Shared System of Care COPD/Heart Failure

Transcription

1 Shared System of Care COPD/Heart Failure Learning Session 2

2 Agenda Introduction (35) Sharing Experiences(10) Medication (60, 40 didactic and 20 discussion) MOA Breakout Break (15) PSM Support COPD and AECOPD Management (30, 20 didactic, 10 questions) Heart Zones and other PSM tools (30, 20 didactic, 10 questions) Smoking cessation (10, 5 didactic, 5 questions) Sharing the care with the specialist and the referral process Planning for Action Period 2 (20)

3 Sharing Experiences (10 minutes)

4 COPD Management Case Presentation

5 A Case of Dyspnea 65 year old smoker Dyspnea Prior history of AMI Sputum daily but clear Intermittent edema 5

6 A Case of Dyspnea Postbronchodilator FEV1/FVC 48% FEV1 55% Echo 2 years prior showed EF 45% Shortness of breath has worsened in past week WHY? 6

7 Case continued Current inhalers include an lone ICS inhaler (Flovent) and short acting anti-muscarinic (SAMA) and short-acting beta-agonist (SABA) Has not followed up with you recently Renews her prescriptions intermittently Other Rx: rosuvastatin, Hydrochlorothiazide, amlodipine, metformin, daily ASA Exam reveals decreased breath sounds bilaterally, wheeze, Heart rate of 90, JVP of 4 cm, pitting edema to shins and BMI 36 How would you proceed with this case? ICS (inhaled corticosteroid), LABA (long-acting ß-agonist), LAMA (longacting muscarinic antagonists), 7

8 Why Might a Patient with COPD Experience Increased Dyspnea? Respiratory examples Progression of COPD vs AECOPD? Parenchymal? Pneumonia Lung cancer ILD PE? Pleural effusion? Pneumothorax? Cardiac examples CHF? Arrhythmia? Ischemia? Valvular decompensation? Systemic examples Anemia? Acidosis? Renal disease ILD (interstitial lung disease), PE (pulmonary embolism), CHF (congestive heart failure) 8

9 Case continued: Does she have symptoms of an AECOPD? dyspnea, cough, sputum or sputum purulence Is her dyspnea related to progression of COPD? Could she have worsening CHF? Could she have both? Could she have developed an arrhythmia? Rule out anemia Think: CARDIAC, RESP, SYSTEMIC 9

10 How would you optimize management of her COPD? 10

11 5 step APPROACH to COPD 1: Patient Registry Identification of Persons at Risk 2: Screening of Persons at Risk Smoking cessation COPD-6 or Spirometry 3: Confirmation Spirometry interpretation Assessment of level of disability 4: Management CTS guidelines for pharmacologic and non-pharmacologic treatment, ACTION PLAN 5+: Continuing Care Follow up, AECOPD management, Rehab, Co-morbidities, End of Life 11

12 Identification BE AWARE OF THE BURDEN OF COPD Canadian study showing 20% in persons >40yrs with 20 pk-yrs WHO IS AT RISK? Formulate a patient registry Identify smokers and ex-smokers in the practice Have smoking cessation tools and contacts at hand Bring patient at risk back for screening 12

13 Screening Screening for COPD requires SPIROMETRY, airflow obstruction not fully responsive to BD needs to be demonstrated Physical exam, X-ray, nor smoking history alone confirms the diagnosis COPD-6 is useful office tool for screening in suspected patients Differentiate from other airway diseases, and other causes of SOBOE Eg. Asthma, Heart Failure(HF) 13

14 Confirmation of COPD and Assessment of Severity Does spirometry confirm fixed airflow obstruction post-bronchodilator? Is the patient still smoking? Provide patient information about COPD How severe is the FEV1? How severe are symptoms and/or disability? 14

15 What constitutes Severity? Lung function Level of symptomatology Level of disability Co-morbidities Exacerbations and hospitalizations Systemic effects 15

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18 Management of confirmed COPD 1. Are they still smoking?* 2. How severe are their symptoms? 3. Have they had 2 or more exacerbations in the past year? (or 1 hospitalization for AECOPD) 4. Answers to the above determines the starting point for the management of COPD. 5. CTS and GOLD 2015 management guidelines AECOPD = Acute Exacerbation of COPD 18

19 Continuing COPD Care Prevention and Treatment of AECOPD Management of progressive symptoms Compliance and Medication Side-effects Pulmonary Rehab Respiratory Education Patient Self-management and Action Plans Re-assessment of lung function Management of Co-morbidities End of Life Care 19

20 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Goals of Therapy Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality Reduce symptoms/ disability Reduce future risk 20

21 FEV 1 (% of predicted) Symptoms Deterioration in Lung Function versus Symptoms in COPD 100 Severe Asymptomatic Lung function normal Lung function reduced Axis of progression Mild Adapted from Sutherland ER, et al. N Engl J Med 2004;350:

22 % of patients Association of disease severity with frequency and severity of exacerbations 50 Hospitalized for exacerbation in year Frequency of exacerbations GOLD 2 (N = 945) GOLD 3 (N = 900) GOLD 4 (N=293) 22 Frequent exacerbations defined as 2/year. Adapted from Hurst JR, et al. N Engl J Med 2010;363:

23 Number of Patients COPD: The Leading Cause of Hospital Admissions Today 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Single Hospitalization 1 Repeat Hospitalization 2 or More Repeat Hospitalizations COPD Angina Asthma Heart Failure Diabetes Epilepsy Ambulatory Care Sensitive Condition * *An ambulatory care sensitive condition is a condition that is normally manageable on an outpatient basis Data are for the Canadian population, excluding Quebec Canadian Institute for Health Information. Health Indicators Ottawa: CIHI;

24 Comprehensive Management of COPD GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%) 24

25 Smoking Cessation is the Single Most Effective Intervention in COPD The only intervention that slows decline in lung function Reduces mortality Reduces symptoms Patients benefit from quitting, irrespective of when they quit O Donnell et al. Can Respir J 2008 Scanlon et al. Am J Respir Crit Care Med

26 Model of Deaths Prevented or Postponed Through Risk-Factor Reduction 35,000 Study of coronary heart disease deaths in England Deaths Prevented or Postponed (N) 30,000 25,000 20,000 15, ,000 5, Unal B et al. BMJ 2005;331:614. Quitting Smoking Cholesterol Reduction Blood Pressure Reduction 26

27 Combined approach to Smoking Cessation Most effective methods of smoking cessation combine pharmacotherapy with advice and behavioural support 2,4 27

28 30-Second Assessment Do you smoke? Do you want to quit? Would you like some help? Ask yourself: Where are they in the Stages of Change/ Readiness to Quit? Assess CONVICTION; How important is it to patient (scale of 0-10)? Assess CONFIDENCE (scale of 0-10)? 28

29 Comparing Medications Medication Nicotine gum Nicotine patch Nicotine inhaler Bupropion Varenicline Treatment length 1-3 months 8-12 weeks weeks 7-12 weeks 12 weeks Main side effects Upset stomach Hiccups Headache Disturbed sleep Site rash Irritation of throat and nasal passages Sneezing Coughing Insomnia Nausea Dosage 2 mg, 4 mg 7 mg, 14 mg, 21 mg 6-12 cartridges per day mg/day 0.5 mg qd to 1 mg bid Effectiveness at six months or longer (OR [CI]) 1.66 ( ) 1.81 ( ) 2.14 ( ) 2.06 ( ) 2.83* ( ) Hughes JR et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2004; 4:CD Jorenby DE et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA 2006; 296(1): Silagy C et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004; 3:CD

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31 NRT Theory: Nicotine urges met by short acting NRT Ideal baseline nicotine level determined by dose of Patch Minimal baseline nicotine level 31

32 Vaccinations Prevent Acute Exacerbations of COPD Annual influenza vaccination Reduces morbidity and mortality attributable to influenza in COPD Recommended for all COPD patients without a contraindication Pneumococcal vaccination Give at least once Repeat a booster in 5-10 years with Pneu-P-23 (Pneumovax 23, Pneum 23 ) O Donnell et al. Can Respir J 2008; Paradiso Clin Infect Dis

33 All COPD Patients Should be Encouraged to Maintain an Active Lifestyle Patients at every stage benefit from exercise training programs Improves dyspnea and fatigue Increases exercise tolerance Be alert to reduced activity, which will mask symptoms Rehab programs shown to improve health status and reduce hospital WHO 2013; O Donnell et al. Can Respir J 2008 admissions 33

34 INHALERS 34

35 Poor Inhaler Technique is Common and Reduces Medication Effectiveness Patient-based barriers Physical limitations and comorbidities (eg, tremors, poor dexterity, poor vision, low inspiratory flow rates) Cognitive and mood disorders impairs ability to learn/remember proper technique Depression leads to non-adherence Language barriers Healthcare professional-based barriers Lack of knowledge regarding proper inhaler use Lack of training in effective educational techniques Omission of reviewing proper technique at each visit Omission of appropriate explanation of side effects Yawn et al. Int J COPD

36 Inhaler Mishandling (MDI) is Common and Associated with Reduced Disease Control Top 5 Inhalational Technique ERRORS with MDI Doesn t shake MDI in preparation No exhalation before actuation Actuation 2 nd half/end of inspiration Forceful inhalation, not deep/slow No 10s breath-hold post inhalation Percentage of user errors

37 Inhaler Mishandling (DPI) is Common and Associated with Reduced Disease Control Top 5 Inhalational Technique ERRORS with DPI Percentage of user errors HandiHaler Diskus Turbuhaler Inhalation not to TLC Slow, non-forceful inhalation Exhales into device before or after inhalation No breath-holding after inhalation Doesn t check for residual powder still in device post - inhalation n/a n/a 37

38 Pharmacotherapy in mild COPD Step 1: Start with a short-acting bronchodilator (SABD) prn Short-acting beta 2 agonist (SABA) or Short-acting muscarinic antagonist (SAMA) or Combination SABA/SAMA Step 2: If symptoms persist, add long-acting bronchodilator (LABD) Long-acting muscarinic antagonist (LAMA) or Long-acting beta 2 agonist (LABA) LABD, long-acting bronchodilator; SABD, short-acting bronchodilator. Adapted from O Donnell et al. Can Respir J 2008, CTS guidelines. 38

39 Pharmacotherapy in moderate to severe COPD Step 3: If symptoms persist, change to combinations bronchodilators Long-acting muscarinic antagonist (LAMA) and Long-acting beta 2 agonist (LABA) or Combination LAMA/LABA Step 4: If symptoms are severe and/or suffers frequent AECOPD Triple therapy with ICS + LAMA + LABA with Short ACTING beta 2 agonist (SABA) LABD, long-acting bronchodilator; SABD, short-acting bronchodilator. Adapted from O Donnell et al. Can Respir J 2008, CTS guidelines. 39

40 SAMA, SABA, and SABA/SAMA inhalers for COPD in Canada CLASS INHALER NAME BRAND NAME/ GENERIC NAME SAMA MDI Atrovent (ipratropium) SABA SABA/SAMA MDI/ DPI Diskus DPI Turbuhaler SMI Respimat Ventolin (salbutamol) Bricanyl (terbutaline) Combivent (salbutamol/ ipratropium) DPI, dry powder inhaler; MDI, metered dose inhaler; SMI, soft mist inhaler. 40

41 LAMA inhalers for COPD in Canada DPI HandiHaler/ SMI Respimat Spiriva (tiotropium) LAMA DPI Breezhaler DPI Genuair Seebri (glycopyrronium) * Tudorza (aclidinium) * DPI Ellipta Incruse (umeclidinium) * Recently approved (since 2012). Spiriva Respimat is also approved for reduction of exacerbations. 41

42 LABA inhalers for COPD in Canada LABA DPI Diskus DPI Aerolizer DPI Breezhaler Serevent (salmeterol) Foradil (formoterol) Onbrez (indacaterol) 42

43 Combination LABA/LAMA inhalers for COPD in Canada Fixed-dose combination LABA/LAMA DPI Ellipta DPI Breezhaler SMI Respimat Anoro (vilanterol/umeclidinium) * Ultibro (indacaterol/glycopyrronium) * Inspiolto (olodaterol/tiotropium) ** DPI Genuair Duaklir (formoterol/aclidinium) *** * Approved Dec 2013 ** Approved May 2015 *** Approved April

44 Combination ICS/LABA inhalers for COPD in Canada DPI Diskus Advair (fluticasone/salmeterol) ICS/LABA DPI Turbuhaler Symbicort (budesonide/formoterol) DPI Ellipta Breo (fluticasone/vilanterol) 44

45 Home Oxygen Therapy 45

46 Long term O2 therapy Indications Continuous (Grade A evidence) Resting ABG po2 < 55 mmhg Resting ABG po mmhg Cor pulmonale, Pulm HTN Hematocrit > 56% Intermittent (Grade B evidence) Exertion: so2 <87% for > 1 min Nocturnal so2 <88% for > 30% night 46

47 Respiratory Therapists and COPD Educators REFERRAL to Community Respiratory Services and Respiratory Specialist 47

48 Action Plans In COPD exacerbations: Patients often have little or no understanding of their symptoms, warning signs of an exacerbation and the specific action to be taken Difficulties are encountered in seeking a timely physician appointment. i.e., delay in consulting and having access to a prescription 48

49 Impact of Exacerbations in COPD Patients With Frequent Exacerbations Faster Decline in Lung Function Greater Airway Inflammation Poorer Quality of Life Higher Mortality Increased health care Wedzicha JA, et al. Lancet. 2007;370: utilization 49 49

50 Know When to Refer to a Specialist Diagnostic uncertainty Severe symptoms disproportionate to degree of airflow obstruction Rapid decline in lung function Patients < 40 years old Combination treatment inadequate to control symptoms Severe disease requiring specialized therapies Can Respir J 2008;15(Suppl A):1A-8A 50

51 Co-Morbidities in Canadian COPD patients Majority (82%) of patients had comorbidities Most common were : % of Patients with: No Co-morbidities 18% One co-morbidity 22% Two co-morbidities 24% Three co-morbidities 16% Four or more 20% Average Number of Co-morbidities: 2.7 Base: 931 Patient Assessments Hernandez et al, Can Respir J Vol 20 No 2 March/April

52 COPD/Heart Failure 25-30% HF patients have COPD 20-40% COPD patients have HF Risk of CAD in COPD is 2-4 times that of matched non- COPD controls Common partners, common problems Presence of each other predicts increased mortality 52

53 Overlap in Therapeutics HF can respond to BD B-blockers showed 22% reduction in mortality and decreased risk in patients with COPD HF patients also need an ACTION PLAN: Daily weight Na reduction Fluid limitation ACE B-Blockers Diuretics 53

54 Use of B-blockers in COPD Journal of Cardiac Failure Vol 13 No. 10 December

55 β-blocker therapy is safe in COPD¹²³ Selective β1-blockers Metoprolol Atenolol Bisoprolol Non-selective α (alpha) and β-blockers used in CHF that are found to be safe in COPD Carvedilol These agents should not be withheld from patients with COPD and cardiac disease 1. Camsari A, Heart Vessels 2003;18: Salpeter SRAnn Intern Med 2002;137: Salpeter SR, Respir Med 2003;97: GOLD guidelines

56 Estimation of Prognosis in COPD 3 year mortality is 30% with FEV₁ of 30% or less 6 month mortality of 30-40% can be anticipated in patients with two of the following: Baseline arterial pco2 >45 mm Hg FEV1 <0.75 L Cor pulmonale >1 episode of respiratory failure in one year Steinhauser, Arnold, Olsen et al. (2011). Comparing three life-limiting diseases: does diagnosis matter of is sick, sick? J Pain Symptom Manag in press. 56

57 Acute Event Mortality Myocardial Infarction 25%-38% of patients hospitalized with MI die within 12 months (Thom et al., 2006) In-hospital mortality for acute MI % Exacerbation COPD 22-43% of patients hospitalized with AECOPD die within 1 year (Eriksen et a., 2003; Groenewegen et al., 2003) In-hospital mortality for AECOPD is 7.8%-11.0% 57

58 Survival in COPD Relationship to Lung Function and Disability 58

59 Survival probability Mortality Increases with Frequency of AECOPD A p< B p=0.069 C p< Group A: no exacerbations Group B: 1 2 exacerbations Group C: 3 exacerbations 0 n= Time (months) Soler-Cataluna JJ, et al. Thorax 2005; 60:

60 COPD Chronic Care Compensation G Annual Chronic Care Bonus (Chronic Obstructive Pulmonary Disease) 125$ G COPD Telephone/ Management Fee 15$ up to 4x per year Requirements: Confirmed diagnosis of COPD (ie spirometry) Seen at least 2x that year Patient provided with a personalized ACTION PLAN 60

61 Break

62 Patient Self-Management Generating an Action Plan COPD and AECOPD Management Patient Education Materials Smoking Cessation

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66 AECOPD

67 A Case of Dyspnea 65 year old female smoker, trying to quit Suspected COPD (does she have FV loop?) Dyspnea for 5 years Prior history of AMI, treated stent Sputum daily but clear, no change Intermittent edema Echo 2 years prior showed EF 45% Post-bronchodilator FEV 1 /FVC 48% FEV 1 55%, Shortness of breath has worsened in past 2 days associated with increased cough and sputum purulence 67

68 Case continued Current inhalers are LAMA plus SABA Has not followed up with you recently Renews her prescriptions intermittently Other Rx: rosuvastatin, HCTZ, amlodipine, metformin, daily ASA Exam reveals decreased breath sounds bilaterally, wheeze, How would you proceed with this case? ICS (inhaled corticosteroid), JVP (jugular venous pressure), HCTZ (hydrochlorothiazide) 68

69 Case continued: Does she have symptoms of an AECOPD? dyspnea, cough, sputum or sputum purulence Could she have worsening CHF? Could she have both? 69

70 Why Might a Patient with COPD Experience Increased Dyspnea? Respiratory examples Cardiac examples Systemic examples AECOPD? Parenchymal? Pneumonia Lung cancer ILD Pleural effusion? Pneumothorax? PE? CHF? Arrhythmia? Ischemia? Valvular decompensation? Anemia? Acidosis? Renal disease ILD (interstitial lung disease), PE (pulmonary embolism), CHF (congestive heart failure) 70

71 CTS Definition of Acute Exacerbation of COPD (AECOPD) Acute and sustained ( 48 h) worsening of dyspnea, cough or sputum production compared to baseline An increase in the use of maintenance medications and/or Supplementation with additional medications eg antibiotics and/or prednisone O Donnell DE, et al. Can Respir J. 2007;14(Suppl B):5B-32B. 71

72 Impact of Exacerbations in COPD Patients With Frequent Exacerbations Faster Decline in Lung Function Greater Airway Inflammation Poorer Quality of Life Higher Mortality Increased health care Wedzicha JA, et al. Lancet. 2007;370: utilization 72 72

73 AECOPD: Management REDUCE trial showed benefit with just 5 days of prednisone 73

74 Antibiotic treatment recommendations for purulent AECOPD Group Basic clinical state Symptoms and risk factors Probable pathogens First choice (in alphabetical order) Simple exacerbation COPD without risk factors Increased sputum purulence and dyspnea Haemophilus influenzae, Haemophilus species, Moraxella catarrhalis, Streptococcus pneumoniae Amoxicillin, second- or third-generation cephalosporins, doxycycline, extendedspectrum macrolides, trimethoprim/sulfamethoxazole O Donnell et al. Can Respir J 2008; 15 Suppl A:1A 74

75 Antibiotic treatment recommendations for purulent AECOPD Group Basic clinical state Complicated exacerbation COPD with risk factors Symptoms and risk factors Probable pathogens First choice (in order of preference) As in simple plus one of: FEV 1 <50% predicted; 4 exacerbations per year; ischemic heart disease; use of home oxygen; chronic oral steroid use As in simple plus: Klebsiella species and other Gram-negatives Increased probability of beta-lactam resistance Pseudomonas species Fluoroquinolone, beta-lactam/beta-lactamase inhibitor O Donnell et al. Can Respir J 2008; 15 Suppl A:1A 75

76 Role of Antibiotics in AECOPD: Cochrane Review Relative Risk Number Needed to Treat Mortality: 0.23 (.1-.52) Rx Failure: 0.47 ( ) Sputum purulence: 0.56 ( ) Risk of diarrhea: 2.86 ( ) NNT mortality: 8 NNT Rx. Failure: 3 NNT to reduce purulent sputum: 8

77 AECOPD: Benefits of Oral Steroids 77

78 As COPD Progresses, Exacerbations become more frequent and more severe 78

79 Survival probability Mortality Increases with Frequency of AECOPD 1.0 A p< p=0.069 B p< C 0.2 n= Group A: no exacerbations Group B: 1 2 exacerbations Group C: 3 exacerbations Time (months) Soler-Cataluna JJ, et al. Thorax 2005; 60:

80 What are the goals in management of AECOPD? 1. Treat Current AECOPD *avoid treatment failure *prevent admission or readmission 2. Prevent Future AECOPD *delay and/or *reduce severity 80

81 Prevention Strategies for AECOPD: Pharmacological Long-acting Bronchodilators: LAMA, LABA, dual combinations of LAMA/LABA Anti-inflammatory agents ICS (combined with LABA) PDE4 inhibitors (Daxas) Combinations of inhaled agents Other approaches Azithromycin N-acetyl-cysteine Vaccinations 81

82 Prevention Strategies for AECOPD: Non-pharmacological Smoking Cessation (NNT = 9) lives saved Pulmonary Rehabilitation and Exercise Program (NNT = 16) lives saved Self-Management Case Manager Written Action Plan Disease Management Programs O Donnell DE, et al. Can Respir J 2007;14(Suppl B):5B-32B 82

83 Components of a COPD Patient Education Program 83

84 Benefits of COPD Self Management Education 84

85 Conclusions: AECOPD Pathway AECOPD has significant mortality and cause for admission and readmission to hospital Distinguish AECOPD from other causes of SOB in patients with COPD Bacterial infections 50%; Antibiotics save lives. Steroids prevent relapse Bronchodilators and ICS reduce future risk of exacerbations Case/Self management, Action Plan and early Rehab reduce readmission 85

86 Patient Education Resources Heart Failure

87 Patient Education Resources Heart Zones 87

88 Patient Education Resources Daily weight 88

89 Patient Education Resources Sodium Restriction 89

90 Patient Education Resources Fluid Restriction 90

91 Patient Education Resources Activity 91

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94 A Comprehensive List of Patient and Provider Resources PATIENT RESOURCES PROVIDER RESOURCES MEDICATIONS REFERRAL FORMS SODIUM PATIENT ASSESMENT FORMS FLUID CARE MAPS & TX ALGORITHMS EXERCISE MEDICATION TITRATION EXACERBATION PLAN PATIENT SYMPTOM STATUS HF 101 VISIT SNAP SHOT 94

95 BC s Heart Failure Website 95

96 Smoking Cessation 96 96

97 Progress in British Columbia BC sues tobacco companies Percentage Smoking Prevalence in BC, Govt funding to $6.5M QuitNow projects 1 st Quit Contest NRT access 0 BC Quitline Year Prevention program in schools BC Progress in BC 97

98 Intention to Quit Intention to Quit 98

99 Physicians discussing quitting Physicians Discussing Quitting 99

100 Effect of Physician intervention Effect of Intervention 100

101 What can Physicians do? What can Physicians do? 101

102 Online Referral online 102

103 Referral Resources Indications for Referral to a HFC Heart Function Clinic Referral Form 103

104 Patient History/Assessment Heart Failure Patient Questionnaire 104

105 A Guide to HF Patient Assessment Patient Assessment Tool 105

106 Referral and Consult Process

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109 Planning for Action Period 2