC 3 and above)

Consider referral for surgery.Consider referral for surgery.

End of Life Care End of Life Care ((need to start these conversations ,what the future will hold, need to start these conversations ,what the future will hold, discuss issues, worries and concerns with patients at an earlier stage. Palliative discuss issues, worries and concerns with patients at an earlier stage. Palliative care being part of end of life care)care being part of end of life care)

Acute exacerbation of COPD

Sustained worsening of patients symptoms from their Sustained worsening of patients symptoms from their usual stable state, which is beyond normal day-to-day usual stable state, which is beyond normal day-to-day variations and is acute in onset. variations and is acute in onset. 11

Symptoms :Symptoms : Increased shortness of breathIncreased shortness of breath Increased sputum production and/or change in colourIncreased sputum production and/or change in colour Increased coughIncreased cough Increased wheeze/tightnessIncreased wheeze/tightness Decreased exercise toleranceDecreased exercise tolerance Increased fatigueIncreased fatigue ConfusionConfusion

1 NICE Guidelines 20041 NICE Guidelines 2004

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

Severe COPD

Smoking cessationSmoking cessation OxygenOxygen Pharmacological TherapyPharmacological Therapy Pulmonary RehabilitationPulmonary Rehabilitation Dyspnoea ClinicDyspnoea Clinic LVRS / Transplantation LVRS / Transplantation Chronic NIVChronic NIV End of Life Care - PalliationEnd of Life Care - Palliation

Natural History

Look magazine ad

from 1951

Oxygen Therapy Long Term Oxygen Long Term Oxygen

Therapy (LTOT)Therapy (LTOT)

Short Burst Oxygen Short Burst Oxygen TherapyTherapy

Ambulatory Ambulatory Oxygen Therapy Oxygen Therapy

Benefits of LTOT Improved survivalImproved survival Prevention of deterioration of pulmonary Prevention of deterioration of pulmonary

haemodynamicshaemodynamics Reduction in secondary polycythaemiaReduction in secondary polycythaemia Neuropsychological benefitNeuropsychological benefit improved sleep qualityimproved sleep quality Increased renal blood flowIncreased renal blood flow reduction in cardiac arrhythmiasreduction in cardiac arrhythmias Reduction in dyspnoea, improved exercise toleranceReduction in dyspnoea, improved exercise tolerance

Should be worn for Should be worn for 15 hrs or more15 hrs or more a day to gain these a day to gain these benefits benefits

Short Burst Oxygen Therapy

Further research is requiredFurther research is required Episodic dyspnoea not relieved by other Episodic dyspnoea not relieved by other

treatments treatments Palliative therapy or in emergency Palliative therapy or in emergency

situationssituations If improvement in dyspnoea or exercise If improvement in dyspnoea or exercise

tolerance can be documentedtolerance can be documented

Ambulatory Oxygen Therapy

Improved exercise toleranceImproved exercise tolerance Reduced dyspnoeaReduced dyspnoea Improved quality of lifeImproved quality of life

Flu and Pneumonia vaccinationFlu and Pneumonia vaccination

Bronchodilators Bronchodilators

CoticosteroidsCoticosteroids

Mucolytics Mucolytics

Pharmacotherapy does not modify long-term decline, but is Pharmacotherapy does not modify long-term decline, but is used to used to

–prevent and control symptoms / improve exercise toleranceprevent and control symptoms / improve exercise tolerance

–reduce the frequency and severity of exacerbationsreduce the frequency and severity of exacerbations

–improve health status improve health status

Medicines Management

Long – Acting Inhaled bronchodilators e.g. Salmeterol / Tiotropium

Significant improvement in lung function Significant improvement in lung function 1-31-3

better sustained improvement in lung function over 12 hours better sustained improvement in lung function over 12 hours than ipratropium bromide than ipratropium bromide 11

Improve shortness of breath day and night Improve shortness of breath day and night 1,31,3

Reduce risk of exacerbations vs. placebo Reduce risk of exacerbations vs. placebo 11

Clinically significant improvements in quality of life Clinically significant improvements in quality of life 4,54,5

unlike ipratropium bromide, Salmeterol significantly increased unlike ipratropium bromide, Salmeterol significantly increased the percentage of patients showing a clinically relevant the percentage of patients showing a clinically relevant improvement in health status compared with placebo improvement in health status compared with placebo 55

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

Xanthines - e.g. theophylline

Less commonly used than other Less commonly used than other bronchodilators bronchodilators

Only modest bronchodilatorsOnly modest bronchodilators Side effects within therapeutic rangeSide effects within therapeutic range Many drug interactionsMany drug interactions Smoking can affect the metabolism of Smoking can affect the metabolism of

theophyllinetheophylline

Inhaled Corticosteroids

Inhaled steroids now limited to moderate Inhaled steroids now limited to moderate symptomatic disease with symptomatic disease with 2 2 exacerbations per year to reduce exacerbations per year to reduce admission rates admission rates 11

Emerging evidence of enhanced effect of Emerging evidence of enhanced effect of xanthines when combined with xanthines when combined with corticosteroidcorticosteroid

1 NICE (2004) 1 NICE (2004)

Mycolytics

CarbocisteineCarbocisteine

Reduces sputum viscosity to aid expectorationReduces sputum viscosity to aid expectoration Reduces exacerbations of COPD in those with chronic Reduces exacerbations of COPD in those with chronic

productive coughproductive cough (caution in peptic ulceration / can cause gastrointestinal (caution in peptic ulceration / can cause gastrointestinal

irritation)irritation)

ErdotinErdotin - - Short course during acute exacerbationShort course during acute exacerbation

GOLD guidelines (2007) suggest there is not enough evidence to support there use. 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 inHowever, there are a group of patients in which it works well in

Lung Reduction In Emphysema

Remove hyperinflated areas of lungRemove hyperinflated areas of lung::Improve V/Q matching Improve V/Q matching Reduce resting length of respiratory musclesReduce resting length of respiratory musclesReduce Dynamic HyperinflationReduce Dynamic Hyperinflation

Pulmonary Rehabilitation

The goal of PR are to reduce the symptoms, disability and handicap to The goal of PR are to reduce the symptoms, disability and handicap to improve functional independence in COPD 5improve functional independence in COPD 5

Programme incorporates a programme of physical training, disease Programme incorporates a programme of physical training, disease education, nutritional, psychological, social and behaviour intervention 5 education, nutritional, psychological, social and behaviour intervention 5

Provided by a inter professional team, with attention to individual goals Provided by a inter professional team, with attention to individual goals and needs. and needs.

Improves exercise tolerance and function / reduces dyspnoea / improves Improves exercise tolerance and function / reduces dyspnoea / improves QOL 1,2QOL 1,2

Empowerment for patients to manage their own condition recognition of Empowerment for patients to manage their own condition recognition of exacerbations. 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 1 Ries et al. 1995, 2 De Paepe et al. 2000 3, Griffiths at al.2000, 4, Troosters et al, 2000 5 BTS 2001

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

Chronic Non-Invasive Ventilation

Domiciliary NIV for a highly Domiciliary NIV for a highly selected group of COPD selected group of COPD patients with recurrent patients with recurrent admissions requiring admissions requiring assisted ventilation is assisted ventilation is effective at reducing effective at reducing admissions and minimizes admissions and minimizes costs from the perspective costs from the perspective of the acute hospital of the acute hospital 11

1 1 Tuggey JM, , Plant PK, , Elliott MW. Thorax. 2003. Thorax. 2003

When does COPD become Palliative? (1 of 2)

Primary clinical indicatorsPrimary clinical indicators FEV1 < 30% predFEV1 < 30% pred History of >2 acute exacerbations in last 12 History of >2 acute exacerbations in last 12

monthsmonths Frequent admissions to hospitalFrequent admissions to hospital Progressive shortening of of the intervals Progressive shortening of of the intervals

between admissionsbetween admissions Limited improvement following admission Limited improvement following admission 11

When does COPD become Palliative? (2 of 2)

Supporting clinical IndicatorsSupporting clinical Indicators On maximum therapy- no other intervention is On maximum therapy- no other intervention is

likely to alter the conditions progressionlikely to alter the conditions progression Dependence on oxygen therapyDependence on oxygen therapy Severe unremitting dyspnoea (MRC Dyspnoea Severe unremitting dyspnoea (MRC Dyspnoea

Scale grade 5)Scale grade 5) Severe co morbidities e.g. heart failure, diabetesSevere co morbidities e.g. heart failure, diabetes Housebound – unable to carry out normal ADLHousebound – unable to carry out normal ADL

MRC DYSPNOEA SCALE

Consider…

Mortality in severe COPD is between 36% and 50% at 2 Mortality in severe COPD is between 36% and 50% at 2 years years 11

In the last year of life In the last year of life 22

40% had unrelieved breathlessness40% had unrelieved breathlessness 68% had low mood unrelieved68% had low mood unrelieved 51% had unrelieved pain51% had unrelieved pain 20% did not know they might die20% did not know they might die 70% died in hospital (for 25% of whom it was not the best 70% died in hospital (for 25% of whom it was not the best

place to die)place to die) It has been shown that NIV in acute exacerbations of COPD It has been shown that NIV in acute exacerbations of COPD

reduces mortality and need for ICU reduces mortality and need for ICU 3,43,4

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 20001 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

Dyspnoea - Symptomatic Treatment

Opioids Opioids

Mechanism unclearMechanism unclear respiratory drive, respiratory drive, sensation of respiratory muscle sensation of respiratory muscle

fatigue, cognitive changes, central effect, cough fatigue, cognitive changes, central effect, cough suppressant suppressant 22

– Oral morphine 2.5 4 hourly (dose maybe escalated if well tolerated) Oral morphine 2.5 4 hourly (dose maybe escalated if well tolerated) 11

No evidence to support nebulised morphineNo evidence to support nebulised morphine

11 Watson et al 2006 2 Jenner 1991Watson et al 2006 2 Jenner 1991

Dyspnoea related to Anxiety

Benzodiazepines Benzodiazepines Examples includeExamples include

- Diazepam 2 – 5mgs BD and PRN- Diazepam 2 – 5mgs BD and PRN

- Lorazepam 1 – 2 mgs p.r.n- Lorazepam 1 – 2 mgs p.r.n 11

1 Watson et al 20061 Watson et al 2006

Oxygen Therapy

Some patients do derive good benefit if not already on Some patients do derive good benefit if not already on LTOTLTOT

But: Beware the CO2 retainersBut: Beware the CO2 retainers

Also:Also: Risk of psychological dependenceRisk of psychological dependence Paradoxical restriction to activityParadoxical restriction to activity Dry mouth / noseDry mouth / nose Isolation and communication problems Isolation and communication problems Consider open window, fan, cool flannel, helioxConsider open window, fan, cool flannel, heliox

Intractable Cough

Steam inhalation Steam inhalation

Nebulisation - Nebulisation - (0.9% sodium chloride. Consider nebulised (0.9% sodium chloride. Consider nebulised

bronchodilation and steroid)bronchodilation and steroid)

Oral morphine 2.5 - 5mg, 4 hourlyOral morphine 2.5 - 5mg, 4 hourly 11

1 Watson et al 20061 Watson et al 2006

Excessive Respiratory Secretions –

Pharmacological Management Hyoscine Hydrobromide – Patches or sub cut. Hyoscine Hydrobromide – Patches or sub cut. Glycopyrronium Glycopyrronium

Care must be taken to prevent dry mouthCare must be taken to prevent dry mouth

Terminal Breathlessness

Non-pharmacological managementNon-pharmacological management TouchTouch RelaxationRelaxation Environment Environment Modelling of behaviourModelling of behaviour

Subcutaneous Route may be necessarySubcutaneous Route may be necessary

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

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

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

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

And I haven’t touched on…

The Management of an COPD ExacerbationThe Management of an COPD Exacerbation Inhaler Technique / Nebulisers Inhaler Technique / Nebulisers Diet & NutritionDiet & Nutrition Anxiety and DepressionAnxiety and Depression

We will leave that for another day…!We will leave that for another day…!

Thank – YouThank – You

Any Questions??

Case Study 1Case 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

COPDChronic Obstructive Pulmonary Disease

COPD Project Nurse – End of Life Care

By Matthew Hodson Respiratory Nurse Specialist COPDWestminster Primary Care Trust

Definition Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease

(COPD) is characterised by airflow (COPD) is characterised by airflow obstruction. The airflow obstruction is obstruction. The airflow obstruction is

usually progressive, not fully reversible usually progressive, not fully reversible and does not change markedly over and does not change markedly over

several months. several months. 11

The disease is predominantly caused by smoking.The disease is predominantly caused by smoking.

1. NICE 20041. NICE 2004

COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma

Emphysema

Airwayobstruction

Chronic severe asthma

Chronicbronchitis

COPD(shaded area)

COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma

Emphysema

Airwayobstruction

Chronic severe asthma

Chronicbronchitis

COPD(shaded area)

The Umbrella Disease

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

The Role

Project Nurse COPD – End of Life

6 Month Role

2 days a week

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.

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.

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