Www.pspbc.ca Shared System of Care COPD/Heart Failure Learning Session 2

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Shared System of Care COPD/Heart Failure

Learning Session 2

Agenda• Introduction (35)

• Patient Voice (15)

• Medication (60, 40 didactic and 20 discussion)• MOA Breakout

• Break (15)

• PSM Support• COPD and AECOPD Management (30, 20 didactic, 10

questions)

• Heart Zones and other PSM tools (30, 20 didactic, 10 questions)

• Smoking cessation (10, 5 didactic, 5 questions)

• Sharing the care with the specialist and the referral process

• Planning for Action Period 2 (15)

Patient Voice

(10 minutes)

COPD Medications

(15 minutes)

5

Comprehensive Management of COPD

6

Classification of Disease Severity in COPD

7

Goals Symptoms Exacerbations Exercise

Beta - agonists Anticholinergics Short vs. long-acting Inhaled corticosteroids Combination therapies Antibiotics Oral prednisone- for

AECOPD PDE4 inhibitors Oxygen Pulmonary rehabilitation Smoking cessation

Treatment of stable COPD

8

Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

9

Short-acting Bronchodilators

10


11

Stepwise increased therapy


12

Mild

Increasing Disability and Lung Function Impairment

Infrequent AECOPD

(< 1/year)

Frequent AECOPD

(> 1/year)

LAAC or LABA+ SABA prn

LAAC + LABA + SABA prn

LAAC + ICS/LABA* + SABA prn

LAAC + ICS/LABA +

SABA prn

SABA prn

persistent

disability

LAAC + SABA prn

or

LABA + SABA prn

persistent disability

LAAC + ICS/LABA +

SABA prn +/- Theophylline


Moderate Severe


* Inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower ICS dose i.e. SALM/FP 50/250 µg twice daily

O’Donnell DE, et al. Can Respir J 2007

Optimal Pharmacotherapy in COPD

13

Comprehensive management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

14

Spirometry essential as screening tool in subjects at risk

Beware false positive/false negative results with COPD 6.

Treatment:

Mild: Short acting BD’s

Moderate: Long acting BD’s (single or comb)

Severe: Combination BD’s + ICS +Pulmonary Rehabilitation.

All: education, vaccinations and smoking cessation.

Summary

15

Dyspnea out of proportion to spirometry

Young age of onset

Remote smoking history and disease severity not consistent with smoking history

Rapid deterioration (symptoms or FEV1)

History of exacerbations

Concern re multiple co morbidities

Stable COPD: Who should be referred?

16

79yo woman severe SOB

PHx: overweight (BMI 32), diet controlled DM2, & HTN

Allergy: mild seasonal allergies - rhinorrhea

Smoking: 40 pack. years - quit 20 y ago.

Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post BD change.

Next step?

Case #1

17

Explore possibility of heart failure/ischemic heart disease/if acute onset consider PE.

Could this patient have asthma? Exam patient and rule out heart failure. Unclear re CHF and COPD: BNP Request spirometry with reversibility. If COPD categorize severity. If non obstructive pattern: detailed lung function

including lung volumes + DLCO Chest x-ray. Echocardiogram Stress test

Case #1

18

Spirometry with post bronchodilator assessment showed a 12% improvement consistent with the diagnosis of asthma.

Echocardiogram: Normal

Stress test: No ischemic changes

Case #1

19

Diagnosis: Adult onset asthma with likely added de-conditioning and obesity, Initiate low dose inhaled corticosteroids and short acting

bronchodilators PRN Advise re immunizations Provide education about inhaler use and refer for education Provide a written action plan

Key learning points: Asthma can occur late in life and can occur independently or in

association with COPD Important to identify co-existence of asthma in COPD as it will effect

adjunct therapies such as beta blockers. If asthma is a consideration request reversibility initially

Case #1

20

68yo man progressive SOB with a history of a recent exacerbation requirng a vist to the ED and a course of prednisone and antibiotics.

PHx: HTN on metoprolol and ramipril. Allergy: no seasonal or environmental allergies Smoking: 55 pack years - quit 5 y ago. Spirometry: 3 years ago: FEV1 53% pred, FEV1/FVC ratio.

No post BD improvement Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H

PRN with increasing use in the last few weeks. Next step?

Case #2

21

Clinically this patient has deteriorated with a recent exacerbation.

What would you do next?

Case #2

22

You repeat the spirometry and the FEV1 is now 45% of predicted.

This patient has severe COPD and a history of exacerbation and therefore would qualify for the use of tiotropium and the addition of a LABA

Need to consider emerging evidence of increased risk of pneumonia associated with fluticasone.

Case #2

23

Larsson et al, J Intern Med 2013

Patient Flow

Patients who met the inclusion criteria identified within the study period n=21 361 Patients who met the inclusion criteria identified within the study period n=21 361

Patients with a record of fixed ICS/LABA therapy (Index date) n=9893Patients with a record of fixed ICS/LABA therapy (Index date) n=9893

FLU/SAL cohort

n=2734BUD/FORM cohort n=2734

Linked data from 76 centres throughout SwedenLinked data from 76 centres throughout Sweden

Matched populations

24

The exacerbation rate was 26.6% lower with BUD/FORM vs. FLU/SAL

The number needed to treat with BUD/FORM vs. FLU/SAL to prevent one exacerbation per patient-year was 3.4

Larsson et al, J Intern Med 2013

COPD Exacerbations

0.80

1.09

0.0

0.2

0.4

0.6

0.8

1.0

1.2

BUD/FORM (n=2734) FLU/SAL (n=2734)

Exa

cerb

atio

n r

ate

RR = 0.74 (CI: 0.69, 0.79)

p<.0001

RR, rate ratio

BUD/Form

Flutic/salmeterol

25

Stepwise increased therapy

Comprehensive Management of COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)myr

26

Question: What reliever medication would you recommend for this patient?

Key learning point: ipratropium should not be used as a rescue medication because of the use of tiotropium and the patient should be prescribed salbutamol on a PRN basis.

Case #2

27

60yo woman progressive SOB

PHx: COPD

Allergy: Seasonal allergies years ago

Smoking: 25 pack years - quit 10 y ago.

Spirometry: 3 years ago: FEV1 54% pred, FEV1/FVC ratio.

Meds: salbutamol and ipratropium bromide PRN and now needing them up to five times daily.

Next step?

Case #3

28

Repeat spirometry and FEV1 unchanged. Next steps?

Case #3

29

Add tiotropium bromide, stop ipratropium bromide and continue salbutamol PRN.

Six weeks later patient reports some improvement but still short of breath and has developed peripheral edema?

What are your concerns now and what would you do?

Case #3

30

Clinically there is evidence of congestive heart failure and you start a diuretic and get an ECHO.

The ECHO shows a reduced EF of 35% predicted.

Key learning point: HF and severe COPD often co-exist and treatment

strategies need to take account of this

Case #3

31

Questions

32

Management of severe COPDGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

33

Maximize inhaled therapy:

› Combined ICS/ long acting beta-agonists

› Long acting anti cholinergic

Additional considerations:

› Ensure patient is adherent and taking inhalers correctly if unable to use spacer and deliver medication correctly consider nebulized Rx.

› Refer to pulmonary rehabilitation.

› If having frequent exacerbations consider a trial of roflumilast.

› Azithromax a consideration but important caveats: see next slide.

› Ensure no untreated co morbidities such as CHF and GERD

Severe COPD

34

Continuous (Grade A evidence) Resting ABG pO2 < 55 mmHg Resting ABG pO2 55-60 mmHg

› Cor pulmonale

› Hct > 56% Intermittent (Grade B evidence) Exertion: sO2 <87% for > 1 min Nocturnal sO2 <88% for > 30% night

Long term O2 therapy indications

35

Continuous home O2 minimum 20h /day

36

Important to note most patients can effectively use inhaler device and a spacer but nebuilizer:

Beneficial in extremes of age Coordination not required Breath-hold not required Note because of the size of aerosol particles the use of a

nebulizer does not lead to increased deposition into the lung.

Nebulizer treatment in severe COPD

37

Chronic oral prednisone therapy in COPD

38

There is no evidence base for the regular use of oral prednisone in COPD.

In one RCT of prednisone for ARCOPD one group who were left on prednisone had increased side effects.

For patients who have frequent AECOPD and continue to exacerbate despise all the measures outlined above then an N-of-1 trial of alternate day OCS can be considered.

Bone density and osteoporosis risk should be regularly reassessed.

Chronic oral prednisone therapy in COPD

39

Patients with moderate-severe COPD (FEV1 < 50%) ± chronic bronchitis with frequent ( > 2/year ) exacerbations.

Patients should be advised re the risk of GI side effects.

Roflumilast: indication:

40

Apart from azithromax there is no evidence that chronic antibiotic therapy is effective in COPD.

For exacerbation: rotating antibiotics between classes are recommended

A significant minority of COPD patients have co existing bronchiectasis and in the presence of significant sputum volume and purulence assessment for atypical TB infection and gram negative pathogens such as Pseudomonas should be completed.

Other antibiotics for severe COPD

41

Heart Failure (15 min)

42

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2005/06 2006/07 2007/08 2008/09 2009/10

56%

58%

60%

62%

64%

66%

68%A

CE/A

RB

%

Region/ year

43

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2005/06 2006/07 2007/08 2008/09 2009/10

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Region/ year

Beta

Blo

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%

44

0

10

20

30

40

50

60

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80

90

100

All Ages Age < 85

ACE/ARB

BB

Evidence Based HF Therapies in BC

45

Principle of HF Management Therapeutic Goals

1. prompt resolution of congestive symptoms 2. initiate patient self management related to lifestyle and medication compliance 3. initiate/enhance therapies direct to underlying disease process

limit recurrent hospitalizations improve mortality

4. prevent adverse events related to administered therapies

46

Heart Failure Therapies

Therapy Agent Reduction in 1° Endpoint

Self Management 23%

Pharmacological ACE-I 8% - 26%

Beta Blocker 23% - 65%

MRA 35%

ARB 15%

Device ICD 23% - 31%

CRT 24% - 36%

47

Contemporary Management of HF

Pharmacological Therapies (1) Beta Blockers (2) Inhibition of the RAAS

ACE-inhibitors (ACEi)Angiotensin Receptor Blockers (ARB)Mineralocorticoid Receptors Antagonists (MRA)

Device Therapies (1) ICD (2) Cardiac Resynchronization Therapy (CRT)

48

Beta-Blockers Reduce Mortality and Decrease the Risk of Hospitalization

49

Impact of ACE Inhibitors on Mortality in HF

50

Benefits of ACE Inhibitors Persist

51

Spironolactone: EF<30 & Advanced Symptoms

10%

ARR

52

Combining Therapies Improves Outcomes

53

Cumulative risk reduction if all three therapies are used: 63%

Absolute risk reduction: 22%, NNT = 5

Fonarow GC. Rev Cardiovasc Med. 2003;4:8–17.

Relative risk 2-yr Mortality

None --- 35%

ACE Inhibitor 23% 27%

MRA (Spironolactone) 30% 19%

Carvedilol 25% 19%

Cumulative Impact of Heart Failure Therapies: All Cause Mortality

54

RAFT

1798 patients with: NYHA class II or III heart failure, LVEF 30% intrinsic QRS > 120 msec

Randomized to ICD alone or an ICD plus CRT

Primary outcome was death from any cause or hospitalization for heart failure

Follow up - mean of 40 months

55

RAFT

56

NEJM 1996

57

Important Therapeutic Considerations in HF Patients

Smoking cessation Cardiac rehab Action plans for acute decompensation Addressing co-morbidities

COPD CKD

Immunizations Symptom management End of life care

some synergies and therapeutic overlap

Break

Patient Self-Management

Generating an Action Plan

COPD and AECOPD Management

Patient Education Materials

Smoking Cessation

60

61

COPD and AECOPD Management

(30 minutes, 20 didactic + 10 questions)

64

72 year old male seen by me in clinic Jan 2012 with moderate COPD

Quit smoking 4 years ago Comorbid illnesses including: CHF, Afib, AVR, CABG

complicated by sternal infection, obesity, asbestos related pleural disease.

Recurrent admissions for AECOPD and CHF (‘dirty’ x-ray). 90 days in hospital this past year.

Discharged post AECOPD Oct 23. Readmitted Monday pm in distress.

Case

65

Had seen GP in community 1 week prior started on higher dose prednisone, PO antibiotics

Requiring high flow oxygen, BiPAP Increased work of breathing Uncontrolled Afib post ventolin and atrovent nebulizer HR 140-160. I’m consulted as on for ICU….

Case continued

66

Clinical course of COPD

67

Burden of illness Under diagnosis and role of targeted screening The role of spirometry in diagnosis and staging Staging by symptoms and by FEV1

Last time…

68

Goals of COPD care

Preventing/

managing

exacerbations

Relieving

symptoms

Improving

quality of life

69

5 point “PRIME” Plan:1. Prevent further damage to your lungs2. Relieve your symptoms

› optimize drug therapy

› work on mental outlook and coping mechanisms3. Improve your general health and physical activity level4. Manage COPD flare-ups with an “Action Plan”5. Establish your COPD team

› family, friends, physician, healthcare professionals, COPD educator

A “Personal Management Plan” for COPD

70

Stepped approach to careEnd of Life Care

Surgery

Oxygen

Theophyline (in certain patients)

Inhaled corticosteroids (with ‘LABA’)

Referral for Pulmonary Rehabilitation

Initial referral to Pulmologist, Respirologist or Other Specialist

Additional therapy: long acting bronchodilators

First line therapy: Short-acting beta2 – Agonists and Anticholinergics

Care Plan & Exacerbation Plans Created & Shared

Influenza & Pneumococcal Immunizations in GP Office

Smoking Cessation Education & Self Management Exercise & Lifestyle

Referral for Diagnostic Spirometry

Case Finding Spirometry by Primary Care Physician

Individuals at Risk

• Smokers

• Environmental Exposure

All Patients:

• Exercise Rehabilitation

• Smoking Cessation

• Healthy Lifestyle

• Patient Education

Increasing severity of COPD

71

An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”

Acute Exacerbations are THE LEADING CAUSE* of deaths, hospitalization and ER visits among COPD patients.

COPD and CHF and #1 and #2 for most common reason for medical admission to BC hospitals

Acute exacerbations (AECOPD) or lung attacks

72

22-43% of patients hospitalized with AECOPD die within 1 year (Eriksen et a., 2003; Groenewegen et al., 2003)

In-hospital mortality for AECOPD is 7.8%-11.0% There is increasing mortality with increased number of

AECOPD. A number of interventions can reduce the risk of AECOPD:

› Long acting bronchodilator – tiotropium

› LABA / ICS combo inhalers

› Roflumilast (but not systematically assessed inpatients on triple therapy)

› Education and Rehabilitation (AECOPD recognized earlier and treated before become severe)

Acute exacerbations (AECOPD) or lung attacks

73

AECOPD frequency: mortality

74

Time course of AECOPD recovery

75

Benefits of COPD self management education

76

Patient education, including smoking cessation program Prevention of exacerbations, vaccinations Initiation of bronchodilator therapy Encouragement of regular physical exercise Close follow-up and disease monitoring

Can Respir J 2008;15(Suppl A):1A-8A.

Management of symptomatic: mild COPD

77

Patient education, including smoking cessation program Prevention of exacerbations, vaccinations 2 long acting bronchodilators and add in ICS if chronic

bronchitis or recurrent AECOPD Encouragement of regular physical exercise Close follow-up and disease monitoring


Management of symptomatic: mild COPD

78

Consider oxygen Mobility assistance Consider roflumilast Consider co-morbidities again Initiate advanced care planning, maybe DNR form Consider palliative help with dyspnea

Management of severe COPD

79

Increasing disability & lung function impairment

Mild

Infrequent AECOPD

(< 1/year)

Frequent AECOPD

(> 1/year)

LAAC + ICS/LABA +

SABA prn

SABD prn

persistent dyspnea

LAAC + SABD prn

or

LABA + SABD prn

LAAC + ICS/LABA +

SABA prn +/- Theophylline

persistent dyspnea

Moderate Severe

LAAC or LABA+ SABA prn

LAAC + LABA + SABA prn

LAAC + ICS/LABA + SABA prn

persistent dyspnea

persistent dyspnea


80

Smoking Cessation Vaccinations Self-Management Education with Case Manager and

written Action Plan Regular long-acting bronchodilator therapy Regular inhaled ICS/LABA therapy in moderate-severe

COPD and > 1 episode per year of AECOPD necessitating therapy

Appropriate treatment of episodes of AECOPD


AECOPD: Prevention Strategies

81

Reducing AECOPD or lung attacks is key to

› Patient survival

› Patient QOL

› Patient lung function

› Keeping patients at home How can we achieve this?

› Medications

› Vaccination

› Smoking cessation/pulmonary rehabilitation.

› Education / self management

Take Home Points:

82

Nishimura K, et al. Chest 2002; 121: 1434: 40

Survival in COPD – Relationship to Lung Function and Disability

83

BODE index helps guide prognosis:

› BMI

› Obstruction (degree of )

› Dyspnea (severity of)

› Exercise tolerance (or lack thereof)

Points add up to answer the Q: Am I going to survive for 4 years?

› 0-2 Points: 80%

› 3-4 Points: 67%

› 5-6 Points: 57%

› 7-10 Points: 18%

Prognosis

84

FEV1 % Predicted After Bronchodilator >=65% (0 points) 50-64% (1 point) 36-49% (2 points) <=35% (3 points)

6 Minute Walk Distance >=350 Meters (0 points) 250-349 Meters (1 point) 150-249 Meters (2 points) <=149 Meters (3 points)

MRC Dyspnea Scale (5 is worst) MRC 1: Dyspneic on strenuous exercise (0 points) MRC 2: Dyspneic on walking a slight hill (0 points) MRC 3: Dyspneic on walking on the level; must stop occasionally due to SOB (1 point) MRC 4: Must stop for SOB after walking 100 yards or after a few minutes (2 points) MRC 5: Cannot leave house; SOB on dressing/undressing (3 points)

Body Mass Index >21 (0 points)

<=21 (1 point)

85

Prognosis - Survival by BODE Index

86

Domiciliary oxygen (≥ 15 hours/day to achieve SaO2 ≥

90%) improves survival in stable COPD patients with severe

hypoxemia (PaO2 ≤ 55 mmHg) or when the PaO2 ≤ 60

mmHg in the presence of ankle edema, cor pulmonale or

hemacrit ≥ 56%)

Can Respir J 2008; 15(Suppl A):1 A-8A

Long Term Oxygen Therapy: Survival

87

88

COPD care isn’t rocket science/brain surgery - you can do

it!

First screen for COPD, then assess severity

Make a treatment plan (include an Action Plan for

attacks)

Recruit help to enact the plan (build the team).

Promote advance care planning and when appropriate

palliative components.

http://www.advancecareplanning.ca/

Summary

89

Heart

Failure

101

Patient Education Resources

90

Heart Zones


91

Daily

weight


92

Sodium

Restriction


93

Fluid

Restriction


94

Activity


95Clinical Care Algorithms

96

97

98

99

PATIENT RESOURCES

MEDICATIONS

SODIUM

FLUID

EXERCISE

EXACERBATION PLAN

HF 101

A Comprehensive List of Patient and Provider Resources

PROVIDER RESOURCES

REFERRAL FORMS

PATIENT ASSESMENT FORMS

CARE MAPS & TX ALGORITHMS

MEDICATION TITRATION

PATIENT SYMPTOM STATUS

VISIT SNAP SHOT

100

BC’s Heart Failure Website www.bcheartfailure.ca

http://www.bcheartfailure.ca/

101

Smoking Cessation

101

102

Progress in British Columbia

Progress in BC

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

5

10

15

20

25

Percentage Smoking Prevalence in BC, 1999-2011

BC

Year

QuitNow

19-24 projects

1st Quit Contest

NRT ac-cess

BC sues tobacco

companies

Prevention program in schools

BC Quitline

Govt funding to $6.5M

103

Intention to Quit

Intention to Quit

104

Physicians discussing quitting

Physicians Discussing Quitting

105

Effect of Physician intervention

Effect of Intervention

106

What can Physicians do?

What can Physicians do?

107

Strategies to help your patients quit

Strategies

Complete Personal Risk Assessment for Rx for Health

Brief advice to quit smoking

Refer to behavioural support (like QuitNow)

Recommend patients call 8-1-1 for NRT

Order Buproprion or Varenicline (prescription)

108

What is QuitNow?

What is QuitNow?

Behavioural quit smoking supportProvincially Funded Managed by the BC Lung AssociationEvidence-based Free, confidential, 24/7

109

Fax Referral Forms

110

Online Referral

online

[email protected]

111

Indications for

Referral

to a HFC

Heart

Function

Clinic

Referral

Form

Referral Resources

112

Patient History/Assessment

Heart Failure

Patient

Questionnaire

113

A Guide to HF Patient Assessment

Patient Assessment

Tool

114

Snapshot of Patient

Visit

Referral and Consult Process

Planning for Action Period 2

Documents

Www.pspbc.ca Shared System of Care COPD/Heart Failure Learning Session 2