Moving in the right direction Dr Nawaid Ahmad

‘Moving in the right direction’ Dr Nawaid Ahmad Clinical Lead for Community Respiratory Services in T&W Consultant Chest Physician @Sa. THNHS Undergraduate Clinical Tutor Keele University nawaid. ahmad 3@nhs. net @nav_doc

Sa. TH Consultants Local GPs Event date to be finalized Will send an email to all through the organizers to gain expression of interest Lets DO it!

Why am I here today? • Talk about COPD • Look at some local data and opportunities for improvement • Discuss the new local COPD guidelines • Discuss a pathway for weaning COPD patients from Inhaled corticosteroids • Discuss some interesting cases • End the session with Q&A

Diagnosing C O P D Elderly Young SMOKING 45 -50% Indoor Air pollution 20% SPIROMETRY RISK FACTORS Alpha-1 Lung dev. Chronic Asthma Marijuana Beasley et al. Smoking and COPD: what really are the risks? ERJ 2006 NICE COPD Pathway HISTORY Winter Bronchitis Chronic Cough Exertional Breathlessness Age>35

COPD spectrum Emphysematous Obese Bronchitic Recurrent Exacerbrators Frail End of Life Overlap With Sleep Apnea Type 2 Respiratory failure Colonizers Bronchiectasis Heart Failure Asthma Overlap Aspergillus Atypical TB

"We treat it. If she[he] gets better we know that we're right. "

Challenges • • • Time Validated Spirometry Asthma Confirmation bias Patient demands Occupational exposure in non smokers e. g. bakers

Smoking 18+ yrs self reported smokers (%) Smoking quit rates/100000 population aged 16+ years

COPD I Estimated Prevalence (%) Reported to Estimated Prevalence (%)

COPD II Diagnosis confirmed by Spirometry (%) Record of FEV 1 in the last 12 months (%)

Prescription of Inhaled Corticosteroids Source: Openprescribing. net

Influenza and Pneumonia Spend (£ per 1000 population) COPD patients who have had Flu immunization (%) Chronic lower respiratory non-elective spend (£ per 1000 population)

Respiratory Focus Pack Apr 2016 Opportunities Summary

E S O D R E H G ide I A H eson ITH Bud W h D t i E T nw A I Y a C T I h O )t L S A S E T A ID R O T S E O AL SER M D ( N I N ne A E o S T s A EC tica E F R F lu E C S h. F ) N I S t A O CL e wi ORT N S I or BIC E M YM R E (S H T

KARMA DEONTOLOGY

Guidelines

Treating Phenotypes

GOLD GUIDANCE

NICE Guidance 2015

RED ALERTS ICS is NOT the first line treatment for patients with COPD ICS is THE first line treatment for patients with Asthma

Inhalers SABA LABA SAMA LAMA ICS

CHAOTIC CO MP DON’T KNOW WHAT TO DO SIMPLE LE X REFERRAL TO SECONDARY CARE GUIDELINES P elsek, T Greenhalgh The challenge of complexity in health care. BMJ 2001; 323: 625 -8

Cases

Mr Joe Bloggs 67 year old gentleman Previous HGV driver, now retired Ex-Smoker 40 pack years. Stopped 5 years ago BMI 30 Short of breath on exertion for last 5 years, getting worse • Gets chest infection in the winters • FEV 1 1. 23 Ltrs (60%) ratio: 0. 5 (Post BD) • • •

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Mrs Bloggs 69 year old lady Worked as a cleaner Ex-smoker 30 pack years, quit 2 years ago Shortness of breath and cough for 5 years FEV 1 1. 2 Ltrs (55%), FVC 2. 6 Ltrs (70%) ratio 0. 46 (Post BD) • No hospital admissions. • Already taking Serevent (LABA) and Ventolin inhalers • • •

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Mr XYZ • • 45 yr old male Tree Surgeon Ex smoker 12 months, 25 pack years of smoking Short of breath, chest tightness, gets hay fever and coughs in presence of wife’s perfume Had Asthma as a child but grew out of it No hospital admissions and no antibiotics FEV 1 1. 8 Ltrs (45%), ratio 0. 4. 30% reversibility. Taking LABA and Ventolin PRN but no better, comes for review

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