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Primary Care Update 2024 COPD Making a good diagnosis Steve Holmes th Thur 6 June 2024 Steve Holmes Declaration of Interests (1) • General practitioner, Park Medical Practice, Shepton Mallet • NHS England South West – Regional Clinical Respiratory Lead • NHS Somerset Integrated Care and Respiratory Lead • Health Education England (GP Trainer / Ed Sup in Somerset) • NHS England (National CVD and Respiratory Programme Board) • NHS England (Appraiser) • Primary Care Respiratory Society (Service development, Policy and Conference committees) • International Primary Care Respiratory Group (IPCRG) Education Committee Chair • RCGP (Chair Severn Faculty Board) RCGP Rep for Taskforce for Lung Health and National Respiratory Audit Programme) • Recent guideline involvement (Air Travel, Asthma, COPD, Respiratory disease in athletic individuals, Spirometry, Tobacco Dependency) Declarations of Interest (2) Speaker engagements, educational projects, conference attendance, advisory board work (in the last three years) Academic work University College, London; Universities of Birmingham, Cambridge, Edinburgh, Sheffield Other providers Asthma and Lung UK, Best Practice, Doctorology, Education for Health, EQUIP, Guidelines in Practice, InterYem, MedAll, Mediconf, MIMS, Omniamed, Pulse, RCGP Conferences, Respiratory Professional Care, Somerset GP Education Trust Pharmaceutical / device companies Aide Health, Astra Zeneca, Boehringer Ingelheim, Chiesi, Pulmonx, Sanofi, Teva, Trudell Medical International, Viatris No tobacco shares. Making a good diagnosis • Identifying and making a good diagnosis • Common catches • Some new grey areas (Pre-COPD and PRISm) • Six reasonably common problems we see but don’t always spot (in people with or with a label of COPD) • 1 - National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over Guidelines and 16s: diagnosis and management NICE guideline NG115. 2019. • 2- Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2023) Global Strategy for the strategies for COPD Diagnosis, Management and Prevention of COPD (2024) Available from: https://goldcopd.org/ NICE (2019) 1 GOLD (2023) 2 Guideline Yes No, report and strategy Representative group on Yes (doctors, nurses, patients,other No (all tertiary academic doctors / clinicians) I guideline HCP, academics, researchers, across think…. no GP / nurse / patients primary / secondary / tertiary boundaries) Academic Literature Yes systematic where area covered Review of literature known to specialists not review systematic or sent in by invitation Last full update 2004 Unknown Last partial update 2010, 2018, 2019 2022 Next guideline planned uncertain 2023 Coverage Comprehensive Comprehensive Drive Clinical with aspirational / financial Clinical, global, no pharma involvement in strategy declared now as an organisationJoan • Joan is 60yr old • Smoker since she was 15yr old. • Wlocal haulage companyr • Attends with a history of getting breathless on walking quickly with family, and often gets infections in the winter Case finding for COPD – consider a diagnosis in those who are over 35, and smokers or ex-smokers, and have any of these symptoms: • exertional breathlessness • chronic cough • regular sputum production • frequent winter ‘bronchitis’ • wheeze 1 - National Institute for Health anguideline NG115. 2019.onic obstructive pulmonary disease in over 16s: diagnosis and management NICEWhat is the point in for Clinical Excellence. NG 115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE; 2019.; 2. Walters JA, et al. Cochrane treating COPD – times Systematic Reviews. 2018(10). 4. Kopsaftis Z et al, Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic of Systematic Reviews. 2017(1). 6 Godtfredsen NS, et al. COPD-related morbidity and mortality after smoking cessation: status of the evidence. Europeanf have changed - the pulmonary disease (COPD): a systematic review and network meta-analysis. Cochrane Database of Systematic Reviews. 2018(12). 8. Horita N, et al. Long-ructive positives? pulmonary disease (COPD). Cochrane database of systematic reviews. 2017;2(2):CD012066-CD. 9. Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T.ructive Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2016(12) Cochrane Review Supportive (QOL/M/H Intervention / Exac) National Guidance Supportive 1 2 Steroids for exacerbation Yes (QOL) Yes Antibiotic for exacerbation Yes (M in ICU) Yes 4 Influenza immunisation Yes (Exac) Yes Pneumococcal vaccination Yes (Exac) Yes Smoking cessation Yes (QOL/M) Yes LAMA Yes (QOL/H / Exac) Yes LABA/ICS Yes (QOL/M/H/Exac) Yes 7 LAMA /LABA Yes (QOL/H /Exac) Yes Pulmonary rehabilitation Yes (QOL) Yes COPD diagnosis • Good history and examination 1, 2 – 90% smokers – No AF / Aortic stenosis / effusions / asthma • Chest xray, full blood count and BMI 1 – No obvious cancer, anaemia • Consider A1AT estimation 2 • Consider HRCT 1,2 • Confirmed by diagnostic quality spirometry 1,2 • Consider cardiovascular evaluation 1, 2 1 - National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2019. 2- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD, Available from: https://goldcopd.org/Think again • The Younger Person • The Older Person who has never smokedPiotr joins your practice • He is 35 years old and was diagnosed with COPD last year after a nasty infection and having had spirometry performed. • What are you thinking?The Younger Person • Think • Asthma • A1AT • Drugs Asthma ? • Imagine a patient with significant asthma being given 500mcg of salbutamol and doing the spirometry 15 minutes later People with asthma do not always reverse fully with a few puffs of salbutamol A1AT deficiency ? • Prevalence of alpha-1 antitrypsin deficiency is about 1 per 3000 to 5000 people,similar to that of cystic fibrosis • Smoking link Brode SK, Ling SC, Chapman KR. Alpha-1 antitrypsin deficiency: a commonly overlooked cause of lung disease. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2012;184(12):1365-71. Drugs? 1 • Heroin smokers – N=753 people (73% of those approached) 1 – 35% COPD using fixed ratio / 39% using LLN 1 – 15% had asthma-COPD overlap (ACO) with features of COPD and asthma 1 2,3 • Cannabis – Around 75% of NZ have tried cannabis by age 25 and 13.7% of NZ have used cannabis in recent years 2 – In adults who predominantly smoked resin cannabis mixed with tobacco, additional adverse effects were observed on respiratory health relating to cannabis use. 3 • Sheesha / water pipes (water pipe tobacco) 4,5 – 100 – 200 cigarettes per pipe 5 1- Burhan H, Young R, Byrne T, Peat R, Furlong J, Renwick S, et al. Screening Heroin Smokers Attending Community Drug Services for COPD. Chest. 2019;155(2):279-87., 2- Ribeiro LIG, Ind PW. Effect of cannabis smoking on lung function and respiratory symptoms: a structured literature review. npj Primary Care Respiratory Medicine. 2016;26(1):16071., 3 - Macleod J, Robertson R, Copeland L, McKenzie J, Elton R, Reid P. Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population. British Journal of General Practice. 2015;65(631):e89-e95., 4- El-Zaatari ZM, Chami HA, Zaatari GS. Health effects associated with waterpipe smoking. Tobacco control. 2015. 5 - Yadav S, Rawal G. Waterpipe Tobacco Smoking: A Mini-review. J Transl Int Med. 2018;6(4):173-Linda attends after she had a COVID19 related cough • 75 years old, non smoker • Worked as a nurse for many years in medical unit • Told she has COPD from her tests The older person who has not smoked • The commonest cause of COPD in people without a smoking history is undertreated asthma 1,2 • Fixed ratio of FEV1/ FVC (70%) overdiagnoses COPD in the older population (compared to Lower Limit of Normal) 3,4 1- Sexton P, Black P, Wu L, Sommerville F, Hamed M, Milne D, et al. Chronic Obstructive Pulmonary Disease in Non-smokers: A Case-Comparison Study. the population-based burden of obstructive lung disease study. Chest. 2011;139(4):752-63. 3- Vestbo J, Rodriguez-Roisin R. GOLD and the fixed ratio. European Respiratory Journal. 2011;38(2):481-2. 4- Swanney MP, Ruppel G, Enright PL, Pedersen OF, Crapo RO, Miller MR, et al. Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax. 2008. Poor adherence to prescribed asthma medications increases subsequent risk of COPD • Used four databases (1998 – 1999 followed up until 2018) • 68,211 people with asthma (mean age 48.2y) • The 18-year incidence of COPD in asthma patients was 9.8 per 1000-persons year. Results • High medication adherence significantly associated with decreased risk of COPD • A significant increase in COPD risk was observed in severe asthma patients with low medication adherence (aHR: 1.72, 95% CI: 1.52-1.93), independent of other patient factors. CONCLUSION: Optimal (≥ 0.80) and intermediate adherence (0.5 to 0.79) levels were associated with reduced risk of COPD incidence over time. Interventions aimed at improving adherence to prescribed medications in adult asthma patients should be intensified to reduce their risk of COPD. Asamoah-Boaheng M, Farrell J, Bonsu KO, Oyet A, Midodzi WK. Association Between Medication Adherence and Risk of COPD in Adult Asthma Patients: A Retrospective Cohort Study in Canada. Clin Epidemiol. 2022;14:1241-54 FEV1/FVC - Fixed ratio or LLN? Missed Diagnosis Misdiagnosis Eschenbache W in COPD Clinical Perspectives, Panos (Ed), 2014 Panos (Ed), 2014 Open Access at https://www.intechopen.com/books/copd-clinical-perspectives. But what about the imaging – it says hyperinflation or COPD or emphysema – how do I manage that? Report suggests emphysema or signs of COPD on cxr or CT scan Primary care undertakes clinical review and spirometry Current smoker, spirometry Spirometry positive and Non smoker, normal normal no symptoms or signs symptoms / signs of COPD - spirometry, no symptoms of respiratory disease make diagnosis or signs of resp disease Smoking cessation Ask about personal or family advise; inform that history of lung or liver more at risk of lung disease (consider A1AT); disease and lung Treat as COPD or refer to reassure unlikely to get cancer; return if specialist care worse; return if symptoms; warn that emphysema on CT symptoms of lung is an independent risk factor problems for lung cancer. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2019. Smokers with Preserved Pulmonary Function • Although they do not meet the current criteria for COPD, symptomatic current or former smokers with preserved pulmonary function have exacerbations, activity limitation, and evidence of airway disease. They currently use a range of respiratory medications without any evidence base . Woodruff PG, Barr RG, Bleecker E, Christenson SA, Couper D, Curtis JL, et al. Clinical Significance of Symptoms in Smokers with Preserved Pulmonary Function. New England Journal of Medicine. 2016;374(19):1811-21 Pre-COPD •Pre-COPD 1 – Not obstructed on post bronchodilator spirometry (FEV1/FVC >/= 0.7) – May have emphysema on CT, respiratory symptoms and or physiological abnormalities (including low FEV1, gas trapping, hyperinflation, reduced lung diffusing capacity and/ or rapid FEV1 decline without airflow obstruction) Agustí A, Melén E, DeMeo DL, Breyer-Kohansal R, Faner R. Pathogenesis of chronic obstructive pulmonary disease: understanding the contributions of gene-environment interactions across the lifespan. Lancet Respir Med. 2022;10(5):512-24. PRISm (Preserved Ratio Impaired Spirometry) • PRISm – Not obstructed on spirometry (FEV1:FVC ratio >/= 0.70) and no reversibility but with abnormal 1 spirometry (FEV1 < 0.80) • Prevalence around 10% 2 • Risk of progression to COPD 3 understanding the contributions of gene-environment interactions across the lifespan. Lancet Respir Med. 2022;10(5):512-24 spirometry. BMJ Open Respiratory Research. 2022;9(1):e001298. 3. Lu J, Ge H, Qi L, Zhang S, Yang Y, Huang X, Li M. Subtypinged preserved ratio impaired spirometry (PRISm) by using quantitative HRCT imaging characteristics. Respiratory Research. 2022;23(1):309.. Pre-COPD and PRISm (Preserved Ratio Impaired Spirometry) • Subjects with Pre-COPD or PRISm are at risk of developing airflow obstruction over time – but not all of them do 1 • More research is needed to determine what is the best treatment for these 1 individuals beyond smoking cessation Agustí A, Melén E, DeMeo DL, Breyer-Kohansal R, Faner R. Pathogenesis of chronic obstructive pulmonary disease: understanding the contributions of gene-environment interactions across the lifespan. Lancet Respir Med. 2022;10(5):512-24. Bronchodilator therapy in tobacco exposed people with preserved lung function • Inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic, tobacco-exposed persons with preserved lung function as assessed by spirometry. 1.Han MK, Ye W, Wang D, White E, Arjomandi M, Barjaktarevic IZ, et al. Bronchodilators in Tobacco-Exposed Persons with Symptoms and Preserved Lung Function. New England Journal of Medicine. 2022;387(13):1173-84.From slide by Daiana Stolz; ERS Barcelona 2022 –relating to 1. Stolz D, Mkorombindo T, Schumann DM, Agusti A, Ash SY, Bafadhel M, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet. 2022;400(10356):921-72.From slides by Daiana Stolz; ERS Barcelona 2022 –relating to 1. Stolz D, Mkorombindo T, Schumann DM, Agusti A, Ash SY, Bafadhel M, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet. 2022;400(10356):921-72.From slide by Alvar Agusti ; ERS Barcelona 2022 –relating to Agustí A, Melén E, DeMeo DL, Breyer-Kohansal R, Faner R. Pathogenesis of chronic obstructive pulmonary disease: understanding the contributions of gene-environment interactions across the lifespan. Lancet Respir Med. 2022;10(5):512-24. Are we • Six reasonably common sure that problems we see but we are don’t always spot (in right? people with or with a label of COPD)Case 1 John has had an exacerbation of his COPD treated 7 days ago and he calls to say he needs another course of antibiotics and steroids because things aren’t better. How soon after worsening of symptoms starts before a patient should commence steroids / antibiotics? • Start SABA early on • Start OCS or antibiotics or both usually 48-72 hours or longer after onset Aaron SD, Donaldson GC, Whitmore GA, Hurst JR, Ramsay T, Wedzicha JA. Time course and pattern of COPD exacerbation onset. Thorax. 2012;67(3):238-43. How long does an exacerbation last Usually last 11 – 13 days (median) and quicker onset settle faster – though many last considerably longer before full symptom resolution Aaron SD, Donaldson GC, Whitmore GA, Hurst JR, Ramsay T, Wedzicha JA. Time course and pattern of COPD exacerbation onset. Thorax. 2012;67(3):238-43. What dose of steroid and antibiotic and for how long? • Prednisolone 30mg 1,2,3 daily for 5 days. • Antibiotic for 5 days 3,4 – Amoxicillin, Doxycycline, Clarithromycin 1JA, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochraneers Database Syst Rev. 2018;3:Cd006897. 3- National Institute for Clinical Excellence. Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing. London NICE; 2018 Dec 2018. I just need another course of antibiotics and steroids – I’m not quite better yet. Clinical review important 1 • Remember n2rmal • Pneumonia recovery • Pulmonary embolus • No benefit from longer course of antibiotics (for • Carcinoma of lung infection)3 • Bronchiectasis • Pleural effusion • No benefit potential harm from longer course of • Heart failure steroids (for exacerbations) • Atrial fibrillation in hospital inpatients (no studies in primary care) 4,5 Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a exacerbation onset. Thorax. 2012;67(3):238-43.3 - National Institute for Clinical Excellence. CG91: Pneumonia in adults: diagnosis and management 2014. 4- Sivapalan P, Ingebrigtsen TS, Rasmussen DB, Sørensen R, Rasmussen CM, Jensen CB, et al. COPD exacerbations: the impact of long versus short courses of oral corticosteroids on DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev.an 2018;3:Cd006897.Case 2 I’m not sure these inhalers are working – I am still always coughing inhalers are making me worse the phlegm is usually discoloured. Oh and can I have some more antibiotics please? Clinical features of bronchiectasis Most common symptoms Other symptoms Haemoptysis, fever, fatigue Daily expectoration of large volumes of purulent Young at presentation and absence of smoking history sputum (75% of people) History of symptoms over Dyspnoea (60% of people) many years Rhinosinusitis, weight loss, sputum colonisation with P. aeruginosa Chest pain present between exacerbations, usually non- pleuritic (19-46% of people) NICE. 20National Institute for Clinical Excellence. Clinical Knowledge Summary - Bronchiectasis. 2022. https://cks.nice.org.uk/topics/bronchiectasis/ When should we suspect bronchiectasis? • Rheumatoid arthritis, • COPD • Asthma • Gastro oesophageal reflux • Inflammatory bowel disease • HIV-1 infection, immunosuppression, organ or bone marrow transplants • Cystic fibrosis • Primary Ciliary Dyskinesia T Hill A, L Sullivan A, D Chalmers J, De Soyza A, Stuart Elborn J, Andres Floto R, et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. Making the diagnosis • Perform baseline chest X-ray in patients with suspected bronchiectasis. (D) • Perform a thin section computed tomography scan (CT) to confirm a diagnosis of bronchiectasis when clinically suspected. (C) • Perform baseline imaging during clinically stable disease as this is optimal for diagnostic and serial comparison purposes. (D) T Hill A, L Sullivan A, D Chalmers J, De Soyza A, Stuart Elborn J, Andres Floto R, et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. Specialist available treatments (examples) Airway clearance (respiratory physiotherapist) • active cycle of breathing techniques or oscillating positive expiratory pressure Mucoactives in bronchiectasis • do not routinely use recombinant human DNase in adults (A) • clearance. (D)se of humidification with sterile water or normal saline to facilitate airway Inhaled corticosteroids (ICS) • do not routinely offer ICS unless other indications (such as ABPA, chronic asthma, COPD) • do not routinely offer phosphodiesterase type 4 (PDE4) inhibitors, methylxanthines or leukotriene receptor antagonists for bronchiectasis treatment. (D) Antibiotics • Consider long term antibiotics in patients with bronchiectasis • who experience 3 or more exacerbations per year. (A) – specialist initiation Pulmonary rehab • Supported in this group seen in specialist care T Hill A, L Sullivan A, D Chalmers J, De Soyza A, Stuart Elborn J, Andres Floto R, et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. How common is bronchiectasis? • 160/100,000 who had a In practice survey (2012) diagnosis of bronchiectasis 1 • 15/16 diagnosed by specialist • 1/16 it was not possible to determine • US studies have suggested when the diagnosis was made (in a 52/100,000 and previous UK patient aged 3yr old in 1950) studies 1 had quoted • 0/16 were made by general 80/100,000 practitioner • UK data in 2013 suggested the prevalence in women was 566/100 000 and in men • 13% of people were being seen in 486/100 000 2 specialist care – and this survey • Recent German study demonstrated that it was the wrong suggests 53-95/100,000 3 13% - for which action has been taken. 1-2012;Glasgow:RCGP. 2- QuintJK, MillettER, Joshi M, NavaratnamV, ThomasSL, HurstJR, etal. Changesintheincidence, prevalenceandmortalityof bronchiectasisintheUKfrom2004to2013:apopulation-basedcohortstudy. EurRespirJ. 2016;47(1):186-93. 4- RingshausenFC, RademacherJ, PinkI, deRouxA, HicksteinL, PlonerT, etal. Increasin2019;54(6):1900499.alenceinGermany, 2009–2017:apopulation-basedcohortstudy. EuropeanRespiratoryJournal. Management of an exacerbation • Send sputum sample for C&S • Offer antibiotic taking account of: – severity of symptoms – previous exacerbation and hospital admission history, and the risk of developing complications – previous sputum culture and susceptibility results. • When results of sputum culture return – review the choice of antibioticnd – change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already • Give advice about possible side effects of antibiotics and to seek help if symptoms worsen rapidly or significantly National Institute for Clinical Excellence. Clinical Knowledge Summary - Bronchiectasis. 2018. Annual review (if required) • Review co-existing asthma / COPD as normal • Review medication requirements in line with current advise (options on stopping inhaled corticosteroids if no asthma / COPD) • Refer back if three or more exacerbations in one year • Encourage influenza immunization (and that had pneumococcal) • Unclear if benefit to primary care lung function review or other monitoring (imaging) unless symptoms National Institute for Clinical Excellence. Clinical Knowledge Summary - Bronchiectasis. 2018. Case 3 My breathing is getting worse and my home monitoring of worse too – are you sure this is COPD? Clinical features – consider cxr / referral • age over 45 years • persistent breathlessness on exertion (sats on arrival in consulting room) • persistent cough • bilateral inspiratory crackles when listening to the chest (Velcro ®) • clubbing of the fingers • normal spirometry or impaired spirometry usually with a restrictive pattern but sometimes with an obstructive pattern National Institute for Health and Care Excellence. Idiopathic pulmonary fibrosis: the diagnosis and management of suspected idiopathic pulmonary fibrosis. 2013. http://guidance.nice.org.uk/CG163. 2013. High resolution CT – appearance vary UIP pattern • Honeycombing with poss peripheral traction bronchiectasis or bronchiolectasis • Mainly subpleural / basal (occ diffuse or asymmetrical) • May be superimposed CT features (ground glass opacity, reticular pattern and pulmonary ossification. Probable UIP pattern • Predominantly subpleural and basal • Often hererogenous distribution • Reticular pattern with peripheral traction bronchiectasis or bronchiolectasis • There may be mild ground-glass opacity Indeterminate for UIP : • Predominantly subpleural and basal • Subtle reticular pattern • May have mild ground-glass opacity or distortion (“early UIP pattern”) Raghu G, Remy-Jardin M, Myers JL, Richeldi L, Ryerson CJ, Lederer DJ, et al. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2018;198(5):e44-e68. Interstitial Lung Disease Cottin V, Hirani NA, Hotchkin DL, Nambiar AM, Ogura T, Otaola M, et al. Presentation, diagnosis and clinical course of the spectrum of progressive-fibrosing interstitial lung diseases. European Respiratory Review. 2018;27(150):180076. Type (examples) Specific Antigen Exposure Bird fanciers lung Avian precipitans Feathers / bird droppings (Pigeon, poultry, breeders) Cheese washers lung Penicillum casei or P. roqueforti Cheese casing Chemical worker’s lung –Toluene diisocyanate (TDI) hexamethylene diisocyanate (HDI) or Paints, resins, and Isocyanate HP methylene bisphenyl isocyanate (MDI) polyurethane foams Coffee worker's lung Coffee bean protein Coffee bean dust Compost lung Aspergillus Compost Aspergillus species, thermophilic actinomycetes, thermoactinomyces Farmers lung vulgaris, saccharopolyspora rectivirqula, absidia corymbifera, eurotium Mouldy hay amstelodami Hot tub lung Mycobacterium avium complex Mist from hot tubs Thermoactinomyces candidus, bacillus subtilis, bacillus cereus, klebsiellaMist generated by a Humidifier lung oxytoca, hermophilic actinomycetes, aureobasidium pullulans, naegleriamachine from standing gruberi, acanthamoeba polyhaga and acanthamoeba castellani water Wikipedia https://en.wikipedia.org/wiki/Hypersensitivity_pneumonitis accessed on 31/12/2019Causes: Inhaled drugs can infect idiopathic malignancies Inhaled Drugs • asbestosis • Chemotherapy drugs. • silicosis – Methotrexate, • pneumoconiosis cyclophosphamide • byssinossis (cotton) • Heart medications. – Amiodarone / propranolol • hypersensitivity • Some antibiotics. pneumonitis (dust, fungus, – Nitrofurantoin / ethambutol moulds and spores, bird / • Anti-inflammatory drugs. be termed extrinsic allergic – Rituximab, sulfasalazine, alveolitis (EAA) methotrexate Scullion J, Holmes S. Interstitial lung disease. Independent Nurse..2014;2014(16):31-5. Causes: Inhaled drugs can infect idiopathic malignancies Connective Tissue Infections Disorders • Tuberculosis • Systemic sclerosis • Chlamydia trachomatosis • Dermatomyositis • Resp Syncytial Virus • System lupus erythematosis • Pneumocystis pneumonia (PCP) linked to HIV • Rheumatoid arthritis • Atypical pneumonia • Polymyositis • Antisynthetase syndrome Scullion J, Holmes S. Interstitial lung disease. Indepen.ent Nurse. 2014;2014(16):31-5. Causes: Inhaled drugs can infect idiopathic malignancies Idiopathic Malignancies • Sarcoidosis • Lymphangitis • Idiopathic pulmonary carcinomatosis fibrosis (20-50% of all) • Post radiotherapy (commonest form) treatment to the chest • Interstitial pneumonia • Hamman Rich Syndrome Scullion J, Holmes S. Interstitial lung disease. Independent Nurse. 2014;2014(16):31-5 2 - Sauleda J, Núñez B, Sala E, Soriano JB. Idiopathic Pulmonary Fibrosis: Epidemiology, Natural History, Phenotypes. Med Sci (Basel). 2018;6(4):110. Complex – Refer (secondary or tertiary) • MDT diagnosis – Clinicians (doctor, specialist nurse) – Radiologist – Histopathologist • Why important?Idiopathic Pulmonary Fibrosis Prevalence and Survival • median survival for people with idiopathic pulmonary • Prevalence (USA) varied fibrosis in the UK is between 14 and 27.9 approximately 3 years from cases per 100,000 the time of diagnosis population • Prevalence (Europe) 1.25 • about 20% of people with to 23.4 cases per 100,000 the disease survive for more population. than 5 years. • The rate of disease progression can vary greatly. 1- Nalysnyk L, literature. European Respiratory Review. 2012;21(126):355-61. idiopathic pulmonary fibrosis: review of the 2 - National Institute for Health and Care Excellence. Idiopathic pulmonary fibrosis: the diagnosis and management of suspected idiopathic pulmonary fibrosis. 2013. http://guidance.nice.org.uk/CG163. 2013. Primary care tips • Symptom control important (patients can get very breathless) • Often higher than normal oxygen concentration used as disease progresses (via specialist assessment) and might have to concentrators working in parallel Nationsuspected idiopathic pulmonary fibrosis. 2013. http://guidance.nice.org.uk/CG163. 2013.is and management ofCase 4 • My COPD is slowly getting worse – and I keep telling you my sleeping isn’t as good. • And my wife asked me to tell you about… my ankles Most people with any long term condition have multiple conditions in Scotland Heartfailure3 9 14 74 Stroke/TIA 6 14 18 62 Atrialfibrillatio7 13 16 65 Coronaryheartdisease 9 16 19 56 Painfulcondition 13 21 21 46 Diabetes 14 20 19 47 COPD 18 19 17 47 Hypertension 22 24 19 35 Cancer 23 21 17 39 Epilepsy 31 23 16 29 Asthma 48 20 12 21 Dementia 5 13 18 64 Anxiety 7 17 20 56 Schizophrenia/bipolar 13 21 21 46 Depression 23 22 18 36 0% 20% 40% 60% 80% 100% Percentageofpatientswitheachconditionwhohaveotherconditions Thisconditiononly Thiscondition+1other +2others +3ormoreothers Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012 COPD – consider other common co- morbidities 1 • CHD (19-25%) • Heart failure (6%) 2 • Diabetes (13.5%)2 • Erectile dysfunction (57%) 3 • Osteoporosis (36-60%) 1 4 • Incontinence >33% • Myalgia • Senile purpura • Anxiety (10-19%) 1 • Depression (10-42%) 1 • Glaucoma / cataracts 1 - Van der Molen T. 2010;PCRJ 19(4):326-34. 2 - Barnett K, Mercer SW et al Epidemiology of multi-morbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012; 3 – ATS Poster 2012 4 ERS Poster 2011 CVD and COPD commonly occur in the same person, and the 1* presence of both conditions increases the risk of death Mortalityassociatedwithmajor 1* comorbiditiesinCOPD InpatientswithCVD 2 Heart failure 1 in 4 patients with HF an1 in 6 with coronary H artery disease also have COPD 3 1 1 3 HR R 1 Atrial Ischaemic 1.27– H 9 fibrillation/ heart disease 15 H flutter R 14– 1.6 2.4 HR In patients admitted to hospital with an COPD 3 acute COPD exacerbation H .9 R1 R1 4 .4– 50% have chest tightness H –1 17 50% have ECG changes .7 Pulmonary R1 10% have raised cardiac troponin levels hypertension H Diabetes Adapted from Rabe K et al 2018 HR – hazard ratio 1. RabeK, etal. EurRespirRev2018;27:180057; 2. 2. BuddekeJ etal. BrJ GenPract2019;69:e398−e406; 3. 3. McAllisterDAetal. EurRespJ 2012;39:1097−1103 Suspected heart failure • Review the person's medication and if appropriate heart failure.If symptoms are sufficiently severe, offer a loop diuretic such as Furosemide 20–40 mg daily. • Admit if acute but otherwise measure N-terminal pro- B-type natriuretic peptide level (NT-pro-BNP). • Arrange ECG • Arrange bloods (if appropriate) Clinical Knowledge Summary – Heart Failure (Accessed 31/5/2024)Case 5 Things are just not improving – I really can’t do what I used to do. It is not the same since I was admitted to hospital Deconditioning – breathless (but no change in lung function, wheeze etc) (treat by gradual increased activity) How inactive is UK? Survey July 2014 (NTS)for England 2012 (HSE); Active People Survey 8, April 2103-April 2014 (APS); National Travel HealthSurveyfor England2012(HSE); ActivePeopleSurvey8, April 2103-April 2014(APS); National Travel SurveyJuly2014 (NTS)How does the UK compare with the following countries for not being active? USA France Netherlands Germany Australia Finland Proportion who are not active International comparison of physical inactivity (at ages 15 and over) Netherlands 18.2% Germany 28.0% France 32.5% Finland 37.8% Australia 37.9% USA 40.5% UK 63.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% % Inactive Note: Comparator = Not meeting any of the following per week: (a) 5 x 30 mins moderate-intensity activity; (b) 3 x 20 mins vigorous-intensity activity; (c) equivalent combination achieving 600 metabolic equivalent-min. 65 Public HealthEngland(2014) EverybodyActive, EveryDay(2014), basedonWHOObservatorydata Deconditioning following admission to hospital • Inactivity (eg resting at home) is associated with atrophy and a loss of muscle strength at a rate of 12% a week 1,2 • After 3 to 5 weeks of bed- rest, almost 50% of the muscle strength is lost. 1,2 • Effective measures to promote physical activity availa3le in hospital (20 trials) 1. Health/Lippincott Williams&Wilkins; 2009.2. Knight J, NigamY, JonesA. Effectsof bedrest 5: themuscles, jointsand mobility. NursTimes. 2019;115(4):54-7.3. Taylor NF, HardingKE, Dennett AM, FebreyS, WarmothK, Hall AJ, et al. Behaviour changeinterventionstoincreasephysical activityinhospitalisedpatients: a systematic review, meta-analysisand meta-regression. AgeandAgeing. 2021;51(1).Case 6 • My breathlessness is getting worse – and I’ve seen them in the hospital what can you do to help? I am just more breathless – they have seen me every 3 months for 2 years and I’ve had lots of CT scans and seen them Pulmonary embolism 3.5-11.5 per 10,000 people 1 per year 8x higher in those over 80yr than 50y 25% of unexplained severe Thinkincreasedriskof thromboembolism COPD exacerbations 2 acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis andgement of management of acute pulmonary embolism of the European Society of Cardiology (ESC). European Heart Journal. 2019;41(4):543-603. 2- Tillie- Leblond I, Marquette C-H, Perez T, Scherpereel A, Zanetti C, Tonnel A-B, et al. Pulmonary Embolism in Patients with Unexplained Exacerbation of Chronic Obstructive Pulmonary Disease: Prevalence and Risk Factors. Annals of Internal Medicine. 2006;144(6):390-6 Pulmonary embolus - risks Moderate risk (OR 2-9) Strong risk factors (OR>10) • Arthroscopic surgery • Lower limb fracture • Autoimmune disease • Blood transfusion • Hospital for heart failure or AF • Central venous or iv catheters (within 3m) • Chemo • Hip or knee replacement • CCF or resp failure • HRT • Major trauma • IVF • MI (within 3m) • Previous VTE • Post partumception • Spinal Cord Injury • Infection (pneumonia, uti, HIV) • Inflamm bowel disease • Cancer • Stroke • Superficial vein thrombosis 1. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing G-J, Harjola V-P, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). European Heart Journal. 2019;41(4):543-603. Pulmonary embolus – clinical features / management Suspect pulmonary embolism • Arrange immediate admission (PE) in a person with for people with suspected dyspnoea, tachypnoea, pulmonary embolism (PE) if: pleuritic chest pain, and/or features of deep vein • They have signs of thrombosis haemodynamic instability (DVT), including leg pain and (including pallor, tachycardia, swelling (usually unilateral), collapse).n, shock, and lower abdominal pain, redness, increased • birth within the past 6 weeks.n temperature, and venous distension . Clinical Knowledge Summary. Pulmonary embolus. 2024. Pulmonary embolus – Wells Score Prandoni P, Lensing AWA, Prins MH, Ciammaichella M, Perlati M, Mumoli N, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. New England Journal of Medicine. 2016;375(16):1524-31. Pulmonary embolus – Wells score less than 4 • Offer a D-dimer test with hours:sult available within 4 • If the test result cannot be obtained within 4 hours, anticoagulation whileutic awaiting the result (if possible, choose an anticoagulant that can be continued if PE is confirmed). Clinical Knowledge Summary. Pulmonary embolus. 2024. Cases 1-6 1. Natural Improvement of an exacerbation 2. Bronchiectasis 3. ILD 4. Heart failure 5. Deconditioning 6. Pulmonary embolism Making a good diagnosis • Identifying and making a good diagnosis • Common catches • Some new grey areas (Pre-COPD and PRISm) • Six reasonably common problems we see but don’t always spot (in people with or with a label of COPD)