5. COPD Treatment Pathway Establish diagnosis of COPD in at risk population with history, examination and spirometry (FEV1/FEV ratio <70%) Establish severity of disease by FEV1 as % predicted Management of RISK FACTORS plus EDUCATION plus IMMUNISATION SMOKING CESSATION Lifestyle Advice Diet/Exercise Influenza vax (annual) Pneumococcal vax. Psychological Issues Pulmonary rehabilitation if functionally disabled – (Ensure treatment is optimised) PHARMACOLOGICAL TREATMENT Review at each step after one month before escalating treatment SHORTNESS OF BREATH COUGH AND SPUTUM prn short acting β2 agonist MUCOLYTICS THEOPHYLLINE Tiotropium + short acting β2 agonist Tiotropium + long acting β2 agonist (LABA)**salmeterol, eformoterol or indercaterol Roflumilast + Tiotropium + short acting β2 agonist ( Weight loss) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Tiotropium + combination LABA and inhaled corticosteroid (Seretide 500 accuhaler or Symbicort 200/6) Consider Palliative Care Referral in End Stage Disease
6. Telemonitoring in COPD – the evidence base Numerous pilot projects with accompanying evaluation reports; Often exceptionally good results (e.g. COPD telehealth in SE Essex – 75% reduction in A&E attendances; 83% reduction in hospital admissions) Often methodologically limited (e.g. before-and-after studies; small sample sizes) Systematic reviews demonstrate that high-quality evidence base is still immature; Bolton (2010): studies included were positive but of a low-quality Polisena (2010): Telehealth interventions improved QoL and reduced hospitalisations
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8. MDT agrees interventionRESPOND Telephone patient Visit - within identified timescale Emergency Response Step up / Step down Community Beds 2. Alerts 3. Triage 4. Response Protocols for response in place: GP, NCT , specialist services, secondary care
10. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; Providing reassurance and support
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12. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; Increasing knowledge of disease process and enhancing self-care Providing reassurance and support
21. Telemonitoring in COPD – suggested mechanisms of action It has been suggested that telemonitoring can support COPD patients by; Enabling earlier detection of exacerbation (e.g. due to reporting of worsening symptoms) Increasing knowledge of disease process and enhancing self-care Providing reassurance and support
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23. The impact of frequent COPD exacerbations - more frequent attacks increase mortality 1.0 0.8 0.6 0.4 0.2 0 0 10 20 30 40 50 60 n=304 A p<0.0002 Survival probability B p<0.0001 p=0.069 C Time (months) Group A: no exacerbations Group B: 1–2 exacerbations Group C: ≥3 exacerbations Soler-Cataluna JJ, et al. Thorax 2005;60:925–931
24. COPD patients with productive cough More likely to have exacerbations Seemungal TA et al. Am J RespirCrit Care Med 98 More rapid decline in lung function Vestbo J 1996, KannerRA et al. Am J RespirCrit Care Med 01 More likely to die early Prescott E et al. EurRespir J 1995
25. Timing of symptoms: when was each symptom the most troublesome? 40 30 20 10 0 19 Cough (n=1,433) Breathlessness (n=1,769) 50 40 30 20 10 0 48.9 31.0 24.0 22.5 % of patients % of patients 19.5 22.3 18.7 17.3 14.9 10.6 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening 40 30 20 10 0 Phlegm (n=1,551) Chest tightness (n=690) 60 50 40 30 20 10 0 56.7 28.8 25.9 25.4 25.5 % of patients % of patients 26.2 16.7 16.6 16.3 11.8 On Later in the In the In the At night Waking morning afternoon evening On Later in the In the In the At night Waking morning afternoon evening Partridge et al. ERS Vienna 2009
26. HULL AIRWAYS REFLUX QUESTIONNAIRE Name: D.O.B:____________________________ UN: _________________ DATE OF TEST: Please circle the most appropriate response for each question www.issc.info TOTAL SCORE_____________ /70
Here we can see two acoustic waveforms. The x-axis is time (covering approx 55 mins) and the y-axis is relative decibels of acoustic events. The upper waveform is from an unprocessed and unfiltered file and the lower waveform is that same file after undergoing the Hull filtering process. We can clearly notice the huge reduction in non-cough acoustic events prior to cough quantification.
