Referring for specialist respiratory input. Dr Melissa Heightman Consultant respiratory physician, UCLH,WH, CNWL

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1 Referring for specialist respiratory input Dr Melissa Heightman Consultant respiratory physician, UCLH,WH, CNWL

2 Respiratory Specialist- who? GPSI Community Team Secondary Care Respiratory physician and MDT

3 Respiratory Specialist- where? Pulmonary rehab Community Clinic Home support Hospital OP condary Care

4 Respiratory Specialist- integration Community Team Secondary Care Minimise routine secondary care follow up and maximise support for self management

5 When to refer? Uncertain diagnosis Try to do as much as possible in primary care Community respiratory assessment may help. Consultant supported. Support for self management/ PR/ stop smoking (community) Mismatch between symptoms and assessment (secondary care?) Red flags: weight loss, haemoptysis, CXR (target referral) Unexpected findings e.g. restriction on spirometry/ CXR abnormality Markers of disease severity: respiratory failure, cor pulmonale, uncontrolled exacerbations Specialist treatment: Domiciliary NIV/ LVRS Palliative care

6 1. Uncertain diagnosis? Try to complete as much diagnostic work up as possible History, Quality assured spirometry, CXR, oxygen saturations FEV1 / FVC FEV1 % predict ed ATS/ ERS [2004] GOLD 2017 NICE clinical guideli ne (2010) <0.7 80% Mild Mild Stage 1 < % Moderat e Moderate Stage 2 < % Severe Severe Stage 3 <0.7 <30% Very Severe Very Severe Stage 4

7 Other useful tests Investigations Eosinophil count Full blood count BNP Serial PEFR/Pred trial Alpha 1 Antitrypsin Sputum MC&S and AAFB ECG Stop Bang / Epworth Sleepiness Role Support for atopy in asthma ( 400 cells/mcl) High end of normal (>200 cells/mcl)?ics in COPD Hb/anaemia Heart failure Repeat spirometry and symptoms review - Asthma Family history, severe COPD at young age/hyperinflation Frequent exacerbations/ bronchiectasis Cardiac causes OSA / hypoventilation

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9 ACOS? Asthma and COPD Overlapping Syndrome or COPD and Asthma ACOS If significant but incomplete reversibility If Hx asthma but develops fixed airflow obstruction? 20% of COPD population Implications for inhaled therapy

10 Uncertain diagnosis: Asthma v COPD spirometry (assess pre ICS) Asthma (NICE 2017) 1. >200mls or 12% response to bronchodilators [FEV1] 2. >400mls response to 30mg oral prednisolone daily for 2/52 (not NICE) 3. Serial PEFR showing 20% diurnal or day to day variability 4.FeNO > 40ppb COPD obstructed ratio on postbronchodilator Chronic Bronchitis No obstruction with symptoms 1. Sputum 2. Cough 3. Wheeze 4. Breathlessness

11 Uncertain Dx: Asthma v COPD v chronic bronchitis can be done in primary care Feature Asthma COPD Age of onset Under 20 After 40 Pattern of symptoms Variation over minutes Worse at night/ am Triggered by exercise/ dust/allergens Chronic cough and sputum Persistent symptoms despite treatment Past or family history Childhood or family atopy >20 pack yr smoking history Progression with time Seasonal Resolution with treatment Gradually worsening Only partial response to bronchodilators CXR Normal Hyperinflation

12 Restriction FVC <80% Extrathoracic? Explained by body habitus? Intrathoracic Lung pathology? Pulmonary fibrosis? Basal crackles (refer secondary care) Needs full pulmonary lung function testing? Gas transfer and lung volumes

13 Markers of disease severity: rate of FEV1 decline Normally lose 25-30mls in FEV1 per year from the age of 25 QA spirometry important (reproducability)

14 Markers of Disease Severity Unmanageable breathlessness despite optimisation of primary care intervention- community respiratory Very frequent exacerbations- community/ secondary care Concordance/compliance problems- community respiratory Inhalers/ rescue pack/ risk of adrenal suppression Housebound stop smoking support- community respiratory Respiratory failure (type 1 hypoxia, type 2- hypercapnia and hypoxia)- HOSAR/ secondary care Right heart failure- echo and?secondary care End of life support or planning- joint palliative/ community respiratory

15 Assessment for Long Term Oxygen Therapy (LTOT) Local Home Oxygen Service Assessment and Review New in Camden SpO2 92% on Room Air in a period of stable disease on 2 or more occasions 6 weeks apart CBG in patient homes Type 2 respiratory failure, consider domiciliary NIV

16 Patient Request

17 Lung volume reduction Both Endobronchial valves (Dec 2017) and surgery (2005) are NICE approved technologies Valve data in >1000 patients Outcomes convincing Anticipated to be part of new NICE guidance 2019

18 Endobronchial Valves One way valves Occlude airways of most destroyed lung Unilateral treatment Treat all airways in one lobe Allow air + secretions out, but not air in Aim is to collapse treated lobe

19 LVRS- Stelvio study NEJM 2015 FEV % Predicted; GOLD stage III or IV Emphysema patient with CT confirming Residual volume (RV) > 180% of predicted value, measured by body plethysmography Little or no collateral ventilation from adjacent lobe, as measured by the Chartis system Complete fissures, as analyzed by validated software program 19

20 Hyperinflation MDT Inclusion criteria Emphysema Severe airflow obstruction FEV1 15% < 60% Limited by breathlessness MRC 3-5 but >140m on 6mwt Quit smoking minimum 6 months Hyperinflated RV >180% TLCO >20% (or >15%) Optimal medical management (ideally done PR) Exclusion: TLCO <20%, Hypercapnia at baseline, not mobile, pulmonary hypertension

21 Minimum investigations CT thorax, 1.5mm max thickness Full lung function with volumes ABG results if any available Potentially useful investigations Echo VQ (but may be best organised post referral) MDT will arrange StratX analysis of imaging if appropriate

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23 How does the MDT work? Refer to CT thorax and PFTs will be reviewed If suitable anatomy for valves StratX analysis will be done MDT 6 weekly, 2 consultants, radiologist, surgeon Decide whether eligible patient Decide whether suitable for valves or surgery. Fissure intact/ anatomy VQ spect scan pre procedure plus echo/ clinic review Procedures done UCLH at WMS

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25 Summary Community Specialist Clinic Diagnostic uncertainty re airways disease COPD related concerns Frequent exacerbations Severe COPD A rapid decline in FEV1 Assessment for oxygen therapy Optimise therapy (stable and acute disease) and exclude inappropriate prescriptions Support self management Difficulty with compliance /concordance Second Opinion Barriers to pulmonary rehab Assessment for oxygen Secondary Care Diagnostic uncertainty- complex Respiratory failure- type 2 Assessment for lung volume reduction surgery Assessment for lung transplantation Dysfunctional breathing Difficult bronchiectasis Concomitant difficult asthma Suspected A1AT Red flag features e.g. haemoptysis Abnormalities on chest imaging Advance care planning Advance care planning