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Hello everyone. Good evening. Uh I said my name is I'm going to presentation overview your PD. Basically the knee does my spine. This is my office. I'm going to diagnosis OXY AC O PD, the Manage Co PD. The use of oxygen therapy, oxygen therapy, lung as well as first is Theology. In a, we found of the range from 7 to 24 8% which is quite a, um, range average found that was a percent, of course, quite a, um, I believe she knows it on time and, but we found prevalence of cop is one medium. The one point affect C UK and is that common of em? And the one in UK admission? It is also estimated that there is going to be in and that causes of going to be 2.5 lbs by two. This shows that uh prevalence of COPD and I probably because most important risk factor, your smoking has not been, I'm very sure all the basic COPD that as for you. So I'm going in that, but I'm specifically going to find out the new things that brought up in the new, the COPD more like just So from of the COPD. Now considering in primary eyelid of COPD in patients of who are and have the s one is a chronic red glass production, frequent bronchia. And we um so to remain on that, no, I want to highlight fact, it is in primary care. This is important patients I have, it is difficult to make it that of. And as it will tell you that in the, we do not try to diagnose, you give the treatment, discharge and to the other cleaning and it can have a lot of that was the reason that they are very, are present that c so you might have a but then there might be, that's just CED that that's still on the hand. II yes, I did people who test or using including people health. But the problem is that some of the C and techniques actually help us diagnose they're not UK up and is not applicable in the. So you can see to people who were pre um positive me but because I use C scan x rays, you being in that it's got side the next time talking about the graduation of the of obstruction. So we can see that the nice guy have gone from before we went. Um the at does not work that we go to eight. Now the reset, um we can see the class not 10, 59. So the first post for fe one F EC the fe volume. F the first is um the amount that you exhale after inhalation while pa volume, just the amount in one second. This is of course, a restrictive disease, obstructive disease and basically always talking about a diagnosis on thyro the but has to be less than seven. So you see that a contact all the levels of flu. Now what the fe one, so the one if it's still than 8% then that stage one. So this is different before you talk about last. But now, even if the and they don from there, um, sever which is between seven and then 10 to 49 next stage, which is severe obstruction. And then we have the back which is stage four. Now, for stage four, very severe all in the s one is below 50% with respiratory failure. The next part of an is a pain was of a patient from the state which is beyond our to date and is acute onset. The common comes production. Of course, most patients are going to, which is a um, excuse me as um, your, your voice, your voice is breaking. Can you check your network? Yes, because it's speakers of complaining. And then I noticed it too. I'm so sorry about that. Your voice is breaking. I don't know whether it is from your network or I think it's sounding better. Now, can you, ok? It's breaking, it's breaking. It's not, can you go back and then join back again. OK. Uh That make me uh fluid. No, you don't have to upload the slide. The slide is already there. Just draw and just exit and join back. All right. Yeah. OK. Cut back. Uh Thank you. Hello. What? No, no, I was asking whether you were able to leave the platform and join back again. Yes, I had the huh I end again. I mean, can you exit the platform completely completely and then join back is in the link. Hello? Yes, I hear me better. Yeah, we can hear you now. Oh OK. Uh So I need to find my slide. Uh I have to check now. OK. I'm sorry for the mix up. I'm just going to quickly run through everything. I was talking about the overview of CO PD new adjustments to guidelines. I know a lot of us already know much about CO PD but I'm going to be pinpointing the major adjustments that we made to the guidelines for managing CO PD so far. This is my outline. I talked about the epidemiology and said that in Sub Saharan Africa, the prevalence was found to be 1.7% to 24.8% which is quite a wide range, but the average was about 8%. Of course, some of this might not actually be very accurate value because of the fact that a lot of people might have CO PD, the diagnosis might be a problem. But in the UK. It was found out at 1.2 million people are affected by CO PD which is quite a significant um number CO PD ex the patients alone account for one in eight UK hospital admissions and their second most common cause of emergency hospital admissions. It is projected there is going to be a 40% increase in CO PD prevalence with an annual cost of 2.5 billion lbs by 2030. And this is just for CO PD concerning the making of a diagnosis of CO PD. We recommend or write aide recommends that considering spirometry in primary care for early diagnosis of CO PD in patients over 35 years of age who are either smokers or ex smoker and have symptoms such as exertional breathlessness, chronic cough, regular production, frequent winter bronchitis. A wheeze. It is important to take note of the word primary care reason being that in acute care settings, sometimes it's difficult to make a diagnosis of COPD because the patient might have other things that might just mimic COPD such as certain viral illnesses. As a matter of fact, some respiratory physicians will not attempt to make a full diagnosis of COPD in the hospital. But rather have you just give your nebs and then discharge the patient possibly on a saba and send to the GP for a proper lung spirometry and have the diagnosis of COPD make there so that you don't make a wrong diagnosis simply because there is a disease mimicking COPD in the acute statin. Of course, the standard still remains spirometry. Evidence has shown that you can use CT scans and chest x rays to accurately identify people who will test positive for CO PD using spirometry including patients or people without symptoms. However, the problem is that the techniques used for the CT scans and chest x rays are not routinely used in UK practice and certain other countries. So it makes the uh application of these techniques limited. I went through the table um showing the severity of airflow obstruction. We can see a graduation from the nice guideline of 2004 to the eight guideline of 2004. And we talk about the goal 2008 and the nice 2010 guidelines. Of course, we you're going to be using the F EV over F VCF EV, meaning the first respiratory volume, F VC, meaning the force vital capacity. No, we need to take note that F VC is the total amount exhaled after a deep inhalation while the F EV is the one exhaled in one second. This ratio helps you to differentiate obstructive and restrictive um airway diseases. And for CO PD, the constant in this is the ratio, it is less than 0.7 all through the stages of airflow obstruction. What now changes is the F EV 1% in the past if someone had an F EV one or greater than eight, you might still not say CO PD. But now even with an F EV one or greater than 80% as long as the ratio is less than 0.1 that patient is said to have CO PD stage one, that is the mild form of airway obstruction. And then we go back to the um 50 to 70 then the 30 to the fortnight. And so far, so you have the stage four as the last one, which is very severe or stage four can also be said to uh to be there if a patient has an S ev one below 50% with respiratory failure. I was also talking about exhibitions and that an exacerbation is a sustained worsening of a patient's symptoms from their usual stable state, which is beyond normal day to day variations and is acute in onset. Commonly reported symptoms are things like worsening, breathlessness cough, increased sputum production change in sputum color. And this is important to take note of because most CO PD patients are going to have a baseline cough. They can just say they have a tickle in their throat and um they comment that they have a baseline cough. But when this cough becomes more productive or as it changes, caution and color, then you cannot think of the fact that this patient might be having an exerbation of the CO PD in CO PD. We talk about the peak flow we do usually don't use peak flow for CO PD reason being that even during exacerbations, there is just a very modest difference in the peak flow of the patients. But in asthma, you have a more significant change in their peak flow, which is why you usually use peak flow each time a patient comes in with asthma to check how they're improving. We might also have heard about the blood index. It's a multidimensional index of disease severity used for CO PD. It used to include the how far a patient can do, do a six minute walk um using the MRC deafness scale, but now it's found to be ineffective. Although the good thing is that most clinicians were actually not using the blood index. So now we are still looking for a multidimensional index of disease severity for CO PD. The next. Now we we're talking about is oxygen in acute exacerbation. Now, once a patient comes in, usually they will teach you in a s that once a patient comes in and is called sick. The first thing is a 15 centimeters of oxygen or we had no repeat that bag. But if you know um that this patient has COPD, then you can start in for 88 to 92. So prior to the availability of blood gasses, you have to use a 28% vent mass at 4 L, aiming for an oxygen saturation of 88 to 92. But this is for patients who have either risk factors who have a capnea or have a history of respiratory acidosis. But if you find out that it's um the pressure, pressure of CO2 is normal, then change your target back to 94 to 98. You know what that was. It's not every CO PD patient that has to be 88 to 92. Now, for patients with CO PD, whose APG is between 7.25 to 7.35. In other words, this is a patient coming in with an acute exacerbation of CO PD and persistent acidotic hypercapnic ventilatory failure and it hasn't improved within one hour of intimal medical therapy. I believe we all know what I mean by optimal medical therapy. It's talking about your um buol nebulizers, nebulizers. You've given hydroa or prednisoLONE, you've given Mao and the patient is still not making improvement. Then you need to consider this patient for a noninvasive ventilation. That's the N IV. So the first one we're going to talk about is one as best suitable for most CO PD patients. And that is the bipap. So this is intermittent positive air pressure. You're looking at this delivers oxygen at two different pressures. We are going to talk about is the expiration and the inspiratory um pressures. So it helps in the clearance of carbon dioxide, which makes it useful in CO PD. As in other words, when you talk about type two respiratory failure. However, our bipap comes in the form of a max a uh a face mask. So you find out that certain patients might not be able to tolerate it. I mean, the patient is hyper aic. So you expect that he might be a bit drowsy from the CO2 and he's pulling off, pushing off the the face mask because it's not uh um suitable or convenient for him or her. So such patients are not going to be able to stay on the N IV. So the recommended initial setting for the bi-level pressure supporting CO PD, you talk about the expiratory positive airway pressure of 4 to 5 cm of water. The inspiratory positive airway pressure of 10 cm of water, although some other guidelines have their suggestions, but you can see obviously that inspiratory pressure is going to be higher than the expiratory pressure to help play out co to better. So there is a backup in expiratory ratio of one is to three expiratory being more than inspiration. The next thing we're going to be talking about in the oxygen delivery systems is what we call the my O2. Some of us might know this as the optic flow, these delivers who modified high flow oxygen and delivers oxygen almost as a percentage of 95 to 100%. I mean we have the um not re breeder, the usual one that lives as 15 L per minute, but some people have stipulated that oxy flow can give as large as 60 L per minute, which is a lot of oxygen. I would definitely be good for people who are hypoxic. You know, that was type one respiratory failure. It also helps to reduce the walk of Britain. This optic flow, as you can see, we will say is more for type one resp failure. But when patients are not doing well on the uh bipap, they are not tolerating the bipap rather in terms of because it's a hood or a face mask, the patient has secretions and they are still putting a hood on the patient. It's just going was in their secretions, it's just going to make them more comfortable. They cannot eat when they have the hood on or the face masks on. So then we can sometimes give them the intermittent optic flow which comes as a nasal cannula. So that way they can eat, they are able to um some suction suction. The patient also um these are just pictures of the bipap and then there is also the CPAP which I'm going to be talking about. Next, we can see the oxy nerve and the my two. So CPAP. So difference to CPAP um bipap, CPAP as a continuous positive pressure. Hence, it is ideal for keeping that those alveoli open. And when it keeps the Veli open, it is noted also to have to reduce the hidrotic pressure. And this is good for patients with pulmonary edema. So you are trying to reduce hydrostatic pressure. Remember that fluid leaving or entering is dependent on the hydrostatic and oncotic pressures. Then the next one is the oxy, no, the free O2, automatic oxygen titration. Now, this is the new one that's coming up in the sense that it measures the oxygen saturation of arterial blood and automatically adjusts the flow of oxygen is delivering to the patient through a nasal ka or non occlusive max. So it's basically going to check the patient's here. O2 and it's um SP O2 and it's going to adjust the flow to meet the target that you set on the machine. It also comes as a nasal cannula. Hence, the patient can eat while is is not going to be very inconvenient. And then you also have it as a non occlusive max. Um and it also has an alarm that goes off once there's a shortage or a break in the oxygen supply for the patients. Of course, this is just new. Um They are still weighing the evidence in terms of the cost effectiveness and um it's actually going to be cost effective in the long run management of stable CO PD. So update has its guidelines on the management of chronic obstructive Pulmonary Disease. In 2018, there is a general management, we cannot stop harming on smoking cessation advice, offering nicotine patch, nicotine inhalers, um and other medications that can be used for smoking cessation. Then the vaccinations, the annual influenza, the one of pneumococcal vaccine is also important and um pulmonary rehabilitation also. So talking about the management of stable CO PD, we'll talk about the inhalation or therapies we use. There is a saba sama saba meaning the short acting beta agonist. Sama means the short acting muscarinic antagonist laba which is long acting muscarinic antagonist I CS, which means inhaled corticosteroids. Now, the guidelines say is that the first thing of course, is going to be the saba or the SAM as required. Now, if this is still not helping the patient patient is still having exacerbations, increasing daytime symptoms, then you have to consider are there features in this patient that that tailor towards the fact that this is an asthmatic feature or this this CO PD might be steroid responsive. You know, are there asthmatic features or features suggestive of steroid responsiveness? And what are these features? Previous diagnosis of asthma raised blood? You if you count substantial variation in ev one over time, at least 400 mills and a down down. Now peak flow variation, we see that all these features listed here are features usually seen a purely asthmatic patient. If these are present, then we'll continue with our OAB as required. But then we'll add on a laba plus inhaled corticosteroid. But if these are not present instead of inhaled corticosteroid, you'll be going with Lama, which is the um long acting scarring antagonist plus laba and of course, sa as required, some of the studies show that the reason for the IC has been added for patients who have asthma is who have asthmatic features or steroid responsive features is because the steroids help to walk on the fields, reducing them. So you have patients who asthmatic usually would have higher eil counts. So definitely if steroid is working in terms of the fiels, it's going to benefit more than the other patients. But if this is still not working, meaning that the patient might be having two exacerbations in a year and he's having increased day to day symptoms, then you have to check the criteria and start this patient on a triple therapy. In other words, you are combining everything SBA is required, the lama plus lumbar and I CS regularly. I've already talked about all of this, the bronchial, the dilator therapy, that's the saba, the Sama asthmatic features, determining which way to go next. Um The inhaled therapies, inhaled corticosteroids. And it's important to take note of the fact that when patients come and we give them oral prednisoLONE, 30 mg for five days and then they are responding. It doesn't mean that that patient is going to respond to an inhaled corticosteroid. Apparently, it doesn't predict that that patient has um is going to go towards the features that are asthmatic. And so you go through the I CS pathway. No, the next step is the oral prophylactic antibiotic therapy. Now, they've recommended Azithromycin prophylaxis. But I know some trusts who also use other drugs, um patients should not smoke and should have optimized standard treatments and continue to have it. The patients before you can place them on oral prophylactic antibiotic therapy. The other prerequisites such as CT to rule out bronchitis, which of course is going to be uh if present could then explain a chronic sputum production and a chronic cough that the patient has and also sputum culture to exclude atypical infections, tuberculosis in the patient. And before you comment on azithromycin, you have to check the ECG the QT interval because Azithromycin can cause QT prolongation and affect liver function. Then there is the mucolytics which can also be considered in patients with a chronic productive cough and continued if symptoms improve. I'm just going to briefly talk about carpal, which we all know is a right sided heart failure coming from a lung disease. So the features of course include the peripheral edema, ravenous pressure, a systolic prosal he LP two. It's an advice that we don't use ace inhibitors, carbon channel blockers, alpha blockers on patients that have Coronale instead what has been found to be most effective is the loop diuretic. Unfortunately, I've tried to find out why exactly we are not using any of them, but there is not very clear explanation to that. I'm sorry, I couldn't find why, but it's been found that those drugs are not actually ideal for patients with Cor Pulmonale, but generally, these seem to be drugs that we could use in people who have um certain things like heart fail or hypertension. So you probably have to adjust the medication for patient once they have called Pulmonale and factors which can improve survival for patients with stable COPD includes smoking cessation, which we keep hammering on, which is the single most important interventions in patients who are still smoking long term oxygen therapy, which I'll talk about lung volume reduction surgery, which I will also talk about. Now for long term oxygen therapy assessment is done by measuring the ABG of this patient on two occasions, three weeks apart. So you have um patients with stable CO PD and they have to be on optimal management and to measure their ABG on two occasions, three weeks apart, you can then offer them long term oxygen therapy. If their partial pressure of oxygen is less than 7.3 or if they have a partial pressure up to 7.3 to 8. And the following um secondary polycythemic hypoxia, basically, you do not offer long term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment and referral to specialist smoke smoking devices and services. This is important, obviously because oxygen is um highly inflammable. So it is not right to do that. And the fact that the patient is still smoking also means that their, their lungs are probably still going to be sustaining a lot more injury and they are giving long term oxygen therapy. So, almost in a way mycin like, are you really utilizing the resource as well for that patient? Couldn't these resources be used elsewhere since this patient is still having damaged their lungs, ambulatory oxygen therapy. So, if a patient has a mild or no uh hypoxemia, there's no need to consider ablate oxygen therapy. But when a patient um is having desaturation during exercise and um have shown to have improvement in their exercise capacity with oxygen and also motivated to use oxygen. Then you can talk about oxygen therapy, ambulate oxygen therapy. We prescribe ambulatory oxygen therapy to people who are already on long term oxygen therapy who wish to continue oxygen therapy outside the house. So they can make use of things like small cylinders and oxygen concentrators. Um And it's also good for them when they are undergoing pulmonary rehabilitation or they've undergone it already. So it helps them during the exercises for all of this. Uh The next I'm going to talk about is a lung surgery and lung volume reduction procedures. Now, um there are various methods, interventions involved in lung surgery and lung volume reduction procedures. You talk about the m and not me, there is a video assisted and thoracic surgeries there is uh endobronchial valves. So the the basically are removing the, the damaged part of the lung is what you are removing in order to allow the part that is good to go on with breathing. So when you put endobronchial valves, what you are doing is that you look for those aspects of the lung that are damaged, you put a valve there and apparently the valve is going to stop air from flowing into those places shrink or collapse those places allowing for the size that are good to then expand and continue to help the person in Britain. Um So how and when do you refer for this lung volume reduction procedures? You offer a respiratory review to assess whether a patient can have lung volume reduction procedure if they complete pulmonary rehabilitation. And if all of the following apply, they have severe CO PD which F ev one less than 50% and breathlessness that affects their quality of life. Despite optimal medical therapy, they do not smoke here. Is it again, they can complete a six minute walk distance of at least 140 m. Then you refer them for respiratory review. The respiratory review of the respiratory doctor is now going to refer them to the lung reducing volume MDT who would then assess them if they are fit enough. So you have patients who have an uh who have a variant and five matters lung bullous. So you can do bullectomy for them removing of the upper lobe if they have a physma there. But unfortunately, there are certain conditions that some patients might have that might not make them eligible for this surgery. Sometimes things like heart failure, pulmonary fibrosis, pulmonary hypertension or patients have a widespread hy uh emphysema. In other words, where do you start from to reduce the lung volume? And the fact that the patient has had this long volume reduction procedures doesn't mean that you don't refer them for lung transplantation if need be, uh this should be the last part of the discussion. So hospital discharge care bundle, we've treated the patient and now the patient is to be discharged. Usually um from what I see, the COPD nurse masses, the patient and then they will always document that the discharge bundle has been given or you should uh prescribe or ensure that this patient goes with discharge bundle. So it's a group of evidence-based elements of ongoing care that should be implemented, checked and verified on discharge from the hospital. This child care bundle should cover the following understanding of their medication and inhaler use selfmanagement plan, smoking, cessation, pulmonary rehabilitation and sometimes they give them a rescue P is going to comp comprising of steroids and antibiotics. In conclusion, CO PD causes significant morbidity and mortality with estimated rise in prevalence. Therefore, there is need to continuously update guidelines. Smoking is an important risk factor for CO PD and its exposure needs to be reduced. Thank you very much. Do you have any questions? Ok. Thank you very much. Um doctor for that um presentation. It, it was quite um and then light me and, and I open that phone management of COPD. So, um, let's look at the questions. Does anyone have any questions if you have any questions, you can just pop it in to the um checkbook and then we will um go through them. So, um any questions? Ok. So um there is a question from Doctor Jeremiah Cornerstone. Ok, thank you very much. Please. Could you enlighten me on the use of Oxy off? I didn't quite get it. Ok. So oxy Nov is a new form of oxygen delivery system that's coming up. So it's deliver high flow oxygen and then is um is good in the sense that it measures week. Hello Monday. Yes. Can you hear me? Yes, we we we we can hear you. Ok? Ok. It delivers oxygen. I notice that it's deliver oxygen is measuring the po two of the patient and adjusting the oxygen flow according to the already set target on the medicine. So it could set a target of greater than 94. So if the patient's um oxygen saturation is going down, it's going to automatically be increasing the the flow of oxygen is leaving to that patient or like in other cases where oh SP O2, you have to measure it and then it's going down. I change from nasal came and then I'm going to uh a face mask change from a face mask and then I'm going to repeat that bag and all of that, but this one can deliver all those levels of oxygen flow on its own and also has an alarm that sets off once the patient's oxygen delivery system is shut down or cut off. So it's still upcoming. Um I think I found only about four comments from specialists about it. They're still checking the cost effectiveness, but I guess nice is hopeful that it might become useful in the future. What's that? Clay? Ok. Thank you very much for that. Um OK. II think Jeremiah is happy with the answer you gave to the question. Do you have any other questions? Ok. So in the absence of um any other questions, um we can come to the end of um this presentation, please do not forget to fill in the feedback forms that will be sent to you um emails after. Sure. Then um uh once you, once you feel, once you feeling the um um feedback from, send it back to us and um you can be able to get your um automatically regenerated and certificate. Um So in the absence of any question, thank you very much, Doctor. Thank you. Thank you everyone for attending the presentation. Goodnight.