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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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2
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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