COPD: Management of The Frequent Exacerbator

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1 SPRING 2013 Primary Care Asthma Program A number of primary care sites offering the Primary Care Asthma Program either have or are beginning to integrate COPD education as part of a broader Lung Health Program. In this edition, we feature an article by Dr. Denis O'Donnell from Queen's University, a world-renowned expert in COPD management as well as other COPD related topics that we hope you will find of interest COPD: Management of The Frequent Exacerbator The estimated prevalence of chronic obstructive pulmonary disease (COPD) in the general population is approximately 10%. It is predicted that COPD will become the third leading cause of death by In Canada, acute exacerbation of COPD (AECOPD) is the most common reason for admission to hospital Internal Medicine units and this has major economic implications. Exacerbation refers to a sudden and sustained worsening of the usual respiratory symptoms (dyspnea, cough and sputum) above the normal day-to-day variability, requiring an increase in usual medications or the use of additional medications. Currently, we have no biomarkers to confirm what is sometimes a rather tenuous diagnosis, based exclusively on clinical impression. The Importance of AECOPD Exacerbations, which are precipitated in the majority of patients by viral or bacterial infections, are important life events for patients with more Dr. Denis O Donnell, M.D., FRCP(I), FRCPC advanced COPD. AECOPD is associated with accelerated decline of lung function, increased activity restriction and reduced health-related quality of life. AECOPD requiring hospitalization is associated with increased short-term and long-term mortality, which incidentally, exceeds that of acute myocardial infarction. One of the most revolutionary developments in respiratory medicine in the past two decades has been refinements in non-invasive mechanical ventilation, which has reduced mortality in patients with AECOPD and acute respiratory failure by greater than 50%. While such patients are more likely to survive these lifethreatening events than ever before, they are at increased risk for future bouts of respiratory failure and require ongoing complex multi-disciplinary care.

2 The Frequent Exacerbator Phenotype Recent longitudinal studies in COPD populations have determined that some patients are more susceptible to recurrent AECOPDs (i.e. >2 per year) than others and that this susceptibility increases as the severity of airway obstruction increases. Patients with chronic bronchitis increased cough and sputum productivity for 3 consecutive months for 2 consecutive years appear to be more susceptible to recurrent AECOPD than those without. The single best predictor of future AECOPD is a previous AECOPD and can occur even in patients with moderate airway obstruction. Caregivers who encounter smokers who seek medical attention for repeated bouts of winter bronchitis must be vigilant that their patient may well be suffering from unrecognized exacerbations of COPD. This encounter presents an opportunity to confirm the diagnosis of COPD by arranging for elective spirometry and by initiating appropriate preventive measures. How Can We Effectively Prevent AECOPD? Our first task is to identify those patients with COPD who have a history of AECOPD, particularly those who have regular flare-ups (or lung attacks ) averaging 1-2 per year. Those who have previously required emergency visits or actual hospitalization for AECOPD merit special attention. All patients need to be instructed about the importance of early recognition and prompt treatment of AECOPD. The following are evidence- based recommendations for the prevention of AECOPD from the Canadian Thoracic Society. Effective treatment of AECOPD (characterized by muco-purulent sputum production) with first-order antibiotics and oral prednisolone (e.g mgs daily for 5-10 days) and intensified bronchodilator usage, should hasten recovery and delay the time to next AECOPD. For patients with advanced COPD, anti-microbial coverage against gram-negative organisms (e.g. the respiratory fluoroquinolones or amoxicillin-clavulanic acid) is generally recommended. For active smokers, every effort should be made to help them quit through regular counseling and pharmacotherapy when appropriate. Annual influenza vaccines are imperative and the pneumococcal vaccine (repeated once in 5-10 years) is indicated, as streptococcus pneumoniae remains one of the three main causes of bacterial AECOPD. Referral to a qualified COPD educator for initiation of a collaborative self-management plan, which has been shown to reduce hospitalizations and unscheduled office visits, is an important intervention. Basic instruction in proper inhaler technique is also a pivotal intervention which is often neglected. Action Plans the provision of a prescription for antibiotic and a short course of oral corticosteroid have been shown in selected patients to be effective (particularly if it is carefully supervised by a skilled health professional) in delaying the time to next AECOPD. Patients with moderate-to-severe COPD, who have a history of AECOPD, should receive a prescription for a long-acting anticholinergic bronchodilator and a combination long-acting beta-agonist/inhaled corticosteroid (i.e. triple therapy ), together with as needed short-acting bronchodilator. Ideally, patients with frequent AECOPD should be encouraged to engage in regular physical activity or, if possible, be enrolled in a supervised pulmonary rehabilitation program. Special Considerations Selected patients with COPD with recurrent AECOPD who have mucus- hypersecretion (chronic bronchitis) and moderate- to- severe airway obstruction, may benefit from prophylactic treatment with an oral antiinflammatory, phosphodiesterase-4 inhibitor (e.g. roflumilast 300 µg once daily) provided they can tolerate the gastrointestinal side effects. For selected patients with significant airway obstruction, who suffer recurrent exacerbations despite triple therapy, macrolide prophylaxis (e.g. azythromycin 500 mg p.o. three times weekly) may reduce the number of future AECOPD. Some patients with difficult to treat, recurrent AECOPD may require additional investigations to exclude the presence of bronchiectasis, recurrent aspiration or localized intra-luminal bronchial obstruction. Summary Exacerbations are important events in the lives of patients with COPD; they are known to increase morbidity and, in some instances, can be life-threatening. A careful history is needed to identify individuals who are at risk for recurrent exacerbations, so that they can be targeted for special attention and regular follow-up. Such individuals will benefit from structured education and participation in a collaborative self-management plan,

3 which will ensure the prompt recognition and treatment of AECOPD. Smoking cessation, annual vaccination and optimal foundational pharmacotherapy to maximize bronchodilation and reduce airway inflammation have all been shown to reduce the frequency and severity of AECOPD. Collectively, these measures together with rapid treatment of muco-purulent AECOPD, will improve associated morbidity and may actually prolong survival. Table 1: AECOPD Prevention Checklist Smoking cessation Vaccinations Self-management education with Case Manager and written Action Plan (antibiotic, oral corticosteroids) Regular triple therapy (LAMA + ICS/LABA) Pulmonary rehabilitation, activity promotion Consider PDE4 inhibitors or macrolide prophylaxis Abbreviations: LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroid; LABA, long-acting beta2-agonist; PDE4, phosphodiesterase-4. References 1. O Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk DD, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Kaplan A, Keenan S, Lacasse Y, Maltais F, Road J, Rocker G, Sin D, Sinuff T, Voduc N. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 2007 update. Can Respir J 2007; 14(Suppl B): 5B-32B. 2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease revised Rennard SI, Calverley PM, Goehring UM, Bredenbroker D, Martinez JF. Reduction of exacerbations by the PDE4 inhibitor roflumilast the importance of defining different subsets of patients with COPD. Respir Res 2011; 12: Albert RK, Connett J, Bailey WC; for the COPD Clinical Research Network. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011; 365: PCAP Welcomes New Provincial Coordinator: Sara Han According to the World Health Organization (WHO), lung disease will soon be the third leading cause of death in the world. Today, more than 2.4 million people in Ontario are living with serious lung disease and this number is expected to grow by 50 percent in the next 30 years. The Primary Care Asthma Program (PCAP), part of the Asthma Plan of Action, has just celebrated its 10 year anniversary. PCAP has shown evidence of decreasing ER visits for asthma by 50% and decreasing asthma attacks by 30% by implementing best practice for asthma in the primary care setting. I am excited to join this group to continue to promote best practice in chronic respiratory disease management in primary care for the future. Sara Han, RRT, CRE, B.Sc. PCAP Provincial Coordinator Ontario Lung Association I am a Registered Respiratory Therapist and coming from a hospital/acute care background, I have been in the frontline of exacerbations. I have always wanted to support the patient before they walked into the emergency room department to prevent them from going there in the first place. I followed this passion to obtain my certification in respiratory education (CRE) and have worked as a respiratory educator in various primary care settings (solo physician s offices and Family Health Teams). This has led me to where I am today, the new PCAP Provincial Coordinator at the Ontario Lung Association. Although I am not in direct contact with the patient anymore, I have a satisfaction in knowing that my role in implementing an evidence-based program throughout primary care in Ontario, will ultimately provide best practice standards to the patient. I envision PCAP to expand its standards throughout Ontario and be a leader in chronic respiratory disease care, aligned with the Ministry of Health and Long Term Care s health strategies to provide the best care for people suffering from respiratory disease in Ontario. I am excited for the next years to come for PCAP as we find ways to innovate and use technology to support PCAP to promote healthier lungs in Ontario.

4 SARA Dear Sara, The FHT I work in has decided to provide a respiratory health education program. I have heard about CAE and CRE designations. What is the difference and how do I go about becoming certified? That is great! The cornerstones of a good respiratory health education program are credible and knowledgeable providers and the Canadian Network for Respiratory Care (CNRC) helps to ensure this through national certification and designation. In order to be eligible to write the Certified Asthma Educator (CAE) or the Certified Respiratory Educator (CRE) exam, you must have a degree or diploma in a recognized health care profession, your scope of practice must include counseling clients, you must have completed a CNRC approved education program, and you must pay the required sitting fee for the exam. In regards to the CNRC approved education program requirement; if you would like to challenge the CAE exam, you must have successfully completed a CNRC approved asthma educator education program. If you would like to challenge the CRE exam, you must have successfully completed both a CNRC approved asthma educator program and a COPD educator education program or a CNRC approved respiratory educator program. Please see for more information and for a list of CNRC approved educator programs. at shan@on.lung.ca

5 Asthma and COPD Education: Much the Same But Different Asthma and COPD are very similar but also very different disease processes that educators need to remember. There is an overlap in the clinical features of both diseases, but we must remember that these are two distinct conditions and often care of a person with COPD is much more complex. Once our patients who have asthma have achieved good control of their disease, we know that they can go through most days doing the things they want to do and need to do with little impact from their asthma. However, with COPD airway obstruction is not fully reversible, so symptoms are usually fairly constant and progressive. Pamela Wilton, RN, CRE Although, our COPD population includes younger women than it did years ago, it is rare to be diagnosed in young adults. Once past the age of 55 years, the chance of having one or more chronic diseases increases every year for Canadians. It means that we must help patients with COPD manage with co-existing disease such as arthritis, diabetes, cardiac disease, hypertension and cancer. Depression and anxiety, common in people with chronic disease, need special attention to manage. It is essential to have an interdisciplinary approach to COPD management. Principles of adult education do not change, but our strategies and tools may need to change in COPD to accommodate those who may have more problems with hearing and/or vision. Cognitive problems present further challenges. On a positive note, often (not always) patients with COPD are no longer working and have more flexibility in terms of their time. They are often very well motivated to learn how to better manage their disease as they want a better quality of life. Greater access to information helps many to be better informed about their own health, standards of care, community resources and choices of therapy. Educators can provide assistance to navigate the health care system, helping patients to know when and how to seek care appropriately. We must remember that frequently our patients with COPD are the sole caregiver for a spouse or other family member, in their home, who has even more health problems. Fixed incomes, transportation difficulties and limited support systems may become barriers to education. We must be alert to this and work to facilitate access to education and follow-up that makes sense for each patient. Getting to better understand and know about their socio-economic situation and working to assist them, as appropriate, can increase their ability to learn and better manage their own health. Fortunately, PCAP encourages follow-up. Follow-up gives educators a chance to evaluate changes, to enhance skill development, to adjust care plans, and to understand how well patients have been able to utilize what they have learned to reach their goals. More importantly, it gives patients and educators a chance to develop a rapport, working together to enhance knowledge and skills to achieve better health outcomes. So remember, while there are many similarities in asthma and COPD, there are important differences that educators need to think about and be prepared to adjust to meet the needs of both groups of patients. Fortunately, educators know how to do it and for those who are new to caring for individuals with COPD it will just take time and practice.

6 Community COPD Rehabilitation Program Somerset West Community Health Centre The Lung Health program, at Somerset West Community Health Centre (CHC), provides COPD care for a network of seven Community Health Centres and one Aboriginal Health Centre. The population served is over 80,000 people. If we consider that currently 4% of the Canadian population is diagnosed with COPD, there are approximately 3,200 people in our catchment areas diagnosed with COPD who could benefit from Pulmonary Rehabilitation (PR). The capacity of the Lung Health program, with current funding, is 250 unique clients per year. There are 36 PR client spots available per year, therefore; approximately 15% of clients who are followed by the Lung Health program can attend PR. This is better than the national average of 2%. Better, but still not great. A recent national report card issued by the Canadian Lung Association identified that most provinces could do better. Exercise is the predominant modality including muscle strengthening, endurance training (cycling or treadmill), breathing exercises, training for activities of daily living, energy conservation and a home exercise prescription. What is different about this program? Twenty-eight percent of the clients attending PR are still smoking. Clients may begin PR while using a reduction strategy to quit smoking. They are offered free nicotine replacement therapy through the STOP with CHC CAMH study. Experience shows that change is facilitated by supporting quit attempts, as clients begin to make change in lifestyle by exercising regularly. Regular exercise and physical activity are The Lung Health program at Somerset West CHC vital to clients physical and emotion health. COPD clients gain confidence in their ability to exercise and are supported to get started on a more active way of life. Community Health Centre Somerset West Community Health Centre 55 Eccles Street Ottawa, Ontario SWCHC Satellite Location 30 Rosemount Avenue Ottawa, Ontario

7 Ontario is improving care for seniors and others with complex conditions through Health Links. This innovative approach brings together health care providers in a community to better and more quickly coordinate care for high-needs patients. How will Health Links benefit patients? When different health care providers work as a team to care for a patient, they can better coordinate the full patient journey through the health system, leading to better care for patients. Health Links will help to ensure that patients with complex conditions: No longer need to answer the same question from different providers. Have support to ensure they are taking the right medications appropriately. Have a care provider they can call, eliminating unnecessary provider visits. Have an individualized comprehensive plan, developed with the patient and his/her care providers who will ensure the plan is being followed. How will Health Links work? Networks in Ontario Health Links will encourage greater collaboration between existing local health care providers, including family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, patients will receive faster care, will spend less time waiting for services and will be supported by a team of health care providers at all levels of the health care system. Health Links put family care providers at the centre of the health care system. By bringing local health care providers together as a team, Health Links will help family doctors to connect patients more quickly with specialists, home care services and other community supports, including mental health services. For patients being discharged from hospital, the Health Link will allow for faster follow-up and referral to services like home care, helping reduce the likelihood of re-admission to hospital. The 23 Health Links Networks that are currently implemented: 1. Erie St. Clair LHIN Chatham City Centre Health Link Coordinator: Chatham Kent Health Alliance 3. WATERLOO WELLINGTON LHIN Guelph Health Link Coordinator: Guelph Family Health Team 5. CENTRAL WEST LHIN North Etobicoke-Malton Health Link Coordinator: Central West Community Care Access Centre Dufferin Health Link Coordinator: Headwaters Health Care Centre 2. SOUTH WEST LHIN Perth County Health Link Coordinator: North Perth Family Health Team 4. HAMILTON NIAGARA HALDIMAND BRANT LHIN Hamilton Central Health Link Coordinator: McMaster Family Health Team 6. MISSISSAUGA HALTON LHIN South East Mississauga & West Toronto Health Link Coordinator: Summerville Family Health Team

8 7. TORONTO CENTRAL LHIN Don Valley/Greenwood Health Link Coordinator: WoodGreen Community Services East Toronto Health Link Coordinator: South East Toronto Family Health Team Mid-Toronto West Health Link Coordinator: Taddle Creek Family Health Team Partners include: o University Health Network (Toronto General, Toronto Western, Princess Margaret, Toronto Rehab) o Toronto Central CCAC o Women's College Hospital o CAMH (Queen Street, The Clarke, ARF) o Primary care providers: Toronto Western FHT, Women's College FHT, Mount Sinai FHT o Access Alliance Community Health Centre o Central Toronto Community Health Centre o Toronto Public Health o Anishnawbe Health Toronto o Centre Francophone de Toronto o And other community support services North Toronto East Health Link Coordinator: Sunnybrook Hospital 10. SOUTH EAST LHIN Kingston Health Link Coordinator: Maple Family Health Team Quinte Health Link Coordinator: Belleville and Quinte West Community Health Centre Rural Hastings Health Link Coordinator: Gateway Community Health Centre Rural Kingston Health Link Coordinator: Rural Kingston Family Health Organization Thousand Island Health Link Coordinator: Upper Canada Family Health Team 8. CENTRAL LHIN South Simcoe and Northern York Region Health Link Coordinator: Southlake Regional Health Centre North York Region Health Link Coordinator: North York General Hospital 9. CENTRAL EAST LHIN Peterborough Health Link Coordinator: Central East Community Care Access Centre 12. NORTH SIMCOE MUSKOKA LHIN Barrie Community Health Link Coordinator: Barrie Family Health Team South Georgian Bay Health Link Coordinator: South Georgian Bay Community Health Centre 13. NORTH EAST LHIN Temiskaming Health Link Coordinator: Le Centre de santé communautaire de Temiskaming Timmins Health Link Coordinator: Timmins Family health Team Submitted by Nancy Garvey (Senior Program Consultant at Ontario Ministry of Health and Long-Term Care) and reproduced with permission from the Ministry of Health and Long-Term Care. (Ministry of Health and Long-Term Care news releases December 6, 2012: About Health Links) and Ontario Health Links

9 Provider Education Program (PEP) Workshops June 26, 2013 Adult Asthma in Hamilton registration here: Dr. Chris Allen Presenting September 11, 2013 Spirometry Interpretation Renfrew/Pembroke venue to be confirmed stay tuned to for more information September 18th, 2013 Spirometry Interpretation in Hamilton at the Royal Hamilton Yacht Club 5:30 8:30pm registration available soon. September 25, 2013 Spirometry Interpretation North Bay venue to be confirmed stay tuned to for more information