Update on Asthma and Update on Asthma and COPD COPD

Fiona Horwood & Diana Hart Fiona Horwood & Diana Hart

We are both from:-We are both from:-

Our RolesOur Roles

Diana – Nurse practitionerDiana – Nurse practitioner

NP since 2006 NP since 2006

Works in community 80%Works in community 80%Fiona – respiratory physicianFiona – respiratory physician

Based at MiddlemoreBased at MiddlemoreWorks in multi disciplinary clinicsWorks in multi disciplinary clinics Interest in chronic respiratory conditions Interest in chronic respiratory conditions

(COPD) and pulmonary rehabilitation(COPD) and pulmonary rehabilitation

Aim of this sessionAim of this session

Update on a few topical issues in Asthma and Update on a few topical issues in Asthma and COPDCOPD

Encourage awareness and necessity of Encourage awareness and necessity of multidisciplinary and integrated management of multidisciplinary and integrated management of these chronic conditionsthese chronic conditions SpecialistSpecialist Nurse – NP and CNSNurse – NP and CNS PhysiotherapistPhysiotherapist GPGP PN / DNPN / DN

Asthma Asthma

Asthma affects 1in 5 children and 1 in 10 adults Asthma affects 1in 5 children and 1 in 10 adults (Asthma and Respiratory Foundation of New (Asthma and Respiratory Foundation of New Zealand)Zealand)

There are still tragic deaths despite There are still tragic deaths despite improvements in knowledge and treatments to improvements in knowledge and treatments to assist those who have the condition. assist those who have the condition.

What is new and topical in asthma?What is new and topical in asthma?

Inflammometry in asthma

Symptoms of asthma may be non-specific and may cross over with other syndromes

It can be difficult to treat for a number of reasons

Poor adherence to treatment regimeImprovement over time may be mistaken for

response to treatment

Corticosteroids should be used judiciously It makes sense to target asthma therapy to

underlying inflammation

InflammometryInflammometry

Eosinophilic airway inflammation reliably responds Eosinophilic airway inflammation reliably responds to corticosteroid therapyto corticosteroid therapy

Identifying and treating eosinophilic inflammation Identifying and treating eosinophilic inflammation can allow targeted use of corticosteroidscan allow targeted use of corticosteroids

Induced sputum is the investigation of choice for Induced sputum is the investigation of choice for identifying eosinophilic inflammation but its identifying eosinophilic inflammation but its availability is limitedavailability is limited

Can use FeNO or serum eosinophilia as proxyCan use FeNO or serum eosinophilia as proxy

Vitamin D

May have an effect on asthma morbidityAntiviral (↓vit D associated with ↑respiratory

illness)?enhanced steroid responsivenessDown regulation of atopy

Vitamin DVitamin D

Currently there is insufficient evidence of a causal Currently there is insufficient evidence of a causal association between vitamin D status and asthma to association between vitamin D status and asthma to recommend for or against vitamin D supplementationrecommend for or against vitamin D supplementation

But there is consistent evidence from observational But there is consistent evidence from observational studies that vitamin D protects against asthma studies that vitamin D protects against asthma exacerbations. exacerbations.

There is no evidence to support screening for vitamin D There is no evidence to support screening for vitamin D deficiencydeficiency

It would be advisable to screen high risk individualsIt would be advisable to screen high risk individuals Low sun exposureLow sun exposure Pigmented skinsPigmented skins

Medication AdherenceMedication Adherence

Researchers at Henry Ford Hospital in the USA have Researchers at Henry Ford Hospital in the USA have found that one-quarter of severe asthma attacks could found that one-quarter of severe asthma attacks could be prevented if only patients consistently took their be prevented if only patients consistently took their medication as prescribed. medication as prescribed.

Moreover, an asthma attack was only significantly Moreover, an asthma attack was only significantly reduced when patients used at least 75 percent of their reduced when patients used at least 75 percent of their prescribed dose, according to the study.prescribed dose, according to the study.

Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD)Disease (COPD)

The Asthma Foundation estimates that 1 in 7 New The Asthma Foundation estimates that 1 in 7 New Zealanders aged 45 and over has COPD - more than Zealanders aged 45 and over has COPD - more than 200 000 people, or the population of greater Hamilton (in 200 000 people, or the population of greater Hamilton (in Auckland 90 000)Auckland 90 000)

Many of these are currently undiagnosedMany of these are currently undiagnosed

COPDCOPD

By 2030 chronic obstructive pulmonary disease is By 2030 chronic obstructive pulmonary disease is estimated to be the third most common cause of death estimated to be the third most common cause of death worldwide, a leading cause of hospitalizations, as well as worldwide, a leading cause of hospitalizations, as well as being one of the most expensive chronic diseases. being one of the most expensive chronic diseases.

However, in comparison to diseases, such as diabetes , However, in comparison to diseases, such as diabetes , there is little public awareness of COPD and the funding, there is little public awareness of COPD and the funding, research and profile is not the same as other diseases research and profile is not the same as other diseases with a similar burden.with a similar burden.

COPD riskCOPD risk According to the first comprehensive estimate of lifetime According to the first comprehensive estimate of lifetime

risk for chronic obstructive pulmonary disease (COPD) risk for chronic obstructive pulmonary disease (COPD) published in a special European Respiratory Society published in a special European Respiratory Society issue of issue of The LancetThe Lancet, one out of four individuals aged 35 , one out of four individuals aged 35 and over are likely to develop COPD at some stage of and over are likely to develop COPD at some stage of their lives. their lives.

The discoveries indicate that people have a much higher The discoveries indicate that people have a much higher risk of developing COPD than congestive heart failure, risk of developing COPD than congestive heart failure, acute heart attack , and several common cancers. acute heart attack , and several common cancers.

average woman at 35 years of age is >3 times more likely to average woman at 35 years of age is >3 times more likely to develop COPD compared to breast cancerdevelop COPD compared to breast cancer

average 35 year old man the risk of developing COPD is three average 35 year old man the risk of developing COPD is three times higher than prostate cancertimes higher than prostate cancer

COPD and CVDCOPD and CVD

Despite it being common for individuals to have both Despite it being common for individuals to have both COPD and cardiovascular disease, it usually goes COPD and cardiovascular disease, it usually goes unrecognized by physicians due to overlapping clinical unrecognized by physicians due to overlapping clinical manifestations. manifestations.

In individuals with heart disease , COPD diagnosis can In individuals with heart disease , COPD diagnosis can remain unsuspected, however, having both of these remain unsuspected, however, having both of these conditions can lead to a considerably worse outlook for conditions can lead to a considerably worse outlook for the patient.the patient.

COPD and heart diseaseCOPD and heart disease

According to a new investigation, individuals who suffer According to a new investigation, individuals who suffer with chronic obstructive pulmonary disease (COPD) or with chronic obstructive pulmonary disease (COPD) or those with reduced lung function have a serious risk of those with reduced lung function have a serious risk of developing cardiovascular disease.developing cardiovascular disease.

Presented at the European Respiratory Society's Annual Presented at the European Respiratory Society's Annual Congress in Amsterdam 2011, the discoveries indicate Congress in Amsterdam 2011, the discoveries indicate that because individuals with COPD and reduced lung that because individuals with COPD and reduced lung function appear to be at a significantly higher risk of function appear to be at a significantly higher risk of developing cardiovascular disease, they should be developing cardiovascular disease, they should be routinely screened for it. routinely screened for it.

The link between COPD and heart The link between COPD and heart diseasedisease

High troponin, chest pain and ECG High troponin, chest pain and ECG changes are commonly seen in patients changes are commonly seen in patients admitted to hospital with AECOPDadmitted to hospital with AECOPD

Elevated troponin T and NT-BNP levels at Elevated troponin T and NT-BNP levels at the time of ECOPD are strong predictors the time of ECOPD are strong predictors or increased risk and poor outcomeor increased risk and poor outcome

COPD and heart diseaseCOPD and heart disease

We need to take hospital presentations with We need to take hospital presentations with AECOPD very seriously and think more broadlyAECOPD very seriously and think more broadly Major driver of mortality especially in the acute period Major driver of mortality especially in the acute period

and immediately after.and immediately after. Mortality over 5 years increases in direct proportion to Mortality over 5 years increases in direct proportion to

the frequency of AECOPDthe frequency of AECOPD Exacerbations are associated with important Exacerbations are associated with important

outcomes outcomes ↑ ↑ risk of mortalityrisk of mortality ↓ ↓ health statushealth status Impaired lung functionImpaired lung function Muscle weaknessMuscle weakness Cardiopulmonary complicationsCardiopulmonary complications

COPD and heart failureCOPD and heart failure Reduced lung function and obstructive airway disorders such as Reduced lung function and obstructive airway disorders such as

chronic obstructive pulmonary disease (COPD) increase the risk of chronic obstructive pulmonary disease (COPD) increase the risk of heart failure, a new study has found.heart failure, a new study has found.

For the new study, researchers analyzed data from 16,000 people in For the new study, researchers analyzed data from 16,000 people in the United States, aged 45 to 64, who took part in the the United States, aged 45 to 64, who took part in the Atherosclerosis Risk in Communities study and were followed for an Atherosclerosis Risk in Communities study and were followed for an average of 15 years average of 15 years

The researchers noted that it's common for patients with heart The researchers noted that it's common for patients with heart failure to have COPD, and vice versa. But only recently has prior failure to have COPD, and vice versa. But only recently has prior COPD been shown to be a long-term risk factor for heart failure. COPD been shown to be a long-term risk factor for heart failure.

European Journal of Heart FailureEuropean Journal of Heart Failure, news release, Feb. 25, 2012 , news release, Feb. 25, 2012

The impact of co morbiditiesThe impact of co morbidities For health professionals, the problem of co-morbidities, For health professionals, the problem of co-morbidities,

when a person is suffering from more than one condition when a person is suffering from more than one condition at the same time, is an increasing concern.at the same time, is an increasing concern.

This will only become more of a concern as the This will only become more of a concern as the frequency of co-morbid conditions increases as the older frequency of co-morbid conditions increases as the older population live longer. population live longer.

Often individuals are treated by a specialist for one Often individuals are treated by a specialist for one particular system eg cardiac, respiratory.particular system eg cardiac, respiratory.

It will become more important for physicians to recognize It will become more important for physicians to recognize other symptoms as the frequency of co-morbidities other symptoms as the frequency of co-morbidities increases. increases.

Pulmonary rehabilitation

Pulmonary Rehabilitation Pulmonary Rehabilitation Pulmonary rehabilitation is a structured programme of Pulmonary rehabilitation is a structured programme of

exercise and education for those with chronic respiratory exercise and education for those with chronic respiratory disease.disease.

It is one of the few interventions shown to result in It is one of the few interventions shown to result in sustained improvements in quality of life for those with sustained improvements in quality of life for those with COPD.COPD.

Benefits include:Benefits include: Improved quality of lifeImproved quality of life Less dyspnoeaLess dyspnoea Increased exercise capacityIncreased exercise capacity Reduced hospital admissionsReduced hospital admissions

The Burden of COPD in New Zealand, Asthma and Respiratory Foundation of NZ (Inc.) and The Thoracic The Burden of COPD in New Zealand, Asthma and Respiratory Foundation of NZ (Inc.) and The Thoracic Society of Australia and New Zealand, New Zealand Branch Inc., 2003, p8. Society of Australia and New Zealand, New Zealand Branch Inc., 2003, p8. http://www.asthmanz.co.nz/burden_of_asthma_in_nz.phphttp://www.asthmanz.co.nz/burden_of_asthma_in_nz.php

Am. J. Respir. Crit. Care Med., Volume 159, Number 5, May 1999, 1666-1682Am. J. Respir. Crit. Care Med., Volume 159, Number 5, May 1999, 1666-1682

Pulmonary rehabilitationPulmonary rehabilitation

Controlled studies have also shown a Controlled studies have also shown a reduction in the use of health care reduction in the use of health care resources such as admissions after resources such as admissions after attending a programme.attending a programme.

Ries, A. L., R. M. Kaplan, T. M. Limberg, and L. M. Prewitt. 1995. Effects of pulmonary Ries, A. L., R. M. Kaplan, T. M. Limberg, and L. M. Prewitt. 1995. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann. Intern. Med. 122: 823-832 pulmonary disease. Ann. Intern. Med. 122: 823-832

Wright, R. W., D. F. Larsen, R. G. Monie, and R. A. Aldred. 1983. Benefits of a community Wright, R. W., D. F. Larsen, R. G. Monie, and R. A. Aldred. 1983. Benefits of a community hospital pulmonary rehabilitation program. Respir. Care 28: 1474-1479 hospital pulmonary rehabilitation program. Respir. Care 28: 1474-1479

Agle, D. P., G. L. Baum, E. H. Chester, and M. Wendt. 1973. Multidiscipline treatment of chronic Agle, D. P., G. L. Baum, E. H. Chester, and M. Wendt. 1973. Multidiscipline treatment of chronic pulmonary insufficiency. Psychosom. Med. 35: 41-49 pulmonary insufficiency. Psychosom. Med. 35: 41-49

Jensen, P. S.. 1983. Risk, protective factors, and supportive interventions in chronic airway Jensen, P. S.. 1983. Risk, protective factors, and supportive interventions in chronic airway obstruction. Arch. Gen. Psychiatry 40: 1203-1207obstruction. Arch. Gen. Psychiatry 40: 1203-1207

Pulmonary rehabilitationPulmonary rehabilitation

Pulmonary rehab should not be Pulmonary rehab should not be considered as the last resortconsidered as the last resort

Catching those early on in their disease Catching those early on in their disease can help with can help with Medication adherence and understandingMedication adherence and understandingSmoking cessationSmoking cessationSocial interaction and reducing the incidence Social interaction and reducing the incidence

of depression and social isolationof depression and social isolationSelf management skillsSelf management skills

Case

Mr Simmonds68 yr old retired builder Severe COPD started home O2-felt it was

a death sentence.Seen in Howick Pulmonary Rehab and

after by NP at home involving family2 years later still severe COPD but QAL

and exacerbations much improved

Multidisciplinary management of Multidisciplinary management of COPDCOPD

Historically, the practice of many health professionals Historically, the practice of many health professionals has been characterized by has been characterized by unidisciplinary thinkingunidisciplinary thinking

Individualistic and sometimes competitive behaviors Individualistic and sometimes competitive behaviors have emphasized the roles and boundaries of each have emphasized the roles and boundaries of each disciplinediscipline

Management of a patient with a chronic condition Management of a patient with a chronic condition requires a requires a multidisciplinary approachmultidisciplinary approach

Multidisciplinary approach to COPD Multidisciplinary approach to COPD

Multidisciplinary, collaborative health care practice is an Multidisciplinary, collaborative health care practice is an effective means to plan, coordinate, and implement care.effective means to plan, coordinate, and implement care.

Family members and caregivers should be participants Family members and caregivers should be participants in this process, although they may not be present at all in this process, although they may not be present at all meetings of the multidisciplinary teammeetings of the multidisciplinary team

Their contribution to the assessment process, problem Their contribution to the assessment process, problem solving, goal and outcome setting is vital.solving, goal and outcome setting is vital.

Multidisciplinary approach to COPDMultidisciplinary approach to COPD

Self management is an essential part of chronic Self management is an essential part of chronic care, and COPD, managementcare, and COPD, management

Disease knowledge is the most studied outcome Disease knowledge is the most studied outcome of chronic disease or self management of chronic disease or self management programmesprogrammes

Knowledge is not the only outcomeKnowledge is not the only outcome Health literacyHealth literacy MotivationMotivation Behavioural changesBehavioural changes Engagement of patients and families / whanau to take an Engagement of patients and families / whanau to take an

active approach to managementactive approach to management

Multidisciplinary approach to COPDMultidisciplinary approach to COPD

Doctors often provideDoctors often provide Disease knowledgeDisease knowledge

Nurses will addNurses will add AdvocacyAdvocacy Education – medications, disease knowledgeEducation – medications, disease knowledge Support – psychological, smoking cessation etcSupport – psychological, smoking cessation etc Exacerbation action plansExacerbation action plans Integrated follow upIntegrated follow up

Others – physiotherapists, social workers, Others – physiotherapists, social workers, community support workers, cultural community support workers, cultural supportsupport

Case ExampleCase Example

58 Maaori female58 Maaori femaleSevere bronchiectasis with multi resistant Severe bronchiectasis with multi resistant

microbiologymicrobiologyMoved to the area 6 months ago and has Moved to the area 6 months ago and has

had 3 hospital admissions sincehad 3 hospital admissions sinceSeen in clinic twice by chest physician but Seen in clinic twice by chest physician but

still not making any progressstill not making any progress

Case exampleCase example

Seen in clinic in combined appointment Seen in clinic in combined appointment with physician and CNSwith physician and CNS

DiscussionDiscussionAdvanced care planningAdvanced care planningAction plansAction plansAcceptability of LTOTAcceptability of LTOTPacing herselfPacing herself

Case exampleCase example

OutcomeOutcome

CNS home visit in 2 weeks to follow up CNS home visit in 2 weeks to follow up response to antibiotics and further discuss response to antibiotics and further discuss advance care planning, advance directive advance care planning, advance directive and LTOTand LTOT

Physio appointment within 10 daysPhysio appointment within 10 daysBetter communication with GPBetter communication with GP

To End…To End…

We hope we have given you a topical We hope we have given you a topical overview of asthma and COPDoverview of asthma and COPD

We hope that we have demonstrated the We hope that we have demonstrated the importance of multidisciplinary importance of multidisciplinary involvement in the management of chronic involvement in the management of chronic respiratory diseaserespiratory disease

We hope to continue to work closely We hope to continue to work closely across secondary and primary care to across secondary and primary care to offer the best possible care to our patientsoffer the best possible care to our patients