COPD Resources – Hereford

Introduction

COPD Annual Review: Using the 4C ABLE framework provides a structure for consultation using the patient’s electronic notes, enabling information to be gathered prior to patient consultation.

The first step (4C’s) involves interrogation of notes to establish correct diagnosis and efficacy of management. Use the filters within Emis to assist with searching for specific criteria (HMG will be available to click on the filters to tick the drop box set up)

Once the data is collected it can be saved and available for the consultation, giving an opportunity to establish outcomes of the 4C’s, following discussion with the patient.

The second step (ABLE) establishes what the patient understands about the disease, what they would like to achieve, barriers and agreeing achievable goals.

4C – ABLE
Confirm diagnosis
Current treatment
Control
Compliance
Agree aims
Barriers to success
Learning & self-efficacy
“E”mend & agree treatment

The patient will be sent links to BLF COPD Passport, which encourages questions about managing their disease, The CAT score to complete and send with their Height/ Weight & O2 sats if have access to device, prior to appointment. This is to encourage patient participation and ensure the consultation is as efficient as possible.

Supporting information – current treatment

On initial assessment of the patient’s notes you can only establish what prescriptions they have received.
Once you have confirmed what the patient is taking, establish their sypmtom scores and ensure it is appropriate.

GOLD recommend: Group c Group D
>2 moderate exacerbation or LAMA LAMA or LABA
>1 leading to admission or ICS & LABA

Group A Group B
0 or 1 moderate exacerbation Bronchodilator LABA or LAMA
not leading to admission.

mMRC 0-1 mMRC >2
CAT <10 CAT >10

Additional factors to consider if inhaled steroids are appropriate.

NICE 2018 – Offer LAMA+LABA to people who:
have spirometrically confirmed COPD and
do not have asthmatic features/features suggesting steroid responsiveness

Consider LABA+ICS for people who:
have spirometrically confirmed COPD and
have asthmatic features/features suggesting steroid responsiveness

Take note of any documented or patient description of less control when ICS reduced.

Check documented Eosinophils – GOLD suggest considering ICS in Eosinophils >0.3.

Patients on high doseICS, regular or maintenance oral steroids need to be given a steroid card. Consider Bone Protection for this patient group.
See link below for supporting advice regarding reducing ICS safely & Steroid Cards.
NB the latest NICE COPD Covid guidance (2020) states:
Explain to patients there is no evidence that treatment with ICS for COPD increases the risk associated with COPD.
Tell patients established on ICS to continue them, and delay any planned trials of withdrawal of ICS. While there is some evidence that use of ICS in COPD may increase the overall risk of pneumonia, do not use this risk alone as a reason to change treatment in those established on ICS and risk destabilising COPD management.
Tell patients on long term oral steroids that they should continue to take them at their prescribed dose, because stopping them can be harmful. Advise patients to carry a steroid card.

Clinician preparation

Due to Covid, most annual respiratory reviews will be done remotely, ideally via video consultation, to enable the clinician to assess inhaler technique, peak flow, 02 sats, and any evidence of acute symptoms. The initial information gathered from the notes can then be briefly recapped with the patient to establish any changes.

Clinical links

This link from PCRS is a useful example how we can undertake video consultation for respiratory patients.
PCRS telephone/ video consultation for remote respiratory reviews

Supporting Information – Patient Consultation

MUST tool calculator – BAPN
Hypertension in Adults: Diagnosis and Treatment NICE Aug 2019
CVD Risk Assessment and Management NICE 2019

Oxygen Saturation:
Some patients may have pulse oximeters at home – ideally ask them to record it during the video consultation, to ensure they are recording it correctly.

If the patients recording is lower than usual or they describe an increase in their symptoms they may need to:
– Have an appointment in the surgery to assess base line.
– Enquire if there are available pulse oximetry devices that can be sent to the patient.
– Establish if they are currently under the care of the community teams.

Consider referral or discussion with Oxygen Assessment Service @ WVT
01432 364416
Home Oxygen Service Referral can be printed once consultation saved if launched via F12.

Baywater Medical Oxygen Company
e learning oxygen – Baywater medical
Quick assessment – Lets Talk
Health Psychology Referral
CKS Polycythaemia
ADAPT site – Alpha 1

Support Information – Confirming COPD Diagnosis

If patient does not have a code of COPD in their notes, they may have another diagnosis, or been booked in error.

If coded as Bronchiectasis please continue with review and explore in particular sputum expectoration, volume, colour, techniques, sputum surveillance and exacerbation rate. If symptoms appear uncontrolled with frequent exacerbation discuss with appropriate clinician within your surgery.

If coded as Asthma and COPD overlap please continue with review and rebook for an Asthma review if unable to address all aspects safely.
If coded as Asthma proceed with Asthma template and consider ticking COPD resolved if confident with Asthma diagnosis.

Post B2A FEV1 % NICE GOLD 2008
FEV1/FVC Predcited 2004 NICE 2010

Post B2A

<0.7 > 80% Stage 1 Mild

<0.7 50-79% Mild Stage 2 Mod

<0.7 30-49% Mod Stage 3 Severe

<0.7 <30% Severe Stage 4 V severe *

* or FEV1 <50% with respiratory failure

Is this COPD? Check

– Patient coded as PMH of Asthma, establish reasons, may be an error, an old entry as airways more fixed, or overlap
– Patient coded as PMH cardiac failure/ orthopnoea/ pedal oedema
– Patient is coded as PMH anaemia
– Patient has minimal or no pmh of smoking exposure
– There is evidence of reversible airflow obstruction on spirometry or PEF
– There is evidence of allergy
– The patient has variable symptoms, with variable timings

RED FLAGS
Weight loss
Night sweats
Chest wall pain
Unresponsive to COPD medication
Recurring “chest infection”

ANY CONCERNS: If patient presents with acute symptoms, complete consultation – unless urgent response required and refer to supporting clinician as appropriate. Remember to work within your personal scope of practice & seek support with any areas of concern.

Clinical links

Advice re When to provide Steroid Card
COPD Report – GOLD 2020 – Click download for personal use.
Diagnosis & Management of COPD – NICE 2019
Simplified NICE/GOLD COPD prescribing algorithm – PCRS 2019.
Stepping Down ICS Safely – PCRS
NICE COPD Rapid Guidance Covid.

Supporting Information – Control

COPD Assessment Test Scores (CAT): Each question should be ranked from 0-5
With 0 being not very symptomatic and 5 being very symptomatic

When looking at severity of symptoms the scores indicate:
– Less than 10 is low impact
– 10-20 medium impact
– >20 high impact
– >30 very high impact

Exacerbation Definition:
An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, if there is specifically increased sputum production and change in sputum colour, this often indicates an infective exacerbation.
For patients that have had increasing exacerbation rate or acute admission due to exacerbation of COPD, have commenced oxygen therapy, have history of respiratory failure, take the opportunity to approach the subject of EOL wishes.

Common Causes of Poor COPD Control:
Incorrect diagnosis/ missed comorbidities.
Poor medication adherence.
Present treatment unsuitable.
Under use or poor delivery of current inhaled medication.
Poor inhaler technique.
Continued smoking (active or passive).
Persisting occupational triggers.
Psychological reasons.

Address these issues before stepping up treatment.

Consider Red Flag presentations. Weight loss, Haemoptysis, Chest Wall Pain, or just deteriorating symptoms. When was the last CXR

MRC Breathlessness Score non modified as per NICE not GOLD
MRC 1: Breathless with strenuous exercise.
MRC 2: SOBOE: hurrying or slight hill.
MRC 3: Walks slower than others on the level, or has to stop for breath, when walking at his / her own pace.
MRC 4: Stops for breath after 100m. on the level.
MRC 5: Too breathless to leave the house or breathless when dressing/ undressing.

With an MRC > 3 discuss referral to Pulmonary Rehabilitation. During Covid Pandemic services are limited. Continue with referral but introduce other exercise options to prevent continued deconditioning.

Referral can be made to Community Physiotherapy team to support patient’s management of exercises at home if the patient is unable to undertake walking or BLF exercise plan at home.

Document PR discussion outcome as part of QOF later (mandatory) and referral forms can be printed once consultation saved if launched via F12.

The Fatigue and breathlessness course is on hold during COVID but they are contactable for future referrals and supporting advice. 01432 852 080

Patient Information – COPD

BLF COPD Passport
BLF Diagnosed with COPD
BLF How Your Lungs Work
BLF Living With a Lung Condition
BLF COPD Flare Ups
BLF Alpha 1

Patient Information – Keeping Active

BLF Keep Active
BLF – Exercise videos
Harefield Hospital Exercise Booklet

Patient Information – Smoking Cessation

Hereford Council Smoking Cessation
NHS Smoking Cessation
BLF Support to Stop Smoking

Patient Information – Nutrition

BAPEN – Nutrition support
Nutrition Advice COPD

Patient Information – Oxygen

Baywater medical Local Oxygen Provider
Oxygen Therapy – BLF

COPD Resources – Hereford

Introduction

Supporting information – current treatment

Clinician preparation

Clinical links

Supporting Information – Patient Consultation

Patient Information – Links can be sent via AccuRx, email or printed and sent

Patient Information – Breathlessness/ Sputum

Patient Information – Depression & Anxiety

Patient Information – Palliation EOL Discussion

Support Information – Confirming COPD Diagnosis

Clinical links

Supporting Information – Control

Patient Information – COPD

Patient Information – Keeping Active

Patient Information – Smoking Cessation

Patient Information – Nutrition

Patient Information – Oxygen