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Primary Care Update 2024 COPD Making a good diagnosis Steve Holmes Tuesday 1 October 2024 Steve Holmes Declaration of Interests (1) • General practitioner, Park Medical Practice, Shepton Mallet • Somerset ICB Clinical Respiratory Lead / Integrated Care Lead • NHS England (National CVD and Respiratory Programme Board) • NHS England (Educational Supervisor (trainer) and 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.Key Topics in COPD management • Reviewing people with COPD • Exacerbations • Deconditioning Living and dying with severe chronic obstructive pulmonary disease 1 A story with no beginning A middle that is a way of life An unpredictable and unanticipated end Pinnock H et al, Living and dying with severe chronic obstructive pulmonary disease: multi perspective longitudinal qualitative study. BMJ 2011; 342. Available from https://doi.org/10.1136/bmj.d142. Accessed January 2024 Image used with permission •1 - National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: Guidelines and diagnosis and management NICE guideline NG115. 2019. •2- Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2024) Global Strategy for the strategies for COPD Diagnosis, Management and Prevention of COPD (2023) Available from: https://goldcopd.org/ NICE (2019) 1 GOLD (2024) 2 Guideline Yes No, report and strategy Representative group on Yes (doctors, nurses, patients,other HCP, No (all tertiary academic or doctors) guideline academics, researchers, across 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 2023 Next guideline planned uncertain 2025 Coverage Comprehensive Comprehensive Drive Clinical with aspirational / financial Clinical, global, no pharma involvement in strategy declared now as an organisation Institute for Clinical Excellence. NG 115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE; 2019.; 2.tional What is the point in treating pulmonary disease. Cochrane Database of Systematic Reviews. 2018(10). 4. Kopsaftis Z et al, Influenza vaccine for chronic obstructivestructive pneumonia in chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2017(1). 6 Godtfredsen NS, et al. COPD-ng COPD – times have changed - Keeney E, et al, Dual combination therapy versus long-acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): aba Y, antagonist (LAMA) plus long-acting beta-agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary the positives? disease (COPD). Cochrane database of systematic reviews. 2017;2(2):CD012066-CD. 9. Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. 2016(12)y rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. Cochrane Review Supportive (QOL/M/ 1 Intervention H / Exac) National Guidance Supportive Steroids for exacerbation Yes (QOL) Yes Antibiotic for exacerbation Yes (M in ICU) Yes Influenza immunisation Yes (Exac) Yes Pneumococcal vaccination Yes (Exac) Yes Smoking cessation Yes (QOL/M) Yes LAMA Yes (QOL/H / Exac) Yes 8 LABA/ICS Yes (QOL/M/H/Exac) Yes LAMA /LABA Yes (QOL/H /Exac) Yes Most people with any long term condition have multiple conditions in Scotland Heart failur3% 9% 14% 74% Stroke/TIA 6% 14% 18% 62% Atrial fibrilla 7% 13% 16% 65% Coronary heart disea9% 16% 19% 56% Painful condi on 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% Demen a 5% 13% 18% 64% Anxiety 7% 17% 20% 56% 13% 21% 21% 46% Schizophrenia/bipolar Depression 23% 22% 18% 36% 0% 25% 50% 75% 100% This condi on onlyge This condi on + 1 othernd+ 2 othersave+ 3 or more others 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 COPD and CVD Risk Study in Germany 126 795 patients with COPD 58 720 (46.3%) exacerbated at least once and 48 982 (38.6%) experienced at least one CV event or died during a median follow-up of 36 months. Rate of outcome was increased during 1–7  days following a severe exacerbation onset remained elevated for up to a year (181–365  days HR 1.17, 95% CI 1.11 to 1.23). 1. Vogelmeier CF, COPD: results of the EXACOS-CV study in Germany. BMJ Open Respiratory Research. 2024;11(1):e002153.consequences of an exacerbation of QRISK4 Hippisley-Cox J, Coupland CAC, Bafadhel cardiovascular risk prediction. Nature Medicine. 2024;30(5):1440-7.ion of a new algorithm for improved QRISK4 Hippisley-Cox J, Coupland CAC, Bafadhel cardiovascular risk prediction. Nature Medicine. 2024;30(5):1440-7.ion of a new algorithm for improved DOSE and COPD Over 5 years, 116 patients (20.6%) died. Mortality was higher in patients with DOSE index >4 (42.4%) than for lower scores (11.0%) (p<0.0001). DOSE index of 0–3, hazard ratio for mortality set at 1 DOSE index of 4–5, hazard ratio for mortality = 3.48 (95% CI 2.32 to 5.22) DOSE index of 6-7, hazard ratio for mortality = 8.00 (95% CI 4.67 to 13.7) Jones RC, Donaldson GC, Chavannes NH, Kida K, Dickson-Spillmann M, Harding S, et al. Derivation and Validation of a Composite Index of Severity in Chronic Obstructive Pulmonary Disease: The DOSE Index. Am J Respir Crit Care Med. 2009;180(12):1189-95Respir J 2012; 21 DOSE • Better in predicting admissions, exacerbations and quality of life • Not quite as good as BODE for mortality • Recommended use in Owusuaa C, Dijkland SA, Nieboer D, van der Rijt CCD, van der Heide A. Predictors of mortality in chronic obstructive pulmonary disease: a systematic review and meta- analysis. BMC Pulm Med. 2022;22(1):125 The Structured Review Part (DOSE IT) • Dyspnoea - Assess symptoms • Obstruction – FEV1 • Smoking status • Exacerbations • Inhaler technique (including concordance / compliance) • Treatments (consider other interventions and treatments What are the non-drug pharmacological options for COPD?  • Offer treatment and support to stop smoking • Offer pneumococcal and influenza vaccinations • Offer pulmonary rehabilitation if indicated • Co-develop a personalized self management plan • Optimise treatment for comorbidities National Institute formanagement NICE guideline NG115. 2019.bstructive pulmonary disease in over 16s: diagnosis and What are the non-drug pharmacological options for COPD?  • Offer treatment and support to stop smoking • Offer pneumococcal and influenza vaccinations • Offer pulmonary rehabilitation if These treatments and plans shouindicat disited at every review • Co-develop a personalized self management plan • Optimise treatment for comorbidities National Institute formanagement NICE guideline NG115. 2019.bstructive pulmonary disease in over 16s: diagnosis and NICE – asthmatic features or features suggesting steroid responsiveness • any previous secure diagnosis of asthma or atopy • higher blood eosinophil count • substantial variation in FEV1 (400mls) • substantial variation in PEFR (20%) National Institute fmanagement NICE guideline NG115. 2019. obstructive pulmonary disease in over 16s: diagnosis and Offer SABA or SAMA for use as needed If the person is limited by symptoms or has exacerbations despite treatment No asthmatic features or features suggesting steroid Asthmatic features or features suggesting responsiveness steroid responsiveness Offer LABA + LAMA Consider LABA+ICS Person has day to day Person has 1 severe or 2 Person has day to day symptoms adversely symptoms adversely moderate exacerbations impact on quality of life or has 1 severe or 2 impact on quality of life within a year moderate exacerbations within a year Consider LAMA+LABA+ICS Offer LABA+ICS+LAMA Consider 3 month trial of LAMA+LABA+ICS Explore further treatment options if still limited by breathlessness or subject If no improvement revert to LAMA+LABA to frequent exacerbations (see NICE guidance for more details) National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2019. Offer SABA or SAMA for use as needed If the person is limited by symptoms or has exacerbations despite treatment No asthmatic features or features suggesting steroid Asthmatic features or features suggesting responsiveness steroid responsiveness Offer LABA + LAMA Consider LABA+ICS Person has day to day symptoms adversely Person has 1 severe or 2 Person has day to day symptoms adversely impact on quality of life moderate exacerbations impact on quality of life or has 1 severe or 2 LAMA / LABA within a year moderate exacerbations within a year Consider LAMA+LABA+ICS Offer LABA+ICS+LAMA Consider 3 month trial of LAMA+LABA+ICS Explore further treatment options if still limited by breathlessness or subject to frequent exacerbations (see NICE guidance for more details) If no improvement revert to LAMA+LABA National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2019. Offer SABA or SAMA for use as needed If the person is limited by symptoms or has exacerbations despite treatment No asthmatic features or features suggesting steroid Asthmatic features or features suggesting responsiveness steroid responsiveness Offer LABA + LAMA Consider LABA+ICS Person has day to day Person has 1 severe or 2 Person has day to day symptoms adversely symptoms adversely moderate exacerbations impact on quality of life or has 1 severe or 2 impact on quality of life within a year moderate exacerbations within a year Consider LAMA+LABA+ICS Offer LABA+ICS+LAMA Consider 3 month trial of LAMA+LABA+ICS Explore further treatment options if still limited by breathlessness or subject If no improvement to frequent exacerbations (see NICE guidance for more details) revert to LAMA+LABA National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2019.Key Topics in COPD management • Reviewing people with COPD • Exacerbations • Deconditioning Definition: Exacerbations are an acute worsening of respiratory symptoms, resulting in additional therapy 1 Severe A&E visitsation Up to 77% of Moderate Antibiotics and/or OCSts will have at + SABA or SAMA least one moderate- Mild SABA or SAMA onlto-severe exacerbation within 1. GOLD. Global strategy for the diagnosis, management, and preventio2 of COPD: 2021 report. Available from: https://goldcopd.org (Accessed November 2021); 2. Hurst JR, et al. N Engl J Med 201a 3-year period;. Lung function lost with exacerbations 0.02 0.00 FEV 1oss of approx. 15 mL o ) −0.02 f ( g V1 a F c i −0.04 S k n e e W M −0.06 −0.08 −0.10 −8 −7 −6 −5 −4 −3 −2 −1 1 2 3 4 5 6 7 8 Adapted from Watz Weeks from moderate/severe exacerbation H, et al. 2018 Watz H, Tetzlaff K, Magnussen H, Mueller A, Rodriguez-Roisin R, Wouters EFM, et al. Spirometric changes during exacerbations of COPD: a post hoc analysis of the WISDOM trial. RESPIRATORY RESEARCH. 2018;19(1):251. Lung function decline following a severe exacerbation is worse in those with milder disease mild – 87ml moderate – 20ml severe- 20ml very severe – 7ml Dransfield MT, Kunisaki KM, Strand MJ, Anzueto A, Bhatt SP, Bowler RP, et al. Acute Exacerbations and Lung Function Loss in Smokers with and without Chronic Obstructive Pulmonary Disease. American journal of respiratory and critical care medicine. 2017;195(3):324-30. Preventing the first exacerbation could reduce the risk of mortality Time between exacerbations reduces * More exacerbations increases risk of mortality 2 Adapted from Suissa S, et al 2011.0 100 Adapted from Soler-Cataluňa JJ, et al 2005 y n d 0.8 t e 80 g r p v c n r x et 60 s 0.6 e p o e 0 t P<0.0001 e 0 b 0.4 t 01 40 b e er r No acute COPD exacerbations f ph P e a 20 0.2 1–2 acute exacerbations of COPD a d R o ≥3 acute COPD exacerbations 0 0.0 0 1 2 3 4 5 6 0 10 20 30 40 50 60 Time (months) Time after first severe exacerbation (years) . 1. Suissa S, Dell'Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax. 2012;67(11):957-63. 2. Soler-Cataluña JJ, Martínez-García MA, Román PSánchez, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60. How many exacerbations does the average person with COPD have every year? • In major trials of people under specialist care the figure is between 0.85 – 1.3 1,2,3 1- Calverley P, Anderson J, Celli B, Ferguson G, Jenkins C, Jones P, et al. Salmeterol and fluticasone proprionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356:775 - 89. 2- Tashkin DP, Celli B, Senn S, Burkhart D, Kesten S, Menjoge S, et al. A 4-Year Trial of Tiotropium in Chronic Obsmortality in COPD--a review of potential interventions. International journal of chronic obstructive pulmonary disease. 2009;4:203-23.us and How soon after worsening of symptoms starts before a patient should commence steroids / antibiotics? • Start SABA early on • Start OCS or antibiotics usually 48-72 hours or longer 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, 1 - NatioDoxycyclin ,e for Clinical Excellence. NG 115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE; 2019chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018;3:Cd006897. 3- therapy for exacerbations of Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD (2020). 2019. 4- 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. 1 Clinical review important • Remember normal • Pneumonia recovery 2 • No benefit from longer • Pulmonary embolus course of antibiotics (for • Carcinoma of lung 3 infection) • Bronchiectasis • No benefit from longer • Pleural effusion course of steroids (for exacerbations) in hospital • Heart failure • Atrial fibrillation inpatients (no studies in 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.Key Topics in COPD management • Reviewing people with COPD • Exacerbations • Deconditioning Better to keep our COPD population active • highest risk was observed in the sedentary group (adjusted HR (aHR) (95% CI) = 1.70 (1.59 to 1.81)for all-cause ED visit or hospitalisation, 5.45 (4.86 to 6.12) for respiratory ED visit or hospitalisation). • A 500 MET-min/week increase in PA was and respiratory ED visit or hospitalisation in the COPD cohort (aHR (95% CI) = 0.92 (0.88 to 0.96) for all-cause, 0.87 (0.82 to 0.93) for respiratory cause). obstructive pulmonary disease: a nationwide population-based study. BMJ Open Respiratory Research. 2024;11(1):e001789.chronic The legacy of shielding has been predictable – but also in our past care of long term conditions • Isolation and loneliness leading to depression 1,2 • Fear and anxiety of 3 infection 12017;25(3):799-812.2- 2 Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematicmmunity. review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. Journal of the American Academy of Child & Adolescent Psychiatry. 2020. 3- Survey from Asthma UK available at https:// www.asthma.org.uk/support-us/campaigns/campaigns-blog/the-experience-of-shielders/ ICU Acquired Weakness (ICUAW) • Neuromuscular condition that develops during an ICU stay. • This is a common problem of critical illness and occurs in:  – 33% of all patients on ventilators  – severe infection ts admitted with • Features may take a year or more to resolve makes the activities of daily living difficult, including grooming, dressing, feeding, bathing and walking. The Society of Critical Care Medicine. Post Intensive Care Syndrome 2020 [Available from: https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome 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 available in hospital (20 trials) 3 1. Porth C, Matfin G, Porth C. Pathophysiology : concepts of altered health states. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2009.2. Knight J, Nigam Y, Jones A. Effects of bedrest 5: the muscles, joints and mobility. Nurs Times. 2019;115(4):54-7.3. Taylor NF, Harding KE, Dennett AM, Febrey S, Warmoth K, Hall AJ, et al. Behaviour change interventions to increase physical activity in hospitalised patients: a systematic review, meta-analysis and meta-regression. Age and Ageing. 2021;51(1). Deconditioning Summary • More osteoporosis 9,10 • Increases falls 1 9,10 • Worsens mental health 2 • Muscle atrophy • Reduced exercise • Increases risk of infection 3,4 9,10 tolerance • Worse respiratory • Worse diabetes outcomes 5,6,7 outcomes and obesity • Worse cardiovascular outcomes 11 outcomes 8 • Higher blood pressure 12 1 - Sherrington C et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2019. 2- Conn VS. Anxiety outcomes after physical activity interventions: meta- 2020;369:m1386 5 - Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2016. 6. BMJ Blakey JD et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 2013;68:ii1-ii30 8- Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise Skeletal Muscle. Cell metabolism. 2016;23(6):1034-47. 10-Kell RT, Bell G, Quinney A. Musculoskeletal fitness, health outcomes and quality of life. Sports Med. 2001;31(12):863-73. 11 - Sigal RJ, Armstrong MJ, Colby P, Kenny GP, Plotnikoff RC, Reichert SM, et al. Physical Activity and Diabetes. Canadian Journal of Diabetes. 2013;37:S40-S4. 12 Fox K, Hillsdon M. Physical activity and obesity. Obesity reviews. 2007;8(Suppl. 1):115-21Noetel M, Sanders T Gallardo-Gómez D, Taylor P, Cruz BdP, Hoek Dvd, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847Thank you any questions?