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Ok, good evening everybody. It's great to see everyone. Um Just joining on. Um fantastic to have a good number of you this evening. Um My name's Timy. I am an F two doctor and pleasure to chair the middle primary care group. Um It's another great evening. We're looking forward to having the wonderful um familiar face of Steve Holmes with us. Um GP with extensive interest in respiratory medicine. A lot of educational and research involvement and respiratory charity work. Um It's great to have you back with us. It's not Steve's first rodeo. Um We were chatting just before about previous talks that are available as catch up content. So, um we will, we will maybe reference that later on. Um It's great to see everyone and as usual, we'll have around 45 minutes for our presentation. Um and then we will do some Q and A at the end. So I'd encourage you to pop any questions that spring to mind into the chat. I will be keeping an eye on that as we go through and we will harbor off some questions to the side and we will go through them at the end as always, the feedback form will be shared towards the end of tonight's session and you can access that along with so much more content on the metal app. If you aren't already joining from there available on Apple and Android and the links in the chat or via the QR code, as you know, we have our primary care events running almost every week. Um And you'd be the first to know if you're signed up on notifications. Um And you can also get your slides and on demand content there as well. So without any further ado from me, I am going to slip off into the background. Invite doctor Holmes to pop slides up on the screen. Tim, thank you very much indeed. Um Hopefully this will come up. Now, there we go, entire screen coming up now to go on to share the slide set so people hopefully can see that now. Perfect Steve Chat. Ok. So thanks again, Tim. Lovely introduction. Thank you very much indeed. And yes, I have been here before. Yes, online there is a earlier um update on CO PD diagnosis which you might want to access if you're wondering about getting the um the diagnosis right in the first place. And I'm not gonna cover that today today. I'm gonna primarily keep up to date with management assuming we've got a good diagnosis. So that's, that's the first bit is this isn't about making the diagnosis. We've done that before. This is about, we've got a good diagnosis. Now, what are we gonna do? Um, declarations of interest and some other declarations of interest, uh including some academic work, other providers and the pharmaceutical industry, none of them have sponsored this session and none of them have had any say in what slidess that I'm using. I'm gonna try and cover three areas um that are common in clinical practice if you're managing people with CO PD. First one, reviewing people with CO PD. The second one, a slightly deeper dive into what is an exacerbation and how do we manage that? And finally touch on a topic which is highly relevant and much more so since COVID and um highlighted in the UK by the Dasi report, um the problem of deconditioning and its contribution to ill health. So let's kick off and get going. Um One of our colleagues in general practice, Hillary Pinnock uh about 1014 years ago, wrote about living and dying with CO PD. And that was a lovely article. It was um qualitative research, interviewing patients and carers with CO PD and really tried to identify the key themes about the disease and why it might be different. And the first thing that Hillary found was it was a story with no beginning. There's a relevance behind this. The first thing is that if I develop a breast lump, I remember the day I remember feeling I remember going to the doctor getting referred on et cetera. The same with rectal bleeding or a, an unusual lump somewhere or when my vision suddenly dropped down. Um, the same was true. If I get sudden central crushing chest pain, I've got a story with a definite beginning. I can look back for the preli before that, but I don't have, I've got a clear story with CO PD because it's often insidious onset. It's, it's a chronic progressive disease. Um There is no definite beginning for many people. Sometimes it's the moment when they get admitted with a, a more severe exacerbation, but often it can be not quite keeping up with colleagues walking a little bit more slowly. Um having a bit of a mild cough, cold, a bit more than the friends are lasting a little bit longer. It's a, it's a story without a clear starting point and that makes it hard from a primary care and hospital side of things these people aren't coming in saying I think I might have this condition or I'm worried about what's happening here. They adapt to it. They slow down a little bit and, and it becomes a way of life and that's exactly that middle bit people who, if you imagine that if you're younger and fitter going out, running slow down a bit and slow down a bit more and then walk and then can't quite keep up with their friends who are walking and so have to stop and look into shops. They don't particularly like that. Middle is a, it becomes a way of life. It's, I'm, I'm adapting to the fact that I can't quite walk as quickly. Cos I get breathless. I hide my coughs because everyone thinks it might be COVID. When I go out in public, they, they develop techniques to manage the way and that can be quite true in some of those who aren't yet diagnosed as well. So a complexity there is that, that, that story with no beginning and a middle way of life, final thing. And I'm not gonna touch a great deal on this today. But worthwhile thinking about is unfortunately, for many of our patients, like those with heart failure and those with dementia. And unlike those with the deteriorating line, you can predict with cancer, often these people will have quite severe infections, survive, perhaps unexpectedly, survive, go on to have a further event and it's unpredictable or sometimes they'll have one mild, one moderate and then a very bad event and that, and that will end their lives. So it can be an unpredictable and un anticipated end, which makes it hard for the families and people that we care for. So worthwhile. Just thinking about our patients. In that sort of scenario, there are two major er producers of guidance, certainly in the UK. The one that most of us are familiar with in the UK is National Institute for Clinical Excellence Guidance. That's a proper guideline produced by a proper literature review, proper wide representative group of clinicians and patients across boundaries and um isn't quite as updated as commonly as the goal strategy. The gold strategy is designed at a global level. So different to people who are working in the UK or countries like the UK is designed to hopefully be applied throughout the world. It doesn't involve proper literature reviews. They use the literature they're aware of, but it's not a systemic systematic process for doing that. Um And although these doctors that I know quite a few of them are really good clinicians or academics, they all work in a tertiary level environment. There are no general practitioners indeed. I don't think there are any normal secondary care doctors involved in it um at the current time and it does try to advise. So there's, there's differences in the way that the strategies and guidance is produced and who it's produced for nice is clearly made with an aspirational view and it does look at the finances, the uh gold um strategy um doesn't have farmer involvement now, but is clearly working at a global level. And what we could probably be doing now when I started in medicine, when people used to tell me that the only effective treatment for CO PD was to quit smoking. And I very occasionally hear that now, not nearly as often as I used to. Um but can I make a request if you hear a clinician saying um the only effective treatment for smo um for CO PD is to stop smoking, please. Can you just request that they go on an update and they clearly haven't been on one for about 15 years to 20 years because we have known for a long time that there are benefits with steroids and antibiotics. The immunizations are useful as well as smoking cessation and there's good evidence that the medication works and pulmonary rehabilitation works. There is some growing evidence also about Vitamin D but that is less clear at the current time. So that's why I haven't put that in. But plenty of really good reasons why people with CO PD should be on effective early diagnosis and get onto the right treatment. So next thing to think through is our patient who comes in with CO PD. Um We know as generalists that a lot of these patients haven't just got CO PD, they've got more than one condition. And this was nicely um highlighted really well by Stuart Mercer and colleagues. Um again about 12 years ago where they looked at people with long term conditions, things like heart failure, atrial fibrillation, diabetes, COPD, hypertension. And they found it was actually quite rare. You can see the numbers, the pale num the pale area on the left is those who have just that solitary condition, heart failure or CO PD or hypertension, whatever it is as you go to the far side where the blue gets darker. That is the dark blue is people who've got three or mother three or more other comorbidities. So we know that this isn't just about dealing with one disease. We've gotta be thinking quite widely when we see our patient with CO PD. And that's important when we come to both management and when we come to managing exacerbations and these are sort of amalgamated figures from a variety of resources, but probably just worthwhile. Highlighting a few for you, I'll talk about coronary heart disease in a moment. Uh That's important. Um because one of the commonest causes of death in CO PD is heart disease are heart failure. Much commoner in people with CO PD. Over the last 20 years, we haven't been diagnosing CO PD any earlier. We're still diagnosing it usually at around an average age of 65. We equally so over the last 20 years, haven't improved our earlier diagnosis of heart failure that's still around the age of 74. That's the average sort of age. And so certainly a patient who's had CO PD for a number of years, it should be high on our agenda thinking has this patient also got heart failure and anyone with heart failure, please just think about um the likelihood of CO PD because remember, it's a story with no beginning and it becomes a way of life. People may have coexisting problems there. Diabetes is more common erectile dysfunction. We know a very early sign of um cardiovascular disease, common osteoporosis. Again, much commoner than the general population. And key points to remember about that is people who smoke are more prone. People who don't exercise a lot are more prone. People who have steroids are more prone to osteoporosis, all those factors and possibly even the CO PD itself uh increase our risk of osteoporosis. Anybody with CO PD who um has been seen with a low impact fracture, fractured radius or their hip really, in my view, should have a quick significant event review from the caring team to say, ok, um be it a hospital team or a primary care team. This patient's got CO PD. We know that osteoporosis is common. Did we put ourselves and our patient in a position to think about osteoporosis? Give them prevention. If it was I if, if it was important, advise them of the risks, there will be some patients who will still have those fractures, but we should be thinking prevention as well. Next thing on our little target list incontinence. Um A lot of postmenopausal women have symptoms of incontinence. But what was surprising to quite a few people was the number of patients who are men as well who often get uh urinary incontinence, cough incontinence when they're, when they're coughing and, and straining. And this was up to about a third of patients in both men and women. I think often the men keep it more quiet than the women. But something to be aware of if you're reviewing your patient and think cataracts, think vision glaucoma can technically have an increased intraocular pressure. So the pressures in the eye can go up a little bit from use of the anticholinergics, like long acting long acting muscarinic antagonists, tiotropium, et cetera. Um very rare to get that. But also um there is an association of cataracts with um use of topical uh sorry, inhaled corticosteroids. Um and, and a recognized increased prevalence there equally. So, cataracts occur with oral steroids as can glaucoma. So lots of predictors that make things worse. One thing that I haven't put on the graph but I should have done is um rhinitis. A lot of my asthma colleagues say, oh, most of my patients with um asthma have rhinitis as well because it's the same airway. And if you've got allergic asthma, you're much more likely to have allergic rhinitis. John Hurst, a professor in London has done some studies again, published about 10 years ago and found roughly 75 to 80% of people with COPD have concurrent rhinitis when they, we talk to them about it. And it's a similar rhinitis to the CO PD itself. So it's not an allergic basis behind it. It won't, doesn't get better with the inhaled nasal, sorry, the intranasal steroids we use there. Um but it might get better with anticholinergics and so just be aware of our patients presenting with those that's giving you a holistic idea about patients with CO PD. And one of the things that is exciting in the respiratory world and and cardiology world at the moment is the research showing that people who have an exacerbation of CO PD. And if you look on the graph that's there, the events and on the um hazard ratio side of that are showing the likelihood of a nonfatal cardiovascular event or any cardiovascular event including death. And you can see that after an exacerbation, the risk is greatly higher, hasn't ratio much higher up as time goes on, even up to a year, they are still more at risk of a cardiovascular event following an exacerbation, exacerbations matter. And one of the things that we perhaps again should be thinking about should be around how we manage those patients. For those of you who are practicing in Britain, you will be interested to know there is a cure risk for. Now, they're really difficult. You can see each of those little lines is a risk factor that you would have to analyze to work out that patient's overall um cardiac risk. So about 25 of them that's gone up from the Q risk three published about five years ago, which had about 18 and from Q risk two, which is about 14 or 15. Um At the moment I'm aware in a UK practice, most of us can automatically click a button and get AQ two, which is good for most patients. It's harder and you have to do it manually to do Q S3. And Qs four hasn't been um put into a man even a manual system to calculate risk as yet because it was only published um 334 months ago. Um But the reason why I put up the key risk for that is that CO PD is in it for the first time. And CO PD is showing quite a significant risk or hazard ratio for cardiovascular disease. Um, and if I magnify that up a little bit, you're seeing that uh the risk of a patient having cardiovascular disease with CO PD is much greater than it is with rheumatoid arthritis or migraine. Or indeed, it's roughly the same as renal failure and in the same sort of bracket as type two diabetes. So type two diabetes, I think we think, oh, think about heart disease. CO PD should be exactly that same thought. Um And hopefully that's a, a good reminder for those of you working in other countries who don't have Q risk and one of the issues in other countries is, um, a, it's not been validated outside the UK, although it's likely it's going to be very similar. Um I'm aware that you, you'll often use an American cardiovascular risk score or the Framingham work. It is worthwhile trying to do that. One of the things that I'm just gonna touch on before we move on from that though is I said average age of diagnosis for CO PD is 65 and most men will have AQ risk or a 10% risk of a cardiac event within the next 10 years. By the age of 60 virtually every man, man and virtually every woman will get to that level by the age of 74 most of our patients with, uh, certainly the men should have been assessed for their Q risk. Or please think about doing AQ risk or a cardiovascular risk if you're outside the UK to check and help to improve the patient's survival rate from something that can be uh preventable to an extent. How do I manage a patient in clinical practice when they come in? And probably what I'm gonna recommend is keeping it nice and simple. Um The, the acronym here dose er comes from er Rupert Jones and colleagues again from a primary care setting and is now considered to be the best composite index of severity in CO PD. Um talk it through this near the more breathless you are often the worse your outcome that was shown in the, the research that Rupert and colleagues from around Europe did in America, the F EV one that's the obstruction ratio. So F EV one being low meant that the patient was more likely to die. Someone who continued to smoke. That's the essen dose again, higher risk and exacerbations more exacerbations, more risk of death very quick and easy way when you're evaluating a patient, when they come in as to what the risk is um to do an F EV one, I use a microspirometer that takes the same time as it takes me to do a peak flow in a patient with asthma to get that F EV one reading. The other ones are quite quick. There are other things like cat scores and more complex scores that are available. But actually this is quite well validated to pick out those that are more likely to be admitted, have a lower quality of life and are more likely to die. Indeed, this was the, the systematic review published two years ago. Um suggesting that the recommendation from gold which is a secondary care based B index should really be replaced by dose because dose picks up emissions exacerbations, quality of life, not quite as good as mortality, but better on all the other factors. And that uh for your interest bode it should have been done in by nice for anyone who's seen in secondary care. We should have been expecting a body mass index, obstruction, dyspnea and E in this. So B is body mass index O is obstruction, D is dis near like the don dose E is a six minute shuttle walk test. But I don't see many of those actually being following the the nice or gold recommendations. Um move to dose straightforward in primary care and secondary care, better predictions. The other things we should be thinking about when we review a patient and I know that a lot of us nowadays are using um templates. So makes it a lot easier. That's why I'm not trying to give you lots and long lists. Dose is easy to remember. The other thing to do is check their inhaler technique. Can they actually use it? And are they using it? So are they actually picking up the prescriptions and then think about other treatments and interventions that we might want to get involved in? So hopefully get that quite simple as what would be, what would a structured review look like? OK. Moving on when I see a patient with CO PD and when we see them and again, this is similar cross boundaries, what are the, what is the best triple therapy I can give, well, the best triple therapy would be one to offer them smoking cessation, support two to give them vaccinations. I'm quoting this cos this is what it says in the nice guidance. But nowadays, we would add in um COVID vaccination and probably this year it'll be R SB as well. And in some countries, pertussis is being encouraged. Um in all patients in that, in this sort of age group, the third part of triple therapy after immunization and help with stopping smoking is pulmonary rehab, a constructive way of giving patients information about their disease. And um, a structured, um, exercise with supervision. The other two non pharmacological er, options are around again, optimizing comorbidities and helping the patient to understand where to go. A bit like asthma, a bit like diabetes, personalized self management plan. So they know what to do if things aren't going well and this should be done every year. Quick check. Unfortunately, smoking is an issue around tobacco dependence and often people with tobacco dependency, run a fluctuating course, they can stop for a while and then they relapse and then they start again. Uh and then they're encouraged to stop, they manage to stop, but it there's that risk of relapse. So please just keep quite, quite gentle check. Doesn't need to be more than that. Let's get on to the medication treatments now and again, the medication treatments are very similar between both the advice that uh the National Institute of Clinical Excellence nice suggests and the global obstructive lung disease gold suggest. First key thing to remember is if that patient has asthma as well as CO PD or they have asthma features like very higher Sinop count, lots of variation but not going back to normal with their um spirometry or peak flow. Then it's certainly worthwhile thinking about an inhaled corticosteroid definite as asthma treatment for asthma. It's an inflammatory condition, inhaled corticosteroid. Yeah, this is a slightly more complex slide, but I'm gonna walk us through that in terms of what about the next treatments for um CO PD. Traditionally, we've started off with um Ventolin or Ipratropium. So salbutamol or Ipratropium for use as needed that is still in. But most guidance now says if the person is limited by symptoms increase, virtually all of the patients I see are limited by their CO PD. If they're not, they're not exercising hard enough. I tend to exercise harder. The few that aren't needing that are people who've had strokes are very disabled, multimorbidity in residential care where they're not able to exert themselves strongly enough to get particularly breathless, but a normal person who is pottering around, I want them to be exercising more and therefore, I will need to give them more treatment to reduce that. Um That symptom of breathlessness for someone with asthma. The guidance seems to be talking about labor and I CS. So inhale corticosteroid again. But for the rest, if your system will cover it and that's pre true for most of Europe. Um A Laba Lama combination is better than a lamma alone. And that's because a, a lamma and Alaba in combination, reduce the exacerbation rate more and bronchodilate better. So what we're doing for our patient is saying, here's the best bronchodilator we've got, let's give you a Laba lama early on and get you out and about. We want you now to start exercising more, we want to give you the vaccines and we want to encourage you to get really push your lungs get them fitter, get yourself fitter cos that will help. We're not gonna be saying, well, use a blue inhaler. Then again, use it in another couple of hours if it's not better and then another couple of hours um or saying I'm gonna give you part of the bronchodilation and then perhaps I'll give you the other bit if you come back in a few months and make it even better. Give them the best bronchodilation. We've got early on, all of the combinations are very similar in the way in their action. Um The thing that might be more controversial at the moment, but many parts of the UK have changed. This is on the asthma side. Now they say we should maximally bronchodilate like we would for anyone with C APD but give them a steroid. So the asthma change from nice in places like Wales, the Southwest, the Northwest. Um Most for locally now are suggesting asthma features with CO PD lama laba and an I CS together. So that would be triple therapy for patients with no asthma features if they exacerbate, move to triple or if they've still got symptoms, trial of triple for three months seems to be very sensible and that's the quickest way I can sort of um advise on on the on the treatments there. But hopefully that makes sense. So a long acting muscle and laba as your baseline stepping up if you need to or if you've got asthma features, keep it as simple as we can. But while we're doing that to keep them en encouraging them to be active. So that's the sort of review bit done. Let's think about exacerbations. And the first thing to do is think about what is an exacerbation and how do we manage it and what does it mean? Well, first thing is that most patients will have an exacerbation within a three year period of the followed up. That's John Hurst's work. The second thing is definition wise, we've normally used the definitions below which is mild variations in symptoms and mild exacerbation. You just increase your bronchodilator first step for the first few hours of an exacerbation, more saber or short acting muscarinic if you require an antibiotic or an oral corticosteroid or both, that is termed a moderate exacerbation. And if you turn up at an A&E department or go into a hospital that's considered severe, uh that does depend on systems. I think everybody involved in CO PD research is aware that quite a lot of the patients who go into a hospital aren't anywhere near as severe as the moderates managed in primary care and some of the moderates are more severe than severe in hospital. So that sort of mix goes on. But this has been used to try to just highlight severity and certainly those that go into hospital who require a noninvasive ventilation. That isn't the sort of thing we can do um easily in the primary care setting. Those that require steroids and a little bit of nebulization or use of a spacer with the drugs in potentially could have been managed. But quite a lot of that is quite an anxiety provoking situation. The key thing to think through with um an exacerbation is every exacerbation results in a a reduction in your forced exposure volume. It drops down quite markedly over the first week where the red um lightning bolt is and it slowly picks up, but it never quite gets back to the pre exacerbation levels that you see in, in the graph there. This was, this is a post hook analysis of um a large trial linked in with uh bronchodilators, but people losing around 50 mils of their feb forced expiratory volume when they have an exacerbation. And that was the overall average for patients in the study. Further work has shown that people with mild disease, you lose a lot more than that 15 to 20 mils. They're losing 80 mils on that first exacerbation and much more down to the twenties uh when it's a moderate exacerbation and severe. So when they've got very severe disease, they've got very little lung function. They don't lose as much each time. But mild patients are losing a lot more lung function than those with moderate or severe disease. That severity defined by that F EV wall. Other things to think through when somebody comes in with an exacerbation. Number one is um a patient coming in to a hospital setting with an exacerbation has a 90 day mortality rate twice as high as someone who's had a myocardial infarction. So somebody in hospital with a myocardial infarction, somebody in the hospital with CO PD. The patient with CO PD has double some around about 12 to 14%. The mortality rate of a patient going in with a heart attack needs to be treated seriously, heart attacks 5 to 7% sunny Souza's work. The first graph shows f from the first exacerbation, there's quite a delay before the next, but the one after that gets a bit closer, the one after that a bit closer and that goes on and on. And that's why we see people escalating up and having more and more exacerbations with reduced time in between each one. The second graph was quite a long term study done by Sola Cataluna and colleagues in Spain, looking at people who didn't exacerbate, that's the yellow line where the five year survival rate, the bottom graph is saying months at 60 the probability of surviving is 0.8 or so five year survival rate of around 80% for those who have one or two exacerbations a year that drops to about 50 it's down to 30 or so for someone who's had three or more exacerbations. So, exacerbations do matter equally. So, and this might be worthwhile reflecting on the people that you see lots of exacerbations in patients. The average in those seen in the major trials under specialist care. The average number of exacerbations per year is one that seems to probably you think that's pretty low. I've done this qu questionnaire quite a few times. And most of my A&E colleagues say, oh, probably seven or eight and a lot of my respiratory colleagues in the specialist environment say 7 to 8 GP colleagues say three or four practice nurses say two. I think that's because certainly in the UK, the practice nurses deal with all the routine and do review them and we get a increasingly skewed uh group of patients who turn seem to turn up more with these exacerbations requiring treatment. But when you look at the most of those big studies done over quite a long period of time, an awful lot of those end up with only one exacerbation per year. How do we manage it? Well, first thing to bear in mind is an exacerbation usually lasts between about 11 and 14 days in the first few hours. Think about just saying just use a short acting beagon. Don't start after four or five minutes with steroids and antibiotics. Virtually all the research started antibiotics and or steroids at 2 to 3 days or longer. So people weren't being initiated immediately, they had a snuffle or they coughed twice. Um And so that's worthwhile just bearing in mind when someone's coming in and saying I've had this for an hour and a half. Can I have treatment mentioned that they usually last 11 to 13 days? Some are a little bit quicker. Some will take a bit longer. And if you look at the two graphs, um you'll see that numbers in days is 1530 4560. There are quite a lot of people whose symptoms will last for a month, sometimes up to six weeks after not so many after that time, but a month to six weeks is not uncommon for someone who's had an exacerbation. That's important when we get to the, the parts of, of how long do we keep treating for dose, the dose of steroids and antibiotics in m in the nice in the Gold Guidance um is all now at five days and that's the same in the Cochrane review. So prednisoLONE 30 mg for five days. Um an antibiotic for five days too. There was one big trial in Switzerland with prednisoLONE 40 mg. Um But the rest of the, the really successful ones have shown 30 mg daily for five days is as good as longer courses. Indeed, 14 day courses increase risk to patients when you do a randomized trial, makes people more likely to have problems with a longer course of steroids. One of the things quite a lot of our patients do is they come back and say um I've had my treatment. Thank you very much. But I'm not better yet. And this is probably one of these areas where, um I think good, if we want to be good clinicians, we can. Uh And I know that virtually everywhere in the world at the moment we are under tremendous pressure following COVID. Um A lot of that time, remember the normal recovery. If someone says a week in, I'm getting a bit better, but I'm not better yet. That's great. Good. You're on the right track. That's what I expect from my, the, the treatments that we've given you, we're not gonna give you any benefit from a longer course. Indeed, we might make things worse and we're certainly gonna make you worse with longer course of steroids. So let's not just keep doing them if you're, if you're starting to improve. Now, if you're not improving at all or you're worsening in a week, it's probably worthwhile bringing you in for a clinical review or if they can't come in arranging for someone to see them at home. Reason behind that is quite a few studies looking at patients who have had a course of antibiotics and steroids in COPD and aren't better in the worsening and end up in hospital. A lot of those have proper pneumonia or upon the emboli. You can see the list there costing with the lung, bronchi access effusions, heart failure, af they need examining, we won't pick up ap the emboli or a pleural effusion or a heart failure or af by giving them another course of steroids, if they're just requesting another few days, getting worse must be seen again. Hopefully, that's given quite a, a hint on how to manage exacerbations in a more successful way. I know I'm going through this quite quickly and we've got a bit of time at the end for questions, but it's to try to get people into that mindset of saying, OK. Is this a genuine exacerbation the patients had? And if they've had the treatment D is there any good indication to keep going with, um, steroids and antibiotics if they've had them and they're getting better? No, there isn't. It's worse. Um, let's move on to deconditioning and then I'll close the show down and we can have a, a chat about things. Nice little thing here about keeping our co PD population active and finding that people who are more sedentary are much more likely to end up in Ed or hospital. People say that's because of, um, because they've got more severe disease. In actual fact, a lot of these people that F ev one, their lung function is identical to quite a few others that are able to do a lot more exercise have been more to been cajoled, more and prodded and encouraged to take exercise. And that, that is probably one of the key things we need to be thinking about as we move forward because if we go back to the COVID times where people were told to stay home, stay safe, save the NHS. There were three big conditions that we should have predicted and didn't particularly predict. Well, though one is the isolation and loneliness. If you're stuck at home, not being able to go out, another which we're still seeing to an extent is that fear and anxiety of getting an infection. And the final big one was a lot of our patients who might go out to take their dog for a walk, but neighbors now take them to keep it safer for them and their shopping is brought to them and they don't go down to the corner shop to collect their newspaper, um or go out to visit friends and have a coffee that deconditioning has had major impact. And that's one of the I issues that's probably worthwhile just chatting through in a bit more detail. A patient who is admitted to intensive care and say is ventilated for five or six days. Um Now just think about that. That is they're completely sedated. They have a ventilator going, their arms and legs aren't working at all. We're doing it for them. It's the severity is usually worse if it's an infection compared to trauma. But most of these are gonna take about a year to get better. So intensive care infection certainly be something like CO PD or other things. Often it's gonna take a year of determination to get their activities back to where they were before of daily living, getting dressed, washing, bathing and going for a walk. It's quite hard if you're 80 you've been in intensive care to get yourself motivated over the next year to push it so you can get out and about. Um, but hopefully if you can persuade your patients, that's worth it. We probably don't see huge numbers of patients in the intensive care, but we see a lot of patients who've been at home for a week and two. I'm, I'm not really well enough to come out now. Um And just note a week of inactivity reduces muscle strength and that's in the home environment reduces muscle strength by 12% and 3%. It's virtually 50%. Sorry, three weeks in hospital with bed rest, you lose almost 50% of that muscle strength that takes a long time to get better. And although there are a number of measures that hospitals do to um try to promote physical activity within that environment. Um I think with the current resources and paucity of physios around II, think often they tell me they're losing the battle with that, but that means we're getting patients coming out who are very unfit, made worse by their resting at home. And one of the issues around that is deconditioning because your muscle less weak, your proprioception goes a bit, you're more likely to fall fractures if you are less fit. And this is the the converses. Um some of you will have seen in the sportsmen medical journals. Um If you're unfit you, your mental health is much worse. Definite in um increased risk of infection. Prehabilitation was talked about pre COVID to try and get people fit so they could fight off infection better and plenty of evidence around respiratory cardiac outcomes. The other groups there again, well proven, lots of good evidence why deconditioning is a major problem for society. And that's what Darsy in the UK. Lord Darsy has highlighted in his review of the NHS. He says we've been underfunded in our health service and we've been under great pressure with the weights um from a specialist element and from recovery from COVID. But actually the population's health has deteriorated quite a bit. One other thing I thought might be handy just to reinforce that idea of um activity being important is exercise, exercise. And here it's walking or jogging or yoga or simple strength exercising or tai chi being significantly better than standard treatment for people with depression making big differences. The if you look at the graphs, what the green is saying, if it doesn't hit the red, uh sorry, the the orangey pink in the middle, that's showing a clinical benefit for the different types of excise, all of which look pretty good. The bottom one of that list is SSRI uh serotonin reuptake inhibitors. That's a traditional medication. And it again, it shows no significant difference when compared to normal mental health um treatments, these are a big add on to somebody who's feeling low. So I hope I've um challenged a few bits of thinking, helped you to think a little bit about the care that you're given and perhaps helped you to encourage you that a lot of these steps can be easily done and make things better and hopefully what I can do at the end of that. Now, when I get back to here mesmerizing as always. And just to let you know, there's over 200 people on the call listening live, which is just amazing numbers. Um, some comments coming in already, please do fire any questions you have into the chat and we will try and answer as many as we can in the next 1415 minutes or so. I'm going to start with Jack Jack picked up on the comment you had made about, um, smoking, stop smoking being the only treatment. But he has asked, is it true that the most effective treatment for CO PD is smoking cessation? Um I don't think that is true anymore. I think all of those have good evidence. Um And when you're looking at an individual rather than the population and the, the evidence isn't there that smoking is as good as pr or worse, cos people haven't done those trials, but most of us will have seen a patient who's come in and said, I'm continuing to smoke cos my mother smoked till she was 100 and 35 and then they stop. A lot of people can stop, but it doesn't necessarily predict a better outcome. Probably the best one for predicting better outcomes actually is the pulmonary rehabilitation side of it. Um But still smoking cessation, really important, quick tip on that smoking cessation. You should give advice within about 30 seconds. Maximum, anything more than that, you are letting people go down. Uh, and, and it's harder and you get into a fight and most clinicians have been in that battle where they say, uh, I'm really cross, that patient won't stop. And the patient's saying, well, you just leave me alone. I'm where I am and I've got to keep smoking, smoking cessation brief advice available online, National Center for smoking cessation training, free, takes about 20 minutes, trains you to be able to give smoking cessation advice to populations that know it might be bad for me. Like most adults in the western world within 30 seconds. Do you smoke? Yep. Good. That's all I need to know about that. I don't need to know more. Um, do you know the most effective way to stop smoking is with professional advice and the medications we've got available, that's your second line or whatever you want with that. Um, we've got medications and professional support that will help. And the third one is, would you like me to refer you if they say not at the moment. Thanks. Say that's fine. Perhaps talk about it next time. That's all it takes. And you're not getting into the conflict about why they have to smoke. You're just offering the best way to stop proven evidence. Good. Really interesting. And there was a comment came through there. I'm going to jump down a question because it came um in relation to this about some treatments being undersold. Someone had said about um the pulmonary rehab service being undersold. And Stephanie has mentioned in the questions about thinking that vaccination being undersold to CO PD patients. What are your thoughts about those two factors, Steve? Yeah, I think, I think that's why I said the best triple therapy for CO PD is vaccination. Um pulmonary rehab and smoking cessation really important vaccinations. Again, we have really good evidence for um the science behind vaccinations is coming on in leaps and bounds. You'll notice that some vaccines we only give once because it's only needed once and the um ability of the body to maintain immunization against that is better. You remember during COVID, we actually vaccinated twice in one year to keep the antibody levels higher depending on the response to the body and that sort of science is going on. But vaccinations a really good way of helping to reduce disease severity and reduce risk for patients with long term lung conditions. Really helpful. Thank you. Um Anita has asked, can a nonsmoker get CO PD, when should it be suspected? And what other causes are there? Maybe I know we have a session on diagnosis but um maybe a brief comment. So yeah, that, that is covered a bit in the one on uh the diagnosis. But about 90% of smokers, there is some evidence that biomass fuels in countries where they cook in the house where there's no good ventilation and Children are exposed from very young age, both have a lower lung capacity and are more prone to co PD. Quite a few cultures, people don't smoke cigarettes but they smoke Hubble bubble pipes, water pipes and a water pipe is worth about 100 to 200 cigarettes per pipe. They might not think they're a smoker but they are some people who smoke, smoke heroin, cocaine or cannabis and don't see themselves as smokers that can do even more damage than tobacco. Um So those so be wary of that. Is it really smoking? And the final one on this is when, um, two or three studies looked at patients who were admitted to see, um, to hospital with C APD and didn't have any smoking history. 95% of those were asthma undertreated asthma. Big trial in um, the I think it was us where lots of patients studied over 1415 years and they showed that people who don't adhere to the medications are much more prone to get CO PD if they're treat, taking treatment for asthma. That's really interesting the overlap there. Um There is a recurrent question um that has came in to the chat a couple of times and again, I do believe it's more diagnosis related, but because people are asking it recurrently, are there any studies linking vaping to CO PD or is it too early to decide that's come through a couple of times, Steve? Um Just before COVID, you might remember something called. Um, there was a lot of patients dying in America from pneumonia linked to vaping that turned out to be people making their own Vape solutions and cutting up cannabis into it. So there is a risk there. Um The evidence behind carcinogens in smoke comp compared to carcinogens identified in vaping is much lower in vaping than smoking, but putting high temperature air into your lungs isn't a normal factor. Um, so that people are really concerned in the long term. No brilliant studies at the moment, the jury is still out. But yeah, I think there's a little bit of debate going on about water pipes, water pipes, 100 to 200 cigarettes um published in the, er European Respiratory Journal. And there was also a tobacco control article with the science behind that. Really interesting. The jury is out, the jury is out um in terms of management is co PD curable or just manageable. Lovely question. Unfortunately, I've got some bad news for everybody here. Life is uncurable. We are all gonna die and people with diabetes, it's not really curable, but they're gonna die too. And people with heart disease and arthritis, in fact, babies are in, once they've got big baby, you're incurable. Is it? So life will move on. Is co PD necessarily progressive and aggressive and taking your life earlier? No, a lot of people if they're well managed can have a static lung function can maintain. There's a considerable number of patients who are at least running 510 Ks with Co PD. And there's um co PD marathon man, if you want to look him up on the internet, who's doing distances that make me feel a little bit queasy. Um But the, the concept behind that is CO PD, we can, we can manage it like we can heart disease, like we can um diabetes, we can make a big difference to patients lives with getting the basics, right? Really interesting. Once again, um a question regarding other management, apart from medical management, which COPD patients, would you refer to pulmonary rehab? Right. Um So the I'm gonna give you, I'm gonna give the technical line which is in most of the guidance globally and in Britain is anybody who is MRC three in the UK that is uh walking 100 m or less with um at a less than normal pace, but virtually all the guidance as well says or is functionally disabled by their CO PD. So I use the excuse of telling the patients if you can't do exactly what you want to do, you're functionally disabled. I refer to pulmonary rehab because so many patients who get pulmonary rehab, say it really helped them. It's, it's helping them to be motivated to make a difference, to be able to do that. I've seen patients who could walk 4, 500 yards ending up walking up the highest, um, hill in, um, Wales up Snowdon after about a year of work, um getting themselves fitter with severe CO PD. Just think let's get our patients healthier, better conditioned, that will reduce their risks of heart disease. That will allow them to enjoy playing football with their grandchildren if they like football. Um, it, it gives them a chance to have a good life with it. Sure to tag off the back of that. Um, Steve, I'm going to ask what Rosette has asked about that. Um, MRC scoring and we're kind of stratifying people into treatments. How reliable do you think that is in terms of patients fitting into categories? We're kind of boxing patients up, aren't we? Yeah. Um I think two things with that one is, it's been, it's been shown to be reliable with other parameters, like do os in risks of quality of life and admission and exacerbations and death. So it is worthwhile if you want to sort of get an idea on that. But yes, patients vary a bit in, in their symptoms equally. So we all know that some people appear to feel more breathless when they come in and you can't really work out why and others um are tremendously breathless, but they don't seem to be troubled by it. So there is a functional element behind it. A lot of the MRC, the Medi Medical Research Council's documentation is about your ability to walk a certain distance without being symptomatically affected. And that's quite a useful thing so that if you're asking your patients and that I do in, in the clinical environment, how long does it take you to walk down to the local supermarket? They can give me a rough idea. And then in six months time, I can ask that again. And if they're saying, oh, I remember you asked me that last time. It took 10 minutes, then it's taking me three minutes. Now. You've got a good idea. They're getting much better with that. Mhm. Yeah, it's a good, it's a good comparative tool, I guess. Um Absolutely. I, we're going to spend the last couple of minutes talking about another theme that has come up in the chat quite a few times regarding rescue packs. Um So I'm maybe tied to two questions together, Steve if I can be so cheeky. Um, Stephanie has asked about what are your thoughts on rescue packs? And Mola has asked, should we give antibiotics in those rescue packs even if there's no evidence of infection per se right. Um Rescue packs were very much in vogue about 67 years ago. And what we found was patients were taking 1520 a year. Remember that bit of research hospital followed up patients average one per year. So something went wrong in the way in which we encourage patients to identify whether they were exacerbations or just variations. Um And so there was a bit of an issue with that equally. So there's quite a few litigation cases going on in the UK, linked to overprescribing and fractures or osteoporosis or diabetes or problems with multidrug resistant bugs in the chest that are making them worse because they give them too many antibiotics. So, if you're the prescriber, please be wary. If somebody's telling you to prescribe, then if it doesn't sound quite sensible or there's any hint that it's going wrong, just send it back to that person to do the prescribing. Let them be, it's their mortgage. Then if they're signing it, I don't want to, I don't want to have my mortgage stopped, uh, because I'm not allowed to work anymore. So that's rescue packs, rescue packs, a few patients will benefit. They'll know where, you know, they'll go away to another country, they'll know what to do in an exacerbation. They'll have, they'll use one every couple of years. It's fine. My suggestion would be never put it on a repeat prescription. Always review the patient after an exacerbation wherever that took place. Before giving out anything further. Um and be wary about the risks to your career by just prescribing them, but also to the health of the patient. Quick things on the exacerbations. Uh ex um number one steroids, steroids are really good for wheezy patients. And so, so some patients who have had both for one exacerbation, I might say, well, you're mainly wheezy. Why don't you just use the steroid next time? See if that does the job. Keep the antibiotic in, in case you need it, we can try and minimize it. They're onto the same thing. I don't want these treatments if I don't need them. Number one, if you come back and that patient um isn't wheezy but has um lots of discolored phlegm and fever and it's sounding much more permanent bronchitis that patient may, but without the wheeze that might person might benefit with an antibiotic without the steroid. So there's so some people will judge that and say, why don't you do that? You've got this as a backup to start in a couple of days if things aren't getting better. About a third of co PD exacerbations are triggered by bacteria about a third by viruses and about a third from environmental factors. So two out of three courses of antibiotics aren't gonna work. Um So that uh hopefully that's given a bit of a, a practical feel for what we can do in the real world. Very, very much so, and a couple of your other questions. Um Folks have been in relation to that and, and in relation to management of that in relation to drug or antibiotic resistance and, and repeat prescriptions of that. So I'm gonna, I'm gonna pass over a couple of them. Finish with one final question, Steve, if I can steal one more moment of your time. Um Joel has asked at what stage in management of CC O PD? Given tonight's talk has been about management of CO PD. Should a primary care physician be referring to a specialist colleague in respiratory medicine? Right? I think there's a number of times where we want to get our, our specialist colleagues involved. Um What we often have very limited time in a consultation and if this patient has uh anxiety and panic disorder and breathing pattern changes, they will benefit from respiratory physiotherapy. So that's one group. Um they've got COPD, but they're also not breathing easily, dysfunctional breathing. It used to be called, most people know, call it breathing pattern disorder. Um There's a group of patients who are very young and with quite aggressive disease, they may benefit from a specialist involvement. There are some patients who have three or more exacerbations and with those, if you have direct access to act scan, about a third of the UK has direct access. Two thirds don't as GPS get your CT scan to see if there's evidence of bronchi access. If not, you probably want to get the patient to wait to see the specialist who then will do the CT scan and then will see them back if they've got bronchi sis. But it might be easier to be sensible to cut out the middlemen and only refer them the ones they need. Um The final thing that's coming through at the moment is there are around seven different biologic agents um that are gonna be potentially coming online within the next three or four years. So there may be a big push like there has been in rheumatoid arthritis, like ulcerative colitis and the gastroenterological things and asthma to push patients with COPD who are having frequent exacerbations towards our specialist colleagues, two licensed at the moment not being particularly widely used. I think people are working out how to use those at the moment. Both of those seem to reduce exacerbations by about 33%. A third. Ok. Absolutely fantastic. Um Folks, I think in the interest of time as always with these talks could go on all night, but I am going to, I'm going to leave it there and say a massive thank you to Steve. Um There's some lovely comments coming in in the chat which you'd be glad to know about the quality of tonight's teaching and everything that we have shared together. Um Folks, I am going to pop up on the screen that that ever going QR Code um where you can get your feedback form for tonight. Um And at the end of the feedback form, your certificate of attendance as well. You'll see. I have popped into the chat there two links for our upcoming events um with colleagues, Doctor Christopher Dukes is taking us on the eighth of October just a week away on mastering shoulder pain management. And then just the week after that, Doctor Regani Tripathi is taking us on an update on dermatology management. Um So we really look forward to them. Um But can I finish tonight um on giving a one man round of applause on behalf of all 300 people who joined the call to Steve. And a great thank you for giving up your time. We look forward to seeing you again some time. Hopefully. Excellent. Goodnight folks take care and we'll see you on the next one. Goodnight.