A whistle stop tour of Respiratory Medicine and what the RUH & IMPACT offer

A whistle stop tour of Respiratory Medicine and what the RUH & IMPACT offer Jay Suntharalingam, Respiratory Physician, RUH Claire Bullard, IMPACT Team Leader, Sirona

Outline Respiratory 5 year strategy Cases

Respiratory s 5 year strategy CTD-ILD NIV/SLEEP PULMONARY HYPERTENSION Respiratory ward Gen Resp clinics 2ww service Pleural clinic Bronchoscopy Secondary COMMUNITY BRONCHIECTASIS PATHWAY IMPACT COMMUNITY SHO POST Complex conditions THORACOSCOPY Care COMMUNITY CLINICS Simple conditions EBUS RESPIRATORY PSYCHOLOGY OUPATIENT PHYSIOTHERAPY

Outline Respiratory 5 year strategy Cases

Case 1 47 year old man ex smoker - 15 pack year history 2-3 years of intermittent dyspnoea recently seen in ED with wheeze discharged on tiotropium & salbutamol ΔCOPD exacerbation

Case 1 Pre-bronchodilator Post-bronchodilator FEV1 1.9L (72%) 2.3L (96%) FVC 3.0L (97%) 3.1L (100%) FVR 63% 77% PEFR 340 (70%) 400 (86%) Measure post-bronchodilator spirometry to avoid missing a diagnosis of asthma

Misdiagnoses of COPD are common A study of registered COPD patients in Devon found that repeat assessment showed COPD 68.5% COPD with asthma 4.3% Asthma 6.7% Restrictive disorder 4.0% Cardiac 0.3% Normal 16.2% Jones et al, Resp Research 2008

Pitfalls in performing spirometry RUH study 87 patients 1ry care spirometry compared with 2ry care results FEV1 74ml difference (p=0.034) FVC 241ml difference (p=0.0001) 21% patients originally labelled restrictive had obstructive spirometry Harris et al, Thorax 2015

Spirometry interpretation FEV1 FVC FVR Volume (L) FVC FEV1 forced expiratory volume in 1 second forced vital capacity FEV1/FVC - forced expiratory ratio Abbreviated FVC 1 2 3 4 5 Time (sec)

COPD when to refer Diagnostic uncertainty Age <50 Smoking history <20 pack years Discordancy between symptoms and spirometry

Case 2 66 year old 45 pack year smoking history still smoking 2-3 year history of SOBOE MRC 4 2-3 exacerbations/year Poor attender occasionally uses a LAMA FEV1 0.7L (34%), FVC 2.1 (83%)

Which inhaler (s) are you going to give him?

Local COPD algorithm SOB & exercise limitation SABA or SAMA as required Persistent symptoms FEV 1 50% Breathless LABA LAMA FEV 1 <50% Exacerbator LABA/ICS LAMA/LABA LABA/ICS + LAMA

COPD care not just about inhalers.. Primary care IMPACT service Secondary care IMProving Access to COPD Therapies

IMPACT - staffing Claire Bullard [Team Leader] Specialist nurses Physiotherapists Rehab assistant Administrator Sirona GPST post 1ry care Respiratory Consultant input 2ry care

GP referral Exacerbation management Oxygen assessment Primary care referral Secondary care referral I M P A C T Community COPD clinics Pulmonary rehabilitation Medication optimisation Self referral Other community services

Working with the wider healthcare community.. Psychological services Gyms District nurses Ambulance service GP Oxygen assessment Dietetics Palliative Care Community matron Social services COPD patient & carer 3 rd sector services Smoking cessation services Reablement teams Community pharmacists Secondary care IMPACT Outpatients Community hospitals Occupational health Housing services

GP referral Early supported discharge Oxygen assessment Primary care referral Secondary care referral I M P A C T Community COPD clinics Pulmonary rehabilitation Medication optimisation Reduced preventable admissions and improved patient experience Self referral Education & training for healthcare professionals Other community services

Outcomes Since 2010.. >1700 COPD patients seen 708 patients accepted for ESD (9.5% readmission rate) 992 patients accepted for admission avoidance 628 community PR places provided in 4 accessible locations (73% completion rate) 3088 oxygen assessments RUH median LOS 3 days (vs 4 nationally)

Outcomes Excellent feedback Very caring service with good advice Friendly, knowledgeable & reliable Explained how my inhalers worked All members of the team willing to spend time listening

Case 3 64 year old lady never smoker chronic productive cough frequent infections worsening dyspnoea spirometry FEV 1 0.9L (46% predicted) FVC 2.0L (81% predicted) FEV 1 /FVC 45%

Case 3 Always consider bronchiectasis in patients with a chronic cough and frequent infections

Bronchiectasis - pathophysiology

Bronchiectasis - pathology

Bronchiectasis - management Regular bronchial hygiene Sputum cultures ++ Prompt and aggressive treatment of exacerbations

Bronchiectasis referrals Before you refer.. a normal HRCT excludes the diagnosis Bronchiectasis profile bloods & sputum cultures pre-referral v.helpful

Bronchiectasis service New multidisciplinary clinics since 2014 Standardised letters/database Community based iv s 259 patients Respiratory Consultant Respiratory nurse specialist Patient IMPACT team Respiratory Physio

Case 4 71 year old COPD diagnosed 6 yrs ago FEV1 32% ET 50 yards 1-2 exabns/yr Comes up for his annual COPD assessment on a Friday afternoon No new symptoms Saturations 86-87% on air

Case 4 Do you A. Give him antibiotics/steroids and bring him back in a week B. Make no changes but arrange to see him again in a week C. Admit him to hospital D. Arrange emergency home oxygen E. Refer him for a routine HOSAR assessment

Oxygen saturations at altitude

Long term oxygen therapy (LTOT)

LTOT improves mortality in COPD MRC NOTT

How do you screen patients for LTOT? Patients with SaO2 92% during a period of clinical stability

LTOT historically often prescribed inappropriately. 4% 10% 54% 32% Correctly prescribed LTOT Referred but DNA'd Not referred for assessment Assessed as not requiring LTOT Mason et al RCP Journal 2010

Domiciliary oxygen Long term oxygen therapy (LTOT) Nocturnal oxygen therapy (NOT) Ambulatory Oxygen Therapy (AOT) LTOT patients non-ltot patients Short Burst Oxygen Therapy (SBOT) Palliative Oxygen Therapy (POT)

Domiciliary oxygen IMPACT outcomes Data cleansing 3088 assessments since 2010. In last year: 80% - no change to prescription 6% - prescription reduced 3% - oxygen withdrawn 11% - prescription increased 20% had a change in prescription following assessment

Average monthly spend on domiciliary oxygen

Case 5 76 year old man 30 pack year smoking history 12 month history of exertional dyspnoea recent onset cough FEV1 45%, FVC 85%, FVR 47% ½ stone weight loss

Case 5 Always consider a CXR before diagnosing new COPD is there an alternative diagnosis?

Lung Cancer - symptoms Watch out for red flag symptoms New cough Dyspnoea Constant chest pain Weight loss Fatigue

Lung Cancer - referral 370 referrals to 2ww clinic in 2015/6 120 patients Δ ed with lung cancer (32% of referrals) (87 patients Δ ed outside of 2ww clinic) CXR Staging CT chest

Lung Cancer work up Staging CT chest PET-CT Tissue diagnosis Bronchoscopy CT guided biopsy Thoracoscopy

Thoracoscopy RUH Pleural clinic appt NBT Pleural clinic appt NBT Thoracoscopy NBT FU RUH FU RUH Pleural clinic appt RUH Thoracoscopy RUH FU

Lung Cancer work up Staging CT chest PET-CT Tissue diagnosis Bronchoscopy CT guided biopsy Thoracoscopy EBUS

Case 6 46 year old man comes to see you with his wife Lifelong snorer New witnessed apnoeas 2-3/night Epworth score 7/24 Do you refer for a sleep study?

Pathophysiology Upper airway narrowing Apnoea Increased respiratory effort Arousal occurs Sleep fragmentation Return to sleep Resolution of asphyxia Improvement in upper airway resistance

Definitions Obstructive sleep apnoea (OSA) Snorer plus Witnessed apnoeas Obstructive sleep apnoea hypopnoea syndrome (OSAHS) Snorer plus Witnessed apnoeas plus Excessive daytime sleepiness

Features suspicious of OSA Calculate Epworth score Snorer? Apnoeas? Collar size? BMI? Headaches? Occupation? Driving history? ESS<10 & little daytime sleepines ESS<10 AND good clinical history ESS>10 Lifestyle advice Routine referral URGENT referral if high risk occupation

Case 7 68 year old man with known COPD Ex smoker 40 pack year history Δ ed 2 years ago FEV1 40% predicted Triple inhaler therapy Pulmonary rehabilitation done recently Admitted August 2015 with exacerbation 6 further admissions since no NIV ET fallen from 500m to 50m now housebound

Case 7 what could be going on??disease progression stable spirometry?alternative Δ CTPA negative echo normal?compliance/inhaler technique?functional impairment

What does psychology have to do with hospital admissions? Pre-Hospital - Medical Problem (e.g. exacerbation, infection) - Panic attack - Unable to cope

What does psychology have to do with hospital admissions? Pre-Hospital - Medical Problem (e.g. exacerbation, infection) - Panic attack - Unable to cope Admission - Lots of tests - Oxygen, nebulisers - Round the clock nursing - Supervised recovery period

What does psychology have to do with hospital admissions? Pre-Hospital Admission - Medical Problem (e.g. exacerbation, infection) - Panic attack - Unable to cope - Lots of tests - Oxygen, nebulisers - Round the clock nursing - Supervised recovery period I was right to come into hospital I need professional help to cope with all aspects of the illness I need to be on oxygen to manage my condition/survive I need to rest in order to recover Discharge - Home alone - No oxygen or nebuliser - No call bell - Expected to manage on their own Readmission

Anxiety & Depression on the Respiratory ward Snapshot PHQ-9 screening questionnaire on ward showed PHQ9 10 9 8 7 6 5 4 3 2 1 0 None 0-4 Mild 5-9 Mod 10-14 ModSev 15-19 Sev 20+ Further survey showed 71% had depressive symptoms and 40% had anxiety symptoms

Psychology pilot 2015 98 inpatient referrals 11 outpatient referrals 274 inpatient sessions, 66 outpatient sessions, 163 telephone consultations 16% 30 day readmission rate (vs average 25% in 2014) 76% of patients seen on ward showed a reduction in admission frequency post-intervention 73% of patients with a history of frequent ED attendances showed a reduction in ED attendances post-intervention

Psychology service 2017 Claire Howard Clinical Psychologist Inpatient reviews Telephone FU Outpatient consultation Education & training Group therapy

Case 8 20 year old Bath University student Childhood asthma Paroxysmal SOB for 12 months Re-started inhalers little benefit Attended ED 2-3 times treated with steroids

Case 8 Normal spirometry Normal bloods Normal PEFR diary Positive skin prick tests Negative mannitol challenge test Δ Hyperventilation syndrome

Physiotherapist service 2017 Gail Jones Respiratory Physiotherapist Bronchiectasis COPD Hyperventilation syndrome Asthma Airway clearance Chronic cough >300 patients seen since 2015

Summary Misdiagnoses of COPD are common Latest COPD algorithm Role of IMPACT Productive cough? Think bronchiectasis New cough? Think Lung cancer Hypoxia isn t always an emergency Sleepy snorer vs simple snorer Role of Psychology & Physiotherapy

8 th RUH Respiratory Study day, Wednesday 14 th June 2017 COPD Smoking cessation & E-cigarettes Chronic cough Respiratory infection Asthma Interpreting lung function Reading radiology reports Cases