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Isle of Wight

Respiratory Clinical Network

Sarah Kearney

BLF Respiratory Nurse

Achieving Excellence Across Primary & Achieving Excellence Across Primary &

Secondary CareSecondary Care

IOW LIP project Achieving excellence in COPD care by:

– Maintaining low admissions

– Optimising prescribing

– Optimising treatment including smoking cessation

and referral to pulmonary rehabilitation

– To minimise frequency and severity of

exacerbations and ensure that patients can live as

well as possible with their condition

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What did we do?

One practice reviewed 20 patients with a history of 2

or more exacerbations in the last year, optimised their

medicines and initiated a self management plan..

Have you used INCHECK

Device?

Consider Spacer device to

optmise therapy? Write on

PRESCRIPTION – SPACER DEVICE

‘

Use CATS SCORE

to assess your

patient

Low CAT SCORE = 0- 9

Smoking cessation Influenza vaccine

Pneumonia vaccine Reduce exposure to risk

factors Nutrition

Medium CAT SCORE = 10-19

Refer Pulmonary Rehab

NNT=3 admission prevention

NNT= 6 mortality

Is Patient still smoking?

Passive Smoking?

Review maintenance therapy

Self management plan

High CAT SCORE = 20-29 Refer Pulmonary Rehab

Review maintenance therapy

Consider Additional

Pharmacological Treatments

Self management plan

with rescue medicines

Very High CAT Score =

30-40 As HIGH CAT Score +

Referral to specialist care if you are primary care

professional)

ONLY USE TRIPLE

THERAPY IN SEVERE DISEASE WITH

PERSITIENT EXACERBATIONS

= Consider NNT = The NNT is the

average number of

patients who need to be

treated to prevent 1 additional bad outcome

NNH = The number

needed to harm is an epidemiological measure

that indicates how many patients need to be

exposed to a risk-factor

over a specific period to cause harm in 1 patient

Consider Mucolytic

if productive cough for over 12/52

IN LAST 2 YEARS

Carbocisteine Capsules 750mg TDS for 4/52 (£25.67)

Oral Liquid 750mg TDS 250mg/5ml

NNT=6

Maintenance Dose if effective

Carbocisteine 750mg BD Capsules NNT=6 (£17.92)PM

Liquid 250mg/5ml 750mg BD 3x

300ml (£18.30)

BBrreeaatthhlleessssnneessss aanndd//oorr eexxeerrcciissee lliimmiittaattiioonn

SABA = Salbutamol 100mcg 2 puffs prn £1.50 Dose 200 or SAMA = Ipatropium 20mcg 2 puffs qds £5. 05 Dose 200

Or trial both together if monotherapy not optimal in reducing symptoms

EExxaacceerrbbaattiioonnss oorr ppeerrssiisstteenntt bbrreeaatthhlleessssnneessss

CCoonnssiiddeerr TThheeoopphhyylllliinnee 33rrdd lliinnee:: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications. NNT=33

FEV1 ≥50%

FEV1< 50%

LAMA STOP SAMA

Tiotropium 18mcg od Handihaler (£31.89 refill) Dose 30

Combopack (£34.8)

Tiotropium Respimat 2.5 mcg 2 puffs

daily –only if cannot use handihaler (£35.50) Dose 60

NNT= 21 All patients should be advised not

exceed stated dose.

LABA & ICS (combihaler)

Symbicort Turbohaler 400/12 1 puff bd

(£33.00)Dose 60

Seretide 500 Accuhaler 1

puff bd (£40.92) Dose 60 NNT=13

Consider LABA & LAMA if ICS not tolerated

LABA Formoterol Easihaler

12mcg 1 puff bd (£23.75) Dose 120

Salmeterol 50mcg 1 puff bd

(Accuhaler) (£29.26) Dose 60 NNT 21

NNT=21

LAMA STOP SAMA Tiotropium 18mcg od Handihaler

(£33.50) refill) Doses 30

Combopack (£34.87 Doses 30 Tiotropium Respimat 2.5 mcg 2 puffs

daily –only if cannot use handihaler (£35.50) Dose 60

NNT= 21 All patients should be advised not

exceed stated dose.

RReeccuurrrreenntt eexxaacceerrbbaattiioonnss oorr ppeerrssiisstteenntt bbrreeaatthhlleessssnneessss

LABA & ICS (combihaler)

Symbicort Turbohaler

400/12 1 puff bd (£33.00) Dose 120

Seretide 500 Accuhaler 1 puff bd (£40.92) Dose

60 NNT=13 Consider LABA & LAMA if

ICS not tolerated

LAMA & LABA & ICS (combihaler) STOP SAMA

Symbicort Turbohaler 400/12 1 puff bd (£33.00) Dose 120

Tiotropium 18mcg od Handihaler (£31.89 refill) Dose 60 Combopack (device & refill) (£34.87 = TOTAL (£69.89)Dose 60

Seretide 500 Accuhaler 1 puff bd (£40 .92) Dose 60 - Tiotropium 18mcg od Handihaler

(£33.50 refill) Combopack (£34.87) Dose 60 TOTAL (£75.79) NNT=13

Tiotropium Respimat 2.5 mcg 2 puffs daily –only if cannot use handihaler NNT = 13

Check Inhaler technique Check BMI

Consider anxiety and reactive depression

Symptomatic benefit is expected within 4 weeks but reduced exacerbations may be longer

High dose ICS can increase the risk of pneumonia (NNH=47) i.e fluticasone 1000mcg

Rescue Medicines held by patient for exacerbations:TREAT with Prednisolone (NOT EC) 30mg 7 days Consider osteoporosis prophylaxis if patients that have

had 4 courses of steroids within 12 months. Any patients over 65 should be started on prophylaxis without the need for monitoring.

Antibiotics only given for purulent exacerbations: TREAT with Amoxicillin 500mg TDS for 5 Days or Doxycycline 200mg stat then 100mg OD for 7 days

2nd line Clarithromycin 500mg 12hrly (Co-Amoxiclav) 625mg 8hrly5 days. Only 30-50% are bacterial; many viral. Only use 2nd line if failure to respond to 1st line agents. Take sputum for culture and treat according to sensitivities if pathogen isolated. Do not use tetracyclines in pregnancy.

Please turn over for device/month/costs guidance

Check SP02 at each visit and

consider Oxygen Assessment if

SATS below 92%

NICE Clinical Algorithm for COPD Isle of Wight

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COPD Action Plan Taking your chest infections seriously

You can spot a flare-up coming if your usual symptoms get worse for at least one or two days. It’s very important to know how to recognise the symptoms because the earlier you spot them the better.

Key points to think about: Name:

My usual medication:

Including name, strength, dose, route and frequency.

Medication if unwell:

Useful contacts:

• GP and Practice Nurse Telephone:

• Community Respiratory

Team

Telephone (office): 01983 552428

Telephone (mobile): 07826908704

British Lung Foundation Helpline for confidential advice and

support.

Telephone: 08458 50 50 20 (Monday to Friday, 10.00am –

6.00pm)

Website: www.lunguk.org

Please ring the surgery when you start this medicine and say “I have started my rescue medicines –

please ask ____________ to call me to see if I need an

appointment or not”

• 15 patients were already on optimal medication

indicating that there was a lot of good practice already.

• The numbers of urgent, non urgent and t/call contacts

with the surgery, as well as use of antibiotics and

admissions were recorded for the 6 months prior to the

review. The same metrics were then reviewed at 6

months.

• There was a reduction in urgent appointments for 11

patients from 27 in the 6 months pre-use of the plan to

8 in the 8 months afterwards (33%)

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So What?

This can be extrapolated to demonstrate that a

reduction of 30% demand for urgent / routine

appointments on a list size of 100 COPD patients

would amount to a cost benefit of £2800 and saving of

13 hours GP time

Case Study • 65 year old gentleman who has Severe COPD with co-morbidities

of epilepsy, coronary heart disease, and a past history of TIA.

• He was given a personalised Exacerbation Action Plan as he was having regular telephone consultations which resulted in prescriptions for Rescue Medication to manage his COPD.

• He had completed Pulmonary Rehabilitation and was on optimum inhalers but difficult and challenging to manage.

Case Study

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4

6

8

10

12

14

Booked

Appointments

: Emergency

Appointments

Telephone

Consultations

Rescue

Medication

Prescriptions

Typer of Contacts

Nu

mb

er

of

Co

nta

cts

PRE Exacerbation Action Plan

POST Exacerbation Action Plan

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