COPD Care. Course Handouts & Post Test. COPD Care. Objectives: o To download presentation handouts, click on the attachment icon

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1 COPD Care Jhn Mrris MD FCCP FAAHPM Medical Directr f Palliative Care Curse Handuts & Pst Test T dwnlad presentatin handuts, click n the attachment icn Presenter disclses n financial relatinships with a cmmercial entity prducing healthcare-related prducts and/r services. Cnflict f interest disclsure and reslutin statement is n file with HEN. This presentatin is fr educatinal and infrmatinal purpses nly. It is nt intended t prvide legal, technical r ther prfessinal services r advice. COPD Care Objectives: Identify the burdens f caring fr COPD patients and the keys t successful management f COPD Discuss the challenges f prgnsticatin and tls t help determine hspice eligibility Describe a hspice COPD prgram and key cmpnents f imprved COPD end f life care 1

2 GOLD Website Address Definitin f COPD COPD is a preventable and treatable bstructive lung disease with sme significant extrapulmnary effects that may cntribute t the severity in individual patients. Its pulmnary cmpnent is characterized by airflw limitatin that is nt fully reversible. The airflw limitatin is usually prgressive and assciated with an abnrmal inflammatry respnse f the lung t nxius particles r gases. COPD Definitin Includes: Emphysema Chrnic Brnchitis Brnchiectasis Des nt include: Pulmnary Fibrsis Asthma 2

3 Burden f COPD COPD is a leading cause f mrbidity and mrtality wrldwide and results in an ecnmic and scial burden that is bth substantial and increasing. The burden f COPD is prjected t increase in the cming decades due t cntinued expsure t COPD risk factrs and the changing age structure f the wrld s ppulatin. Burden f COPD: Mrtality COPD is 4th leading cause f mrtality wrldwide and prjected t increase t 3rd by 2012 COPD mrtality trends generally track several decades behind smking trends. In the US and Canada, COPD mrtality fr bth men and wmen have been increasing. In the US in 2000, the number f COPD deaths was greater amng wmen than men. Percent Change in Age-Adjusted Death Rates, U.S., Prprtin f 1965 Rate Crnary Heart Disease Strke Other CVD COPD All Other Causes % 64% 35% +163% 7% Surce: NHLBI/NIH/DHHS 3

4 COPD Mrtality by Gender U.S., Number Deaths x 1000 Surce: US Centers fr Disease Cntrl and Preventin, 2002 Missin Hspital COPD Burden 27% WNC smke 1,447 admits fr COPD 6% readmits in 30 days Cst per admit $6,498 Lss per admit $ Net hspital lss $1.9 M 2010 Hspital lss $2.6 M Nrmal Lungs vs. COPD Lungs 4

5 Symptm Burden f COPD Shrtness f Breath Cugh Frequent lung infectins Wheezing Fatigue / weakness Decreased intake f fd / weight lss Edema Excess mucus prductin Physical Signs f COPD Rapid respiratin Prlnged expiratin Muscle wasting (esp. intercstal) Pursed lip breathing Increased A-P chest diameter Accessry muscle use in respiratin Expiratry wheeze, rhnchi nne Gals f COPD Management Varying Emphasis with Differing Severity Prevent disease prgressin Imprve exercise tlerance Imprve health status Prevent and treat cmplicatins Prevent and treat exacerbatins Reduce mrtality Relieve symptms 5

6 Fur Cmpnents f COPD Management 1. Assess and mnitr disease 2. Reduce risk factrs 3. Manage stable COPD Educatin Pharmaclgic Nn-pharmaclgic 4. Manage exacerbatins 1. Assess and Mnitr COPD SYMPTOMS cugh sputum shrtness f breath EXPOSURE TO RISK FACTORS tbacc ccupatin indr/utdr pllutin SPIROMETRY COPD Classificatin by Spirmetry Stage I: Mild FEV 1 /FVC < 0.70 FEV1 > 80% predicted Stage II: Mderate FEV 1 /FVC < % < FEV 1 < 80% predicted Stage III: Severe FEV 1 /FVC < % < FEV 1 < 50% predicted Stage IV: Very Severe FEV 1 /FVC < 0.70 FEV 1 < 30% predicted r FEV 1 < 50% predicted plus chrnic respiratry failure 6

7 2. Reduce Risk Factrs fr COPD Nutritin Infectins Sci-ecnmic status Aging Ppulatins Management f Stable COPD Educatin Smking cessatin Vaccinatin Exercise and pulmnary rehabilitatin Medicatins Nutritin Symptms and management ADL s and energy cnservatin Advance Care Planning 3. Manage Stable COPD: Medicatins Brnchdilatrs B-2 agnist Antichlinergics LABA increased benefits and risks Sterids Inhaled helpful fr 30% -cugh and phlegm Cstly and assciated with increased pneumnia Best dne in 2-3 mnth trials, then stpped PO helpful fr exacerbatin, but nt chrnic use 7

8 3. Manage Stable COPD Nn Pharmaclgic Smking cessatin Pulmnary rehabilitatin Vaccinatins Oxygen Surgery Therapy at Each Stage f COPD I: Mild II: Mderate III: Severe IV: Very Severe FEV 1 /FVC < 70% FEV 1 > 80% predicted FEV 1 /FVC < 70% 50% < FEV 1 < 80% predicted FEV 1 /FVC < 70% 30% < FEV 1 < 50% predicted FEV 1 /FVC < 70% FEV 1 < 30% predicted r FEV 1 < 50% predicted plus chrnic respiratry failure Active reductin f risk factr(s); influenza vaccinatin Add shrt-acting brnchdilatr (when needed) Add regular treatment with ne r mre lng-acting brnchdilatrs (when needed); Add rehabilitatin Add inhaled gluccrticsterids if repeated exacerbatins Add lng term xygen if chrnic respiratry failure. Cnsider surgical treatments Cst Effective Recmmendatins Utilize albuterl and ipratrprium Add titrprium fr lng acting Avid LABA Avid inhaled sterids except fr time limited trial Teach breathing exercises Encurage aerbic exercise Teach actin plan fr exacerbatins 8

9 4. Manage COPD Exacerbatins Antibitics Tip: inexpensive just as gd as expensive Brnchdilatrs B-2 agnist (albuterl) Antichlinergics (ipratrprium) Sterids: ral/ IV xygen Nninvasive Ventilatin (BiPAP) Pulmnary EOL Care: Challenges Difficult t predict prgnsis Physicians nt skilled at gal discussins Patients develp Lazarus syndrme Dyspnea treatment difficult Anxiety Family burden and stress Hspice staff prly trained fr COPD Hspital staff prly trained fr EOL Pulmnary EOL Care: Facts Mre ICU time, mre ED visits Less effective symptm management Dyspnea, pain, anxiety, depressin Less advance directives Less satisfactin with medical care 25% f last year spent in hspital despite wishes t cntrary Less palliative care and hspice utilizatin SUPPORT. J. Am. Geriatr. Sc. 48(5),S91 S100 (2000) 9

10 Palliative Care fr COPD ATS Statement 2007 Palliative care shuld begin when a patient becmes symptmatic and is usually cncurrent with restrative and life-prlnging care. All patients with symptmatic r life-threatening diseases, particularly thse with advanced respiratry disease r critical illness shuld have access t palliative care. Palliative care shuld be prvided in a cmprehensive interdisciplinary apprach. ATS supprts effrts t increase availability and educate public n value f palliative care in patients with respiratry disease. What D Patients With Serius Illness Want? Cntrl pain and symptms Avid inapprpriate prlngatin f the dying prcess Achieve a sense f cntrl Relieve burdens n family Strengthen relatinships with lved nes Singer et al, JAMA 1999 COPD Patients Desire Educatin Disease infrmatin Treatment ptins Prgnsis What dying might be like Advance Care planning Curtis, JR et al. CHEST 2002; 122,

11 Symptms f COPD Dyspnea 93% Severe 56% Pain 34% Fatigue 88% Depressin 52% Anxiety 80% Janssen, JPM Vl14, (6) 2011 SUPPORT. J. Am. Geriatr. Sc. 48(5),S91 S100 (2000) Dyspnea Defn: sensatin f needing mre air 80% f COPD Primary prblem and surce f disability Respiratry system signals brain Brain prcesses based n histry, experience, values, and beliefs Affected by physical, emtinal, scial, spiritual factrs Key: Believe the patient! Causes f Acute Dyspnea Pulmnary COPD, Pneumnia, Brnchitis, Pneumthrax Cardiac Heart failure, Tampanade Vascular Pulmnary emblus 11

12 Causes f Chrnic Dyspnea Pulmnary COPD, Pulmnary Fibrsis, Pulm. hypertensin Cardiac Heart failure, tampanade Vascular Anemia, pulmnary embli Muscular Decnditining Evaluatin f Dyspnea Histry Physical Oximetry X Ray Lab Spirmetry Dyspnea 3 Step Treatment Dyspnea shuld be regularly assessed and rated n scale 1. Optimize Medicatins and Oxygen Shrt acting brnchdilatrs (Alb, ipratrprium) Lng acting brnchdilatrs (titrprium> LABA) Oxygen (nly if hypxic) Minimize p and inhaled sterids 2. Nn- pharmaclgic Treatments 3. Palliative Treatments 12

13 Dyspnea: Nnpharmaclgic Appraches Breathing exercises: Pursed lip Fan: cl air mvement Relaxatin techniques Prgressive muscle, mental imagery, etc. Cunseling Nninvasive Ventilatin (BiPAP) Cntrl Actin plan Energy cnservatin Dyspnea Palliatin Opiids P/ IV effective (nebulized +/-) N significant respiratry depressin at effective dse 2-5mg mrphine q4h effective start Anxilytics Nt effective fr dyspnea, but fr anxiety Effective fr dyspnea-anxiety-dyspnea cycle Data Analysis Fur Seasns 2,132 new patients entered by August ,141 ttal visits entered Reasn fr cnsult 13

14 Cmparisn f Dyspnea Visit 1 t 2 Imprvement frm Visit 1 t Visit 2 (e.g., Did yur pain imprve frm yur first visit? ) Mderate t Severe Symptms >5/10 Pain Dyspnea Depressin Cnstipatin 67.5% (252 pts) 70.3% (148 pts) 71% (197 pts) 74.0% (100) pts Based n 1,223 subsequent visits Data supprts significant imprvement in symptm management with advanced illness after 1 visit (i.e., frm visit 1 t visit 2) Shws impact f symptm management, thugh n histrical cmparatr (i.e., can t claim better symptm management with the data system than previusly) COPD Diagnsis DNR Status ICD 9 Cdes 496 (12% f patient ppulatin) Data shws high number f patients with full cde. Supprts QI prject 14

15 COPD Diagnsis Pain All Assessed Data shws high number f patients with mderate t severe pain. Fur Seasns Palliative Care Patient and Family centered care Treat pain, dyspnea and ther symptms Advance care planning Initiate discussins abut gals Discuss ptins fr care Psychscial supprt Advcate and cmpanin in medical system Palliative Care Data Imprved care Increased life expectancy Decrease cst Imprved patient and family satisfactin Decrease ER, Hspital utilizatin with mre time at hme Brumley JAGS 55:

16 Acceptance f nes wn mrtality is a prcess, nt an epiphany. R. Krakauer MD Rle f Palliative Care in COPD Disease Trajectries High Organ System Failure Trajectry Functin (mstly heart and lung failure) Death Lw Multiple hspitalizatins Time frame usually 2-5 years Death usually fllw disease exacerbatin 48 16

17 COPD Prgnstic Tls BODE Index BMI Obstructin Dyspnea scre Exercise (6 min walk) ADO Index Age Dyspnea scre Obstructin Bth helpful fr 3 year but nt 1 year mrtality Hspitalized fr COPD: 50% mrtality in 2 years COPD Prgnsis: Hspice Increased risk f dying in next 12 mnths FEV1 < 30% Increased dependence n caregivers Dyspnea <50 ft Depressin N spuse Hspitalizatin Cmrbid illness (DM, CHF, etc) Hansen-Flaschen COPD: the last year f life Resp Care. 2004;49(1):90-97 COPD Prgnsis : Hspice Hspitalized patients with 2 f fllwing: Baseline pco2>45 Cr Pulmnale FEV1<0.75 L Mechanical Vent in past 12 mnths SUPPORT AJRCC M 1996;154 (suppl 4A):959S-967S 17

18 EOL Cmmunicatin in COPD 99% f patients want EOL discussins 20% f patients have discussins COPD patient and lung cancer patients Same prgnsis Same gals regarding hspitalizatin, Cde status, Ventilatin, artificial nutritin COPD patients receive much mre aggressive, uncmfrtable interventins SUPPORT. J. Am. Geriatr. Sc. 48(5),S91 S100 (2000) Hspice Advantages fr COPD Team visits t prevent exacerbatins Symptm management expertise Team prvides equipment, cunsels pt and family Advance Care planning CNA prvides persnal care Vlunteer prvides scializatin Hspice pays fr sme medicatin and equipment 24/7 service and supprt Supprt fr caregiver/ family Bereavement Supprt Fur Seasns Pulmnary Prgram Elements f prgram: FS Educatin RN SW, Chaplain, CNA s, Vlunteers, Bereavement Medicatins Patient Educatin Clinical prtcls 18

19 FS Pulmnary Educatin COPD Educatin prgram fr hspice staff Definitin Risk factrs Pathphysilgy Clinical Medicatins Management f exacerbatins Pst educatin testing FS Pulmnary Educatin COPD Skills Lab fr Hspice Nurses Physical assessment MDI technique Breathing exercises SQ injectins IV skills Nebulizer utilizatin Mentring by RT/RN FS Pulmnary Prgram Staff COPD Educatin SW, Chaplain Anxiety, depressin Meaning, hpe CNA s ADL s Energy cnservatin Vlunteers 19

20 FS Pulmnary Prgram Patient educatin Week 1 COPD Week 2 Living with Shrtness f Breath Week 3 Eating well with COPD Week 4 Infectins and Secretins Week 5 Exercise with COPD Week 6 Stress reductin Actin plan fr emergencies Pulmnary Emergencies Start actin plan Call Fur Seasns first 24/7 nurse visits Dyspnea prtcl Inpatient unit available Physician visits COPD Emergency Kit Albuterl Mrphine Ativan Decadrn (p/sq) Lasix Haldl Atrpine (secretin cntrl) 20

21 FS Pulmnary Emergency prtcls Acute Shrtness f Breath Start prtcl Medicatins and nn pharm treatments Call n call nurse N relief: Cntinue prtcl Nurse assess: HF vs COPD? (cnsider Lasix, nebs, sterids IV/SQ) Cntinue prtcl Call MD COPD Spiritual Care Patients want t discuss spiritual issues Cnsider spiritual issues very imprtant Physicians rated prly in discussins Chaplains rated much better Gd tls available fr MD educatin Gal: achieve peace, meaning Cmpassinate presence, active listening Validating emtins, uncnditinal acceptance Life review COPD Caregiver issues COPD patients ften husebund, anxius, depressed, irritable. Caregivers reprt: scial islatin, bredm, resentment, relatinal tensin, fatigue, anger, guilt, depressin, insmnia, helplessness, lss f freedm, anticipatry grief, identity lss Benefit frm Hspice team: RN, SW, Chaplain, CNA, MD, vlunteer, bereavement cunselr 21

22 Benefits f Hspice in COPD Imprved symptm management Imprved stress, psychscial/ spiritual care Patients live avg 29 days lnger Less financial stress Mre time spent in desire lcatin Caregiver survival Decrease in death rates f caregivers with hspice Patient and family satisfactin Questins? Jhn Mrris MD FCCP FAAHPM jmrris@furseasnscfl.rg Fur Seasns Center f Excellence Cnsulting Hspice, Palliative Care & Research Palliative Care Immersin Curse Mentring physicians, nurse practitiners and physician assistants Curse Handuts & Pst Test Thank yu fr viewing this curse n the Hspice Educatin Netwrk The Curse evaluatin and pst test are available frm yur curse catalg page T achieve credit fr this curse, clse the vide prtin when cmpleted and click n Start Test 22