NICE guideline application

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Published on November 20, 2008

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Putting NICE into practiceKola AkinlabiCOPD and Pulmonary Rehabilitation SpecialistHaringey PCT : Putting NICE into practiceKola AkinlabiCOPD and Pulmonary Rehabilitation SpecialistHaringey PCT In collaboration with Education for Health Did you know…? : Did you know…? By 2020 COPD will be the third leading cause of death from chronic disease worldwide1 1. Murray & Lopez. Lancet 1997. 2. National Institute of Health. GOLD Teaching Slide Kit. Updated 2006. 3.0 2.5 2.0 1.5 1.0 0.5 0 Coronary heart disease Stroke Other CVD COPD All other causes -59% -64% -35% +163% -7% Percentage change in age-adjusted death rates in USA, from 1965 to 19962 Proportion of 1965 rate Did you know…? : Did you know…? In 2004, the estimated number of deaths from COPD in the UK was 27,500 – this equates to 3 people dying every hour1 1. The burden of lung disease (2nd Edition). British Thoracic Society 2006. The financial cost of COPD in the UK : £1.2b asthma lost productivity cost1 The financial cost of COPD in the UK £49m asthma hospital admissions1 £530m COPD hospital admissions2 £2.7b COPD lost productivity cost3 1. Where do we stand? Asthma UK 2004. 2. Britton. Resp Med 2003. 3. Chief Medical Officer Annual Report It takes your breath away 2004. COPD is a progressive disease, most often caused by smoking1 : Symptoms COPD is a progressive disease, most often caused by smoking1 Smoking Airflow limitation Exacerbations Reduction in quality of life Mortality Systemic component Airway inflammation Mucociliary dysfunction Structural changes 1. NICE guideline No. 12. Thorax 2004. Pathophysiology of COPD : Pathophysiology of COPD Smoking Emphysema Changes in the lining and structure of the airways, e.g. an increase in the number of goblet cells and size of sub-mucosal glands1 Inflammatory response = chronic inflammation1 Increased mucus production in bronchi and bronchioles: mucus hypersecretion1 Loss of elastin leads to loss of elastic recoil in the alveolar walls and reduces the area available for gaseous exchange Chronic bronchitis Destruction of alveoli and enlargement of air spaces in the lungs: tissue damage 1. Agusti. Resp Med 2005. Why have guidelines? : Why have guidelines? To provide a consistent, evidence-based approach to management To improve the standard of management To enable planning of services and resources To provide a yardstick for audits To use as an educational tool To help those who are unsure “To do the best thing for our patients” NICE COPD guideline : NICE COPD guideline The British Thoracic Society produced consensus-based guidelines that were last updated in 1997. These have been superseded by the guideline from the National Institute for Health and Clinical Excellence (NICE) NICE produced its evidence-based guideline on COPD in 2004. This is the guideline used by healthcare professionals in the UK The BTS COPD Consortium – play an important role in disseminating NICE guidelines in a practical guide. NICE: key priorities for implementation in COPD1 : NICE: key priorities for implementation in COPD1 Diagnose COPD Stop smoking Effective inhaled therapy Manage exacerbations Pulmonary rehabilitation Non-invasive ventilation Multidisciplinary working 1. NICE guideline No. 12. Thorax 2004. Case study – Margaret : Case study – Margaret Margaret is 52 years old. She works in an office and has two children She has smoked around 25 cigarettes a day for 30 years Her FEV1 is 55% predicted normal Margaret’s father died 4 years ago of ‘chest disease’ She has a productive cough and finds she is breathless on exertion both at work and at leisure Last winter she had a bad chest infection She has tried various inhalers Case study – Margaret (age 52) : Case study – Margaret (age 52) Margaret was diagnosed with COPD 7 years ago. How would you stage her disease per the NICE guideline? The stages of COPD – NICE¹ : The stages of COPD – NICE¹ Mild(FEV1 50–80%) Moderate(FEV1 30–49%) Severe(FEV1 <30%) Breathlessness and exercise limitation Prevention of exacerbations Short- and long-acting bronchodilators If still symptomatic consider a trial of combination long-acting 2-agonist and inhaled corticosteroid* Consider adding theophylline If still symptomatic despite maximum inhaled bronchodilator consider referral for specialist assessment 2-agonists/anticholinergics In patients suffering two or more exacerbations per year add inhaled corticosteroid usually in combination with long-acting bronchodilators 1. NICE Guideline No.12. Thorax 2004. *Discontinue if no benefit after 4 weeks Case study – Margaret (age 52) : Diagnosis Margaret has mild/moderate COPD History Has tried to quit smoking Chest infection last winter Prescribed various inhalers FEV1 = 55% predicted normal Symptoms Breathlessness on exertion getting worse Productive cough What do Margaret’s symptoms stop her doing? Enjoying leisure activities with her family Playing bowls Case study – Margaret (age 52) Managing Margaret’s COPD : Exacerbations Managing Margaret’s COPD Smoking Breathlessness and exercise limitation QoL What does NICE say about smoking cessation? : What does NICE say about smoking cessation? Encouraging patients to stop smoking is one of the most important components of COPD management1 All patients should be encouraged to stop smoking at every opportunity and offered help to do so1 Click here to find out more about the effects of smoking Bupropion, varenicline or nicotine replacement therapy (NRT) + an appropriate support programme should be used to optimise smoking quit rates for people with COPD1, unless contraindicated 1. NICE guideline No. 12. Thorax 2004 Managing Margaret’s COPD : Exacerbations Managing Margaret’s COPD Smoking Breathlessness and exercise limitation QoL What does NICE say about treating breathlessness and exercise limitation? : What does NICE say about treating breathlessness and exercise limitation? Breathlessness is often the most worrying symptom for COPD patients1 The NICE guideline recommends the use of short-acting bronchodilators when needed as the first step in managing breathlessness and exercise limitation In addition, patients should be encouraged to take daily exercise that makes them a little short of breath, aiming to increase the length of time they exercise Pulmonary rehabilitation should be made available to all patients who need it and patients should be made aware of both the commitment required and the benefits that should result Click here to find out more about pulmonary rehabilitation and exercise limitation Click here to find out about the impact of breathlessness 1.. NICE Guideline No.12. THORAX 2004. Managing Margaret’s COPD symptoms : Managing Margaret’s COPD symptoms Smoking Breathlessness and exercise limitation QoL Exacerbations How does NICE define an exacerbation of COPD? : How does NICE define an exacerbation of COPD? 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 onset1 1. NICE guideline No. 12. Thorax 2004. How does NICE suggest that frequency of exacerbations should be reduced in the first instance? : How does NICE suggest that frequency of exacerbations should be reduced in the first instance? The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids* (usually in combination with long-acting bronchodilators) and vaccinations1 1. NICE guideline No. 12. Thorax 2004. * Inhaled corticosteroids as individual therapy are not licensed for the treatment of COPD in the UK Why is prevention of exacerbations key to managing COPD? : Why is prevention of exacerbations key to managing COPD? Disease progression is associated with an increase in inflammation1 After an exacerbation lung function does not return to the same level as before the exacerbation2 An exacerbation is associated with a decline in quality of life3 Click here to find out more about the financial cost of exacerbations Exacerbation Lung function ? Inflammation ? Quality of life ?    1. Hogg et al. N Engl J Med 2004. 2. Seemungal et al. Am J Respir Crit Care Med 2000. 3. Seemungal et al. Am J Respir Crit Care Med 1998. What implications does this have for Margaret’s treatment? : What implications does this have for Margaret’s treatment? NICE recommends treatment to reduce exacerbation frequency for patients with an FEV1 equal to or less less than 50% who suffer frequent exacerbations1 Inhaled corticosteroids* in combination with long-acting bronchodilators can reduce exacerbations requiring oral corticosteroids by over 40% in patients with FEV1 < 50%2 1. NICE guideline No. 12. Thorax 2004. 2. GSK data on file. SFCB3024 COPD Patients <50% FEV1. * Inhaled corticosteroids as individual therapy are not licensed for the treatment of COPD in the UK Further minimising the impact of exacerbations : Further minimising the impact of exacerbations The impact of exacerbations should be minimised by: Giving self-management advice on responding promptly to the symptoms of an exacerbation Click here to find out more about recognising an exacerbationClick here to find out more about self-management of COPD Starting appropriate treatment with oral corticosteroids and/or antibiotics Use of non-invasive ventilation when indicatedClick here to find out more about non-invasive ventilation Use of hospital-at-home or assisted-discharge schemes Managing Margaret’s COPD : Managing Margaret’s COPD Smoking Breathlessness and exercise limitation QoL Exacerbations Case study – Margaret (age 52) : Why has Margaret presented? Case study – Margaret (age 52) It is likely that Margaret has presented because her quality of life is being impacted : It is likely that Margaret has presented because her quality of life is being impacted Quality of life may be progressively impaired in COPD patients, mainly as a consequence of breathlessness and exacerbations1,2 Regular review of patients is needed to be able to compare quality of life at different times and to measure the effect of any new medication or other therapy introduced QoF indicator - Patients with COPD should be reviewed every 15 months NICE recommends that mild or moderate COPD should be reviewed at least once a year; severe COPD patients every 6 months3 1. Seemungal et al. Am J Respir Crit Care Med1998. 2. Mahler et al. Chest 1992. 3. NICE guideline No. 12. Thorax 2004. Reviewing COPD patients : Reviewing COPD patients For all patients with COPD1 Highlight COPD diagnosis in all patient records Offer smoking cessation advice Record diagnostic spirometry results – absolute values and % predicted FEV1 Record opportunistic spirometryClick here to find out more about spirometry Follow-up is vital to ensure patients are optimally managed Impact of disease should also be assessed by: Degree of airflow obstruction The frequency of exacerbations Health statusClick here to find out what questions to ask at review and the steps to an effective consultation 1. NICE guideline No. 12. Thorax 2004. Reviewing inhaler technique : Reviewing inhaler technique Patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and, if necessary, should be shown the correct technique Click here to find out more about inhalers and inhaler technique Managing Margaret’s COPD : Managing Margaret’s COPD Encourage and help her to stop smoking Check that Margaret's inhaled therapy is in line with her disease severity and that both symptoms and frequency of exacerbations are taken into consideration. This may involve treatment with ICS and LABA combination Check Margaret is able to use and understands the benefit of the treatments she is prescribed Consider other interventions, e.g. pulmonary rehabilitation Work with Margaret to develop a self-management plan How can we help you to help Margaret? Respiratory Care Team – ask your RCA for details of the other modules available Education for Health – click here for more information on resources available from Education for health Thank you for your attention today : Thank you for your attention today In collaboration with Education for Health Why is it important to stop smoking?1 : Why is it important to stop smoking?1 Age (years) Stopped at 65 Stopped at 45 Never smoked or not susceptible to smoke Disability Smoked regularly and susceptibleto its effects Death 25 50 75 FEV1 (% of value at age 25) 25 50 75 100 1. Fletcher & Peto. Br Med J 1977. Helping patients stop smoking : Don’t forget! Smoking in enclosed public places is now banned in England, Scotland, Wales and Northern Ireland Helping patients stop smoking Simply Stop Smoking - actions to take: Ask all people who smoke about smoking habits at every opportunity1 Assess motivation to quit Advise the person who smokes to stop, explaining how it will be of benefit2 Assist the person to stop by explaining the steps to take2 Arrange follow up visits 1 and 2 weeks after quit day, then after 1, 2 and 3 months2 1. Nice GUIDELINE No. 12. Thorax 2004. 2. Simply Stop Smoking. Education for Health 2007. Please click here to return to main presentation The impact of breathlessness : The impact of breathlessness COPD patients’ overall health and quality of life has been found to deteriorate as breathlessness becomes more severe1,2 In a survey, patients reported being too breathless to climb stairs, do housework or get dressed by themselves3 One COPD patient described his breathlessness as, “I felt like I had no air to do anything, it was like I was being strangled continuously.”4 1. Seemungal et al. Am J Respir Crit Care Med 2000. 2. Mahler et al. Chest 1992. 3. Morgan et al. Eur Respir J 2001. 4. Breathing Fear. The British Lung Foundation 2003. Please click here to return to main presentation Pulmonary rehabilitation : Pulmonary rehabilitation Pulmonary rehabilitation is a multidisciplinary programme of care for patients with COPD and is individually tailored to optimise a patient’s physical and social performance1 Identify patients who will benefit from pulmonary rehabilitation, usually MRC dyspnoea scale grade 3 or above1 1. NICE guideline No. 12. Thorax 2004. Exercise limitation : Exercise limitation Exercise can be beneficial for COPD patients, despite the symptoms they may be suffering Encourage patients to take daily exercise, such as walking round the garden or round the house1, aiming to increase their walking to 20–30 minutes four times a week 1. Living with COPD. British Lung Foundation. Please click here to return to main presentation The high cost of exacerbations : The high cost of exacerbations An estimated £980 m is spent on COPD each year in the UK1 60% of this is spent on unscheduled care,1 i.e. treatment of exacerbations In 2000/2001, the average cost of caring for someone with COPD ranged from £149 for a patient with mild COPD to £1,307 for a patient with severe COPD2 The estimated cost of an exacerbation ranged from £8–£15 for a patient with mild COPD to £1,400–£1,600 for a patient with severe COPD2 1. Britton. Resp Med 2003. 2. Clearing the air. Healthcare Commission 2006. Please click here to return to main presentation Recognising an exacerbation : Recognising an exacerbation Give written information on recognising worsening symptoms, such as:1 You get much more breathless than you did before (doing the same thing) You produce more sputum than before Your sputum becomes discoloured You feel feverish or unwell Cough gets worse 1. NICE guideline No. 12. Thorax 2004. Please click here to return to main presentation Patient self-management – dealing with worsening symptoms1 : Patient self-management – dealing with worsening symptoms1 Patients at risk of having an exacerbation should be encouraged to respond quickly to the symptoms of having an exacerbation by: Taking oral corticosteroid therapy if breathlessness interferes with normal daily activities Starting an antibiotic therapy if sputum is purulent Adjusting bronchodilator therapy to control symptoms They should be given a course of antibiotic treatment and corticosteroid tablets to keep at home Advise them that they should alert their practice as soon as possible if they have needed to start taking antibiotics or steroid tablets Please click here to return to main presentation 1. NICE guideline No. 12. Thorax 2004. Non-invasive ventilation¹ : Non-invasive ventilation¹ NICE recommends that non-invasive ventilation should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy Please click here to return to main presentation 1. NICE Guideline No.12. Thorax 2004. Spirometry : Spirometry Spirometry gives three important measures: FEV1: the volume of air that the patient can forcibly exhale in the first second of forced expiration FVC: the total volume of air that the patient can forcibly exhale in one breath FEV1/FVC: the ratio of FEV1 to FVC expressed as a percentage The NICE guideline definitions of severity of COPD are as follows:1 Mild airflow obstruction – FEV1 50-80% Moderate airflow obstruction – FEV1 30-49% Severe airflow obstruction – FEV1 <30% predicted Please click here to return to main presentation 1. NICE guideline No. 12. Thorax 2004. What should you be asking your patients at regular review? : What should you be asking your patients at regular review? Has anything changed since we last reviewed your COPD? Has anything got better or worse? What can’t you do that you would like to do? Is there anything you have had to stop doing since I saw you last? What activities cause you to be breathless? Have your breathing problems caused you to feel anxious, unhappy or depressed? Have you had any bad infections or flare-ups since you were last seen? Do you know how to recognise when you are getting worse? Steps to an effective consultation : Steps to an effective consultation Listen to the patient and allow sufficient time for the consultation Ensure the patient understands and accepts their diagnosis and relevance of treatment, and is given appropriate patient education material Share decision-making about the patient’s treatment and future Treatment plans should be individualised for each patient Ensure that there is time during the consultation for the patient to ask questions or book a repeat appointment in the future for the patient to return with any questions once they have had time to think about the diagnosis NICE recommends that patients with mild/moderate COPD should be reviewed once a year, while patients with severe COPD should be reviewed twice a year1 Please click here to return to main presentation 1. NICE guideline No. 12. Thorax 2004. NICE – inhaler technique1 : NICE – inhaler technique1 In most cases bronchodilator therapy is best administered using a hand-held inhaler device (including a spacer device or other aid if appropriate) If the patient is unable to use a particular device satisfactorily or it is not suitable for him/her, an alternative should be found Inhalers should be prescribed only after patients have received training in the use of the device and have demonstrated satisfactory technique 1. NICE guideline No. 12. Thorax 2004. Inhalers and patient adherence : Inhalers and patient adherence Good medication adherence depends on the patient being prescribed a suitable inhaler:1 Does the patient understand how to use the inhaler and how to recognise when it is running out? Is it discreet, easy to use and easy to carry about (for reliever medication)?1 Is your patient physically impaired in a way that would make some inhalers harder to use than others, for example rheumatoid arthritis?1 Can the patient generate sufficient inspiratory effort to use a device?1 Please click here to return to main presentation 1. Simply Devices. Education for Health 2006. Slide 45: Education for Health (previously known as The National Respiratory Training Centre) is the UK’s leading education charity for health professionals caring for patients with long-term conditions Pioneering primary care education since 1987, Education for Health provides training in the areas of: Respiratory and Cardiovascular Disease, Allergy and Diabetes and Consultation Skills Programmes are run nationally and are accredited by the Open University www.educationforhealth.org.uk Education for HealthCourses and Supporting Resources : Education for HealthCourses and Supporting Resources A full range of training and education programmes including One day short Courses Level 2 Diploma Modules Level 3 Degree Modules MSc Programmes Supporting resources include Simply… book series, CD ROMs, breathing tubes, record cards and desk top aids Please click here to return to main presentation

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