Nursing Care Plans For Copd

hello, i'm norman swan. welcome to this programon breathlessness in the older adult, asking the question, 'is it asthma?' we're coming to you liveacross australia through the rural health educationfoundation's satellite network. some older people think that breathlessness isa natural consequence of ageing, unaware that's not the case, even though the prevalence of asthma

and chronic obstructivepulmonary disease, copd, both increase with age. in this program, we'll talk about the differentialdiagnosis of breathlessness, with special referenceto asthma and copd. the distinction between asthmaand copd is important, even when they coexist,as there are significant differences in the care of peoplewith each condition. as always,we have a number of useful resources

on the rural health educationfoundation's website - as usual, the broadcast is interactive, and we want your phone calls and faxeswhen you want to ask a question. you can even drop us an email. we've already had one question inahead of time. we look forward to yours. the numbers to call in on are - fax numbers - or you can drop us an email,

and somebody will be hangingon the computer, waiting for it - now let's meet our panel. christine mcdonald is deputy directorof the austin hospital's department of respiratory and sleep medicine, and a director of the institutefor breathing and sleep medicine at the same institution. - welcome, christine.- thanks very much. as a clinician/researcher, christine'sspecial research interests include airways diseases, asthma, copdand lung cancer.

she's a member of the australianlung foundation's copd executive. gary kilovis a solo general practitioner, currently practising in clarinda,in melbourne, with over 25 years' experience in bothmetropolitan and regional practice. - welcome, gary.- thank you. toni riley is a community pharmacistwith 30 years' experience, currently practisingin bendigo, victoria. a victorian evening this evening. - welcome, toni.- thank you.

toni has a major focus in her pharmacy as a provision of pharmacy servicesto residential care facilities, and is also on the national asthmacouncil pharmacist asthma group. last but not least, vanessa mcdonald, who's a respiratory and sleep-medicineclinical nurse/consultant with hunter new england healthin newcastle in new south wales and has 15 years' experiencein asthma and respiratory education. - welcome, vanessa.- thanks, norman. vanessa's current phd studies

are in obstructive-airways diseasein older people. sounds like her special intereststonight are in mastermind. we'll sit back and have a spotlightgoing on you all. welcome to you all. what are the major issues from a general practice point of view,gary? we see a number of patients who maypresent with shortness of breath or some respiratory symptom. the issue is really to try and tease outthe potential causes, the differential diagnosis,

and then to stratify those in terms of potential seriousnessand potential urgency. - a common walk-in, though, isn't it?- it is indeed. it may often be evenan incidental finding, when somebodypresents with something else. they may present withan upper respiratory tract infection, and when one delves a bit deeperinto the history, they may explain that they routinelyneed several courses of antibiotics, they get more frequent infectionsthan other people.

it's somethingthat we can then explore further. do you ever get a surprise diagnosiswhen you go through the differential? we do. we do indeed. and i think,particularly with the older patient, because the existence often of multiplediagnosis, multiple pathology, even if one is fairly certain aboutone's diagnosis, one has to be vigilant not to miss something else. by the time you get tothe back of the pharmacy, a few must be breathless, toni? you're probably correct.

norman: your head's buried in thecomputer screen. you wouldn't know. no, not at all. the reality is we do get the oddbreathless patient in the pharmacy that perhaps hasn't been to the doctorat that stage. it would be our normal procedure to endeavour to make sure that personwas seen by the doctor. we might even ring the doctor firstand ensure that that was facilitated. if it was urgent, obviously,we'd be calling an ambulance... what are the common medication issues?

as in drug interaction-type things,you're thinking along the lines? we need to be very careful aboutbeta-blockers and people with asthma - not only beta-blockers treatingcardiovascular conditions but beta-blockersthey're using in eye drops. oftentimes, ophthalmologists don'tget to know the rest of their condition. they may not know this isa contraindication for this person. there is another part of the bodythan the eye. there is, yes, yes. vanessa, you'd imagine these days,when smoking rates,

particularly in the over-50s,are incredibly low, that the problems of copd, et ceteraand asthma must be disappearing. we're certainly seeing a decreasingtrend in asthma admissions into the acute setting. however, we're not seeingthe same trend with copd admissions. the prevalence of asthma and copdin this country and internationally is in fact increasing. - really?- mm-hm. christine,why aren't the rates going down?

in copd, we're seeing peoplein the older age group who started off as a cohortwho might have been smokers. we're still seeing the effectsof the smoking down the track. in terms of asthma and copdin the older age group, as we're here to talk about tonight, it can be difficult to tease outone from the other, particularly if they have been smokers. although smoking rates are going down,smoking rates among asthmatics are not dissimilarfrom the rest of the community.

it's still around 17% to 20%. that's why we're still seeing peopleadmitted to hospital with copd, and asthma in the older age group - because, probably,many of them have coexistent disease. i understand that asthma deathsthese days are in the older age group? yes, they are. again, part of that may bethat they're copd patients, partly to do with the fact that we're underdiagnosing asthmain the elderly population.

why is that? possibly not thinking of it as much. in fact, there's data to suggest that - that patients who are oldermay not be tested, or diagnosis may not be thought ofas much as in a younger person. there's also male-female discrepancy. if you see a woman presenting withbreathlessness, you're more likely to think of asthma. if you see an older man,you're more likely to think of copd.

whereas that doesn't always follow. there's a burdenof undiagnosed copd? undoubtedly there is, yes. have people done the epidemiologyof a mixed picture, even if you add incoronary heart disease? not very well, norman. that hasn't been done very well. a lot of the epidemiology, the asthmaprevalence and the copd prevalence, there's probably an interactionbetween the two.

there have been paperslooking at the number of patients who are co-diagnosedwith both asthma and copd. this is quite high. patients themselves will say,'one doctor told me i had asthma, the other one said i had emphysema.what have i got?' often it is difficult to tease that out.they may have both. is there an inordinate focus on theheart, being a respiratory condition? yes, i do think so. as hospital specialists, of course,we see the patients,

they've normally had the investigationsfor the cardiac disease. so they've had their echocardiogram,they've had their ecg. then someone thinks, maybethey should have a breathing test. and the penny drops. do you find that as well, vanessa? yes. in fact, the prevalenceof this overlap and this mixed disease is being increasingly recognised. there was a paper this month in thoraxfrom a group in new zealand that studied a large group of peoplewith airways disease.

they found that only 19% could bedefinitively defined as copd alone. the rest of the populationhad some kind of overlap, whether it be asthma and copd or whether that be chronic bronchitis,emphysema or some other mix. which, gary,must complicate management? absolutely.i know this is a respiratory evening, but as a gp, i am perhaps defendingthe cardiac perspective a little bit. we're holistic here. we can cope. cardiovascular death still - despiteall the advances that have occurred -

it still takes the lion's shareof mortality. there is a mindset among gps that if there is a possibilityof this being cardiac, that's going to be the focus. to some extent, as you mentioned,we don't think about copd enough. the risk factors, or the pathogenesis,of some of these conditions overlap. once the gp has perhaps excludedwhat they perceive might be a cause of sudden deathor of much greater urgency, sometimes the drive to continueto explore the causes is lessened.

hopefully this evening,we can change that a little bit. let's try. we've got a few case studies.let's take a look at our first one. max is a 65-year-old man,new to your surgery, gary. he comes in complaining of increasingbreathlessness with some activities. he's finding it hardergoing to the shops, climbing stairs, walking any distance. he's not too worried. he sayshe's not as young as he used to be. what's your approach to max?

this is a fairly common scenario - a patient who presentsnew to the practice. they may have moved into the areaor their gp may have retired. they'll often minimise the symptoms because they've been coming on over...sometimes decades. they'll attribute it to ageing,to perhaps putting on a little weight or giving up the golf. because it's insidious, people are able to adjust remarkablywell to their declining lung function.

from the gp's perspective,you have undifferentiated disease. we're looking broadly, i suppose, atcardiac causes, respiratory causes, and of coursethere's an overlap of both. then of course there are thenon-cardiac, non-respiratory causes, such as perhaps anaemia, even anxiety. we are seeing more of our patientsbecoming obese and deconditioned. it can be difficult to tease out on the basis of the limited informationwe have at present. anything to add tothe differential diagnosis, christine?

just thinking of thyroid disease.there's a bit of a differential. in terms of respiratory diseases, there are other respiratory diseases,such as pulmonary fibrosis. i mean, much rarer. but, again, in terms of yourdifferential with cardiac diseases - with crackles, for example. if you go into max's history, he's had a run ofupper respiratory infections, but he tells youhe was always a chesty child.

he does talk aboutwheezing and coughing, particularly on exercisefirst thing in the morning. he is mildly obese, with a bmi of 30. he's taking half an aspirin a dayon the advice of his last doctor and atorvastatin, 20mg daily. between the ages of 17 and 50he smoked a pack a day, and he saysthat he's now an ex-smoker. he tells you that his last doctordid an ultrasound of his heart, but he's never had a lung test.

what are you going to do for him now? this focuses our attention now moreon the respiratory side. he's had someof the cardiological investigations, though there's certainly room for more. the previous gp would haveexcluded things like heart failure, but there could still besilent ischaemia. we would like to do other investigationslooking at anaemia and we would like to do spirometry. anybody who presentswith any respiratory symptom

should have spirometry. max would be a candidate for that. and a chest x-ray looking for a tumour? yes, a chest x-ray as well. is it going to take much elseother than a tumour, christine, a reason for an x-rayin a man like this? if you see a major degreeof hyperinflation, you could be thinking asthma or copd. you'd be looking for cardiac signs,as you say.

but tumour, and pulmonary fibrosis, but on examinationyou would have found some crackles. this is presuming we would have skippedover examination. - you have laid a hand on him, gary?- absolutely. assuming there's not much to find. gary, what's your view of the roleof spirometry in general practice? i think spirometry is very important. in a situation like this, it can give usan enormous amount of information, and can possibly obviate the need

for more complicated and expensiveinvestigations. it's an effective wayof picking up obstructive lung disease. we can also pick up restriction, which,as christine said, is less common. it will also help us in terms ofdefining the severity of the disease, if there is any. it's a good baseline to determinethe response of medication. if there's an improvement, we can also track the progressionof the disease as well. spirometryis an absolutely essential part

of any respiratory historyand examination. an essential part of general practice. some people have argued that if you'vegot a stethoscope in general practice, you should have a spirometer. diagnosing respiratory diseasewithout doing it with spirometry is a bit like managing diabeteswithout looking at the blood sugar as far as i'm concerned,but i am a respiratory physician. we need to be doing it morein general practice. what are you looking foron the spirometry, christine,

to differentiate between asthmaor copd in someone like max? we're looking for airflow obstructionto diagnose either of them. in asthma there's variability andreversibility of airflow obstruction. in most patients,that reversibility is complete. post-bronchodilator,you'll get normal spirometry. in copd, by its definition, you have an irreversible or poorlyreversible degree of airflow obstruction and post-bronchodilator spirometry will still showa persisting obstructive defect.

vanessa, what would be the issues,if you're thinking ahead and dealing with max, in terms ofself-management and other things, you'd want to be preparingyourself or him for? with max, despite whetherthis might be asthma or copd, it will be a new diagnosis. he's going to need to understandthe process of the disease and how it's managed in terms ofthe actions of these medications, the side effects that might happenand how they're delivered - most likelythey'll be inhaled medications.

that would be the first thingsto deal with with max. he has been a past smoker,so we'd need to revisit whether or not he is currently smokingor has been smoking recently. just because someonegave up previously doesn't meanthey're still a current smoker. whether max is diagnosed with asthmaor copd, we'd need to look at whether or not he needsexercise rehabilitation. as gary said, he's deconditioned,he's overweight. that would be an effective formof treatment for him

with his decreased lung function, that's if he has decreased lungfunction, after we do the spirometry. the final thing would be developingsome kind of management plan with him so that he knows what to doshould his symptoms deteriorate. christine, is there any evidencethat reducing weight improves respiratory symptomsin asthma or copd? there is limited evidence, norman,that that is the case, yes. but it's very difficultto get people to lose weight, so the studies are difficult to do.

we know from the sleep apnoea world,whenever we try and do such studies, the majority of patientsdon't lose the weight. but i would agreethat an exercise program and a weight-reduction program would be an important partof this man's management. although often with copd,you're thin rather than fat. toni: oftentimes. that used to be the case, although we're finding now,with the obesity epidemic...

you're getting the same paradoxyou get with heart failure - you're more likely to get heart failureif you're obese, but once you're obese,you're more likely to survive it. certainly in copdthere is that obesity paradox, in that if you're obeseyou're protected against mortality. many studies have shown that. it's difficult to know what to doin that situation, i suppose. is there much difference insymptomatology between, say, somebody in their 30s or 40sversus max, in his late 60s?

- in terms of...- asthma. copd, you're not going to expectin the younger person. but asthma? if the person is younger, it's usually more clear-cutthat they have asthma. but the symptoms will be the same. in this instance, the patient'smain symptom is breathlessness. in the younger age group, certainlyteens and children and younger adults, we'll probably see wheezemore frequently rather than the insidious onsetof breathlessness.

it's the older patient whoattributes this to the ageing process that we see commonly, whereas younger peoplewould be usually more energetic, doing more exercise,and this is not normal, so they'll go along perhaps earlier. gary, let's assume for a momentthat max is pure copd, the 1 in 5, the 20% who have got copdrather than the mixed picture. how would you manage him? it would be important to quantifythe degree of obstruction.

that would determinethe choice of medication. say if he had mild copd,we may find that simple prn use of a short-acting bronchodilatormay be enough. even if there's not much reversibility? yes. it has been shown to improveexercise tolerance and quality of life. if he was a little more severe, we mightadd a long-acting bronchodilator such as tiotropium. if it was getting into the more moderateto severe level, we might then add inhaled steroids

and perhaps a long-acting beta-agonistcombination. and the role of antibiotics? the role of antibiotics is importantin intercurrent infection. it can be difficult thoughto differentiate between... norman: an acute exacerbation.- yeah, and also viral versus bacterial. even with a viral infection,they may cough up discoloured sputum. we do know thatuntreated intercurrent infection does in fact further damage the lungs. so early and aggressiveappropriate management

is important with antibiotics. anything to add or change, christine? on the antibiotic question, depending onhow much sputum this man has, another differentialwe haven't discussed is bronchiectasis. quite a large number of patientswith copd, when you go to do hrcts,may have bronchiectasis. that's muddying the water, butwe haven't mentioned it, and we should. norman: if it was bronchiectasis,a chest physio? chest physiotherapy would be posturingand flutter valves

and, again, prompt use of antibioticsfor infections. would you change anythingto gary's management? no, i don't think so. vanessa has mentionedthe pulmonary rehabilitation, but i think that's really importantto emphasise. in this manand in all patients with copd, pulmonary rehabilitationis level-1 evidence to support its use in terms of improvement inexercise capacity and quality of life, and potentially also some reductionin hospital admissions.

as far as my understandingthrough the lung foundation's work, about 2% of patients with copdin australia has access to pulmonary rehab,so it's really inadequate. and i guess the message should be that there's a toolkit available onthe australia lung foundation website. people who are interestedcan go to that. in the rural community, we need to bethinking about setting up groups to assist these patients, as well as... it's easy in melbourne or sydney.

vanessa? absolutely. i agree. the access that people have to rehabis appalling, really, when you look at the population. is this the sort of stuff a local physioor ot could get involved with? it's not complicated,it's just doing it. absolutely. pulmonary rehabilitationprograms that combine exercise together with self-management are those that have been shownto be the most effective.

doing that in the local community centreis easy enough to do if you've got the resources. adherence is pretty important, toni? absolutely.from the pharmacist's perspective, understanding what disease this patientactually has is important. oftentimes we're not privywith that diagnosis. that makes it difficult for pharmacists. going through the adherence programwith the patient, making sure they knowhow to use their devices,

and understanding why andwhat they're doing is really important. we probably see themmore than anyone else does, so it's an opportunity. a question from a general practitionerin rural victoria to you, gary - what would be the recommended antibioticfor acute exacerbations? i'd probably look at a combinationof amoxicillin and clavulanic acid. we know that there's an increasingincidence of atypical organisms, so one may consider macrolide as wellif the initial response isn't adequate, or sometimes in combination.

do you agree with that, toni? it's certainly what we see in practice. norman: that's a diplomatic answer. it's an honest answer. the thing we see a lot in practicewith older patients being put on those groups of antibioticsis the resultant diarrhoea, which is a bit of an issue. you've got the compliance problem,so what happens next? maybe they stop taking the antibioticsand don't tell anybody,

or maybe they do stop taking theantibiotics and get something else. that is an issuewe see quite frequently. christine, the antibiotic question? i suspect gary's thinking about thatthey may have a patch of pneumonia. that combination of therapy would bevery appropriate in that situation. if it's a simple bronchitic illness, some rulide or some amoxicillinmight be enough. a question from a gp in queensland asks, how often would you repeat respirometry

in somebody with, say, copd to look at whether or notyou're maintaining or declining? there's no level-1 evidence for that. this is really level 4. norman: in your opinion. expert opinion, yes. i would be repeating it firstlyin terms of a trial of medication in someone that i might suspecthas coexistent asthma, where i'm expecting to seea significant improvement.

otherwise, probably if the patientis not doing well and the breathlessness is deterioratingdespite my best attempts, to see whether there's any significantchange in spirometric indices. in fact though,spirometry doesn't correlate very well with level of dyspnoeain copd in general. oftentimes,an mrc breathlessness score or a quality-of-life score might bemore useful to monitor the patient. a gp in south australia asks - you think there's coexistingcoronary heart disease.

you want to do a stress test to see ifyou can elicit significant ischaemia, but there's copd as well. how do you get through all thatto not muddy the stress test? you're often usinga dobutamine stress test or something, because you can't exercise the patientenough. what we do in our hospital is a combinedcardio-pulmonary exercise test, where we use a cycle ergometer. we've got cardiac response,we're looking at ecg,

we can also look atwhat's happening to ventilation. that can give a nice pictureof the lungs and heart. - it's a specialist thing?- yeah. in terms of a stress test, dobutaminestress tests are the way to go if the patient cannot exert themselves. do you want to comment, gary? i agree, absolutely. let's go to our next case study,and keep those questions coming in. andrew is 55 years old.he presents with breathlessness.

there's no history of asthma, buthe's been a smoker for 41 pack years. let's have a look at his baseline pulmonary function test. do you want to walk us through these? christine: sure. firstly, on the left-hand side - i'm sure many of you are familiar with spirometric indices, but just to go through them -

the forced expiratory volume in one second. the forced vital capacity - the amount of air you can take in and fully breathe out. the vital capacity, done not as a forced manoeuvre but a slow manoeuvre. the forced expiratory ratio - the ratio

of the forced expiratory volume over vital capacity. in this case, we've also got a measure of gas-exchange capacity, the tlco, or carbon monoxide-diffusing capacity. he's got severe airflow obstruction. he's got an fev1 of less than a litre, 25% i think it is, of predicted. there's an improvement

post-bronchodilator, so it's post-mdi, probably salbutamol, i imagine. he's left with a significant, persisting, obstructive ventilatory defect, even post-bronchodilator. so looking like copd, particularly with that gas-exchange abnormality, but still could be asthma.

there's a 27% improvement in fev1 post-bronchodilator - only a couple of hundred mils, right on the borderline. you'd be thinking about copd. what would you do for him, gary? as christine has mentioned, you're trying to tease outwhether this is copd or asthma or probably a combination of both,

given that there has beena reasonable amount of reversibility. i would look at a steroid challenge,either oral steroid, perhaps prednisolone,25mg a day for four weeks, or inhaled steroids. to some extent,the choice would depend on how symptomatic the patient is. i would then repeat the spirometry and see whether we were able to achievesignificant improvement. what would you do, christine?

exactly the same thing. oral steroids or inhaled? you know what? i know this patient. i know that i gave him oral steroids. this patient was really quite unwell. i take gary's pointthat in a particularly unwell person, probably oral,to get that response quickly. let's see what his pulmonary functiontests were after three weeks. christine?

i'm delighted to say that there's been a significant improvement in the fev1. remembering that it was under a litre in the previous table,and now 2.4 litres, which is 68% of predicted normal. so a significant improvementin baseline ventilatory function, with a forced-expiratory ratiopost-bronchodilator now of 66%. he still has a persisting degree of airflow obstruction,but really an asthmatic-type response,

i would say,to this course of prednisolone. norman: it's a mixed picture? it's a mixed picturein that he still has a persisting degreeof airflow obstruction even after our maximum treatment. gary, how are you going to manage him,going forward? he's on oral steroids.you got a good response. he's ready to run a marathon -a very limited one, given his copd. i would certainly look to transfer himonto inhaled steroids,

probably in combinationwith a long-acting beta-agonist. this fella has quite significant asthma. he's probably got either remodellingfrom undertreated or untreated asthma, but he's also of course a smoker,so he's got the double whammy. norman: how are you going toget him off his smoking? oh, i wish i knew the answer. one of the things that i find works is really to show him the resultof his spirometry. i find that quite powerful

because you can show the patientwhat they achieved - this is the best that you could do,this is what you should be doing, this is as a result of your smoking. there's randomisedcontrol-trial evidence to suggest that telling them their lung agemakes a difference to motivating them. quite a number of spirometers nowinclude that as an option in the print-out. norman: you've got85-year-old lungs, andrew. yes. this is one of the rare situationswhere we can wind time backwards.

we can get your lungs younger. we can't often offer that. toni, what are the pbs issues herein terms of andrew moving forward, given this transition? given the transition, initially,andrew's going to need to try a plain, inhaled steroidbefore he can go on. that needs to be successful before the beta-agonist can be added into a combination. initially he could be havingtwo inhalers.

norman: a short-acting reliever? plus steroid.you know, your inhaled steroid. and the dose of steroid? it would probably be the 250mcg-typedose, i should think, i would imagine. i'd have to defer to myrespiratory physician and gp, of course. well, probably he'd be starting higherat that stage, wouldn't he, because he's been on his oral. so it does depend a biton what the physicians are feeling. from the pharmacist's perspective,there's a lot of other issues

around complianceand understanding the disease stage and the willingness to treat. especially in a younger person, the willingness to treatand accept that that's essential is often the challenge that we're faced, and i should imagine peoplelike vanessa deal with every single day. what about the dosageof corticosteroids, because we're still going too high. it's high. it's difficult, isn't it?

if he's purely got asthma, we've certainly moved awayfrom those very high doses that were used to be usedsort of a decade or so ago. on the other hand,if we think he has copd and we know he's got someirreversible airflow obstruction... it's a moot point, isn't it, whetherit's the remodelling you talked about or whether it truly is the copd. you'll be aware that the studiesthat have been done on copd have used higher doses,fixed doses of inhaled corticosteroid

and long-acting beta-agonistof 1,000mcg in the large studies, such as the torch study, and800mcg of budesonide in studies by... that might have been engineered by the pharmaceutical companyto flog more drugs. indeed so, but the trouble is,we have those studies and we don't have the studiesof the lower doses in copd. in asthma, we know we can use quite lowdoses of inhaled corticosteroids and that there's a plateau effect. norman: are you hamstrung by the pbsrules if you've got copd and asthma?

- um...toni: not necessarily. no. so, but the temptation... i'm trying toget the picture of the mixed picture and how that changes your management. with titration of dose, followingthe national asthma guidelines, the asthma action plans and so on, it's fairly straightforwardhow you teeter up, teeter down. but with copd, teetering down, titratingdown, might be more of an issue. that's right.thinking about this particular man,

i'd be treating him fairly aggressivelyfor his asthma and i'd probably be wantingto back-titrate. if, however, he was a different patient,with severe copd, having recurrent exacerbations, i'd probably be sticking him oncombination therapy, leaving him on that, and getting benefitin terms of quality of life and hopefully reductionsin exacerbation. those are the differences. you don't back-titrate with copd

if you're aiming at reducing hospitaladmissions in that severe group. this man... he started off severe,but we've converted him to moderate. would you expect that spirometryto change much in a month's time? well, not if he's got copd. if he's truly got asthma, we may seesome further benefit, i suppose. as i know the patient, i shouldknow that, but i can't remember. i think his airflow obstructionstayed fairly fixed, so i truly did believehe had two diseases. what would you do for him, vanessa?

there's a range of different thingsthat andrew needs. firstly, one of the best treatments for someone with copd,or asthma for that matter, is to get him to stop smoking. we need to build a partnership with him in terms of getting himto see the things that he needs to do in order to change his behaviour. in terms of his smoking cessation,we'd need to do counselling, but also offer some pharmacotherapy,

either usingnicotine-replacement therapy or some varenicline if necessary, and make a commitmentto continue to see him in terms of his smoking cessationto provide some support. and do referrals to other support lines,such as the quitline, et cetera. but again, with andrew,this is a new diagnosis. he's come in. he's got a new diagnosis.he's been told to stop smoking. he's been givena couple of new devices. he needs to make somesubstantial changes to his behaviour.

he needs to understand why, and how these treatmentsare going to work for him and what he will get out of it. we talked briefly about ways of gettinghim to consider stopping smoking. but he's only 55. if he can see the advanceshe'll get from stopping smoking now, then that might give him some keysto change his smoking behaviour. the fletcher-peto chartis always very useful when you're trying to get peopleto stop,

because they can see the damage thatthey don't do to their lung function by stopping at an earlier age. but it's never too late. so that's his smoking cessation. again, if he's got copdand his tlco is reduced, he would also benefitfrom some pulmonary rehabilitation. but he does have that elementof asthma, so a written action plan for himwould be effective in terms of avoiding exacerbations,et cetera.

finally, we need to just make surehe's using his inhalers correctly. a question from tasmaniaasks to explain more fully what a pack year is. a pack year is smoking 20 cigarettesper day for one year. norman: as simple as that?intuitively, that's what it is. a question from cairns - 'is there any truth in the needto change the spiriva machine yearly? - six-monthly.- six-monthly, ok. let's go to our next case study.

denise is 63, and has lived with asthmafor most of her adult life. she also has seasonal rhinitisand gastro-oesophageal reflux. she's on budesonide, 100mcg, and eformoterol, 6mcgon the smart regime. tell us what the smart regime is,christine. - are we allowed to use drug names?- we are. we have to in this case. it's symbicort used as maintenanceand reliever therapy. the patient would taketwice-daily symbicort,

then use that as their reliever as wellthrough the day. - instead of a short-acting?- correct. don't you riskgetting an overdose of steroids on that? work has been done - the steroid loadseems to be lower in the patient group when smart was comparedto a regular bd plus short-actingbronchodilator regimen. you're effectively treatingmini attacks, i suppose, exacerbations of asthmathrough the day, by nipping them in the budwith the inhaled steroid

as well as the bronchodilator. denise has come inwith increased breathlessness. what are you going to do for her? the idea, of course, isto try and ascertain the cause of that. does she havean intercurrent infection? does she have another diagnosis? is she using her medication correctly,or at all? we often find patientsdiscontinue medications because of something they may have seenon a current affair program.

so it's a matter of teasing outwhat's changed for the patient. if we assumethat all remains much the same, then you may need to then look atother possible confounding factors. we've spoken about some of the thingsthat might aggravate asthma - reflux, rhinitis. these issues can make the controlof the asthma more difficult. norman:what are you going to do for her reflux? a fairly standard treatment now isto introduce a proton pump inhibitor. they work quickly,they work effectively.

norman: does it have to be asthma?- unfortunately, not always. it can. reflux can in itself cause respiratorysymptoms that can cause a cough. it may cause aspiration. there are a number of mechanismsby which reflux can cause respiratory symptoms. you can still have fluid coming up,it's just not as acidic with the ppi. that's right. if it's volume reflux,you may have a problem with that. you may need to add a prokinetic agent. but we know that patients may developa cough even if they're not aspirating,

from reflux effects. the question then is,'are these symptoms in fact asthma?' if it is asthma, and this is againwhere spirometry is so useful, if you have serial spirometry, whilst it's usefulto compare patients' spirometry results against predicted levelsor against lower limits of normal, it's nowhere near as useful as comparing it against their ownperformance, against themselves. and so, if you find that the spirometryhas not declined,

you may be more inclinedto seek other causes. on the other hand, if there's beena definite increase in the obstruction, a deterioration in lung function, you're going to be shifting towards concentrating onthe respiratory medicine. what about rhinitis?that could make the asthma worse. absolutely. we know that 80% of peoplewith asthma do have rhinitis. we also know that uncontrolled rhinitis does make it more difficultto control the asthma.

so we would certainly be inclinedto treat both. what about the steroid dose ifyou're starting to treat the rhinitis? if you're thinking about the dose,it's relatively small - 32mcg or 64mcg, compared to what we're talking here,in hundreds of micrograms. it's relatively small,but yes, you have to think about that. as gary said,it's important to treat the nose because of the improvementin the asthma. what you do with denise is,you treat the reflux, you give her nasal steroidsfor her rhinitis.

a month later, she's still complainingof increasing breathlessness. what are you going to do now? if we've excluded other causes - and we spoke in the case of maxabout cardiac pathology and other non-cardiacand non-respiratory pathology - if we've excluded those, then the important thingwould be to look at what's changed, what's causing this deterioration. it may be something as simple as

the patient not using their medicationcorrectly, losing some coordination. so what you decide to dois try and increase the dose, because you can't really find anything. but she comes back, and toni,she's just not taking the medication because she's getting thrush. she complains to you. she doesn't like to upset dr kilov,'cause he's trying so hard. look, sometimes that is a reality.

the other reality is too,with the nasal steroids, they're not covered by the pbs. ultimately, the person has towear the cost of that medication. commonly we find our elderly patients aren't all that happy aboutpaying a significant amount of money, or just don't have spare money to payfor that, so choose not to use it. of course, they don't wantto bother the doctor with that, because the doctorwants them to have it. they just assumethat everything will go on.

oral thrush is a significant problem, and is quite commonly told to usin the pharmacy. it's about technique,about treating that for them. we would usually let the doctor knowthat this person has had that problem, this is what we've donebecause it's over the counter, and recommended the proper wayof using their steroid inhaler - make sure they've rinsed their mouth and spit out the waterafter they've rinsed. what about drug interactions?

you alluded to beta-blocker dropsearlier. what other drug interactionsdo you need to be wary of? especially in older patients, oftentimes they're taking medicationfor arthritis or rheumatism. they may be well be takinga nonsteroidal anti-inflammatory. in a select group of people, that willcause an exacerbation of their asthma. they're probablyour biggest group of drugs, so we really need to be mindfulof the eye drops, we need to be mindful of the achesand pains that people suffer,

we need to be mindfulof the beta-blockers that they may well be usingfor their cardiovascular problems. the other thing with an older person,we need to think about osteoporosis. that's not in your direction, but it'ssomething else we need to think about. not our place to prescribe, obviously,but it's certainly our place... if somebody was doing a home-medicinesreview for this patient... would you do a baseline dexaon somebody like this, gary? again, coming back to the issue of cost, it's not pbs-reimbursedunless they've had a fracture.

that can be a problem. the other problem is that once you've determined,assuming they do have osteoporosis, again the medicationis not pbs-reimbursed unless they've hada minimal-trauma fracture. unless you're surethat you can act on that, it's probably not worth pursuing. the other alternative is, there is evidence for using calciumand vitamin d.

gary: i think we should be doing thatanyway. i know this is not,perhaps, the forum for this, but there is an epidemicof vitamin-d deficiency. they should all be tested for it, thenhopefully put on calcium and vitamin d. taking a therapeutic dose, too. improving mobility to reduce falls. there's a good point. norman: vanessa?- with denise, we mentioned earlier that older people may not be able to useturbuhalers

as effectively as younger people.this is the device... norman: denise isn't crumbling here.she's only 63. i have no answer to that. she may not be able to inspire deepenough to activate the turbuhaler. if we had established thatthe problem was adherence, that would be a consideration for her. in terms of the adherencedue to side effects, you'd also wantto think about the device, and think about converting herto maybe a puffer and a spacer,

where she's more likelyto get oropharyngeal deposition and therefore less likelyto get oral thrush. norman: christine? christine:can i just make a comment? going back to the pointabout doing her spirometry and maybe not seeing much of a change,and wondering, 'is it worsening of her asthmaor something else?' we've determined thatthere are adherence issues. we can,perhaps not so much in rural areas,

but if you do havea lung-function laboratory nearby, they can do a methacholine challengeand some sort of challenge test to determinethe bronchial hyper-responsiveness that may be still presentin this person. perhaps of interest to peoplewould be other tests that are a bit experimental, but we hope we'll bring intoregular clinical practice, such as exhaled nitric oxideas a measure of inflammation and also sputum eosinophils,again as a measure of inflammation,

can be helpful in patientswhere you're trying to determine, is it flaring of their asthma - the lungfunction is not changing very much - or is it something else, for example,vocal-cord dysfunction? we've got problemswith oropharyngeal candidiasis. that can also mimic asthma. - what about influenza vaccination?christine: in this lady? we would be recommending it,and the guidelines recommend it. irene is an 85-year-old womanwith a confirmed diagnosis of asthma. she's pretty stable on salmeterol 50mcg

and fluticasone 250mcg bd, short-acting, and salbutamol as required. she lives independently near herdaughter and her daughter's family. her mobility is limited,and she has mild macular degeneration. vanessa, take us throughwhat you think... she's come back for a routine check-up.there's nothing changed. what are the issues here for someonewe could justifiably call elderly? vanessa: the first thing to note is thatshe seems to have adequate control on the treatment that she's taking,which is pleasing to see.

but the other things that can behighlighted in terms of her management is that she's gotmild macular degeneration. that will have an effect on her abilityto use the different inhaler devices in terms of loading medicationsand loading the spacer, et cetera. and the other thingis her decreased mobility, and that may have some effecton her strength as well and her abilityto activate the different devices. so those things would need to bereviewed and considered. the other thing to think aboutwith irene

is she is an older personwith some macular degeneration. in terms of her management,or self-management, for example, we'd need to consider thingsa little bit differently. we did mention earlier in the program that the mortality ratesamong older people are increasing. we've very effectively been ableto reduce mortality in australia over the last 20 years. that highlights that maybe there arethings we need to do differently as people age.

our approach may not be workingas effectively. action plans are a major componentof treatment for people with asthma. she may not be able to read it. right. with macular degeneration, a written action planmight be ineffective for her. the size of the fontthat people are given action plans for is a problem in older people. some groups have developedwritten action plans using large fonts to try and avoid that problem.

with her, we would need to involve herfamily members in her management. she does have a daughter nearby who may be involvedin regular follow-up with her and assessment of how she's going. so i would want to involve herin her action plan and simplify the planas much as possible. i'd also want to assess irene's needsand see what the biggest problem is for herin terms of her breathing disability, and see how we could effectivelyimprove her management

based on achievinga better outcome for her and really making ita person-centred approach. gary, in your practice,who gives the patient education? i do. i would almost invariably involvean asthma educator. it's virtually impossibleto manage any chronic disease, be it asthma, diabetes, copd, without the involvementof allied health-care professionals, the pharmacist.

it is a team approach.it needs to be a team approach. it needs to be an ongoing,regularly reviewed program. it's not a set-and-forget. whilst i might educate the patient, they will get more information, they'llget reinforcement of the information, say, from an asthma educator. we know that retention ratesin a consultation are very low. we're talking aboutof the order of 10%, 20%. much of the information does need to bereinforced, does need to be repeated.

in a country town, presumably,you just find whoever you can - whoever's availablein terms of professionals... yes. and i would imaginein most country towns, at the least you'll have the gpand the pharmacist working together. christine, what's the role of spirometryand, say, pulmonary rehabilitation in someone like irene? i was just wondering that myself,norman. depending on how disabled she is...but, as you were suggesting, vanessa, she seems to bereasonably well-managed.

i would like to see all patientswith either copd or asthma having at least had some spirometry at some pointin their management process so that we know where we are. depending on her accessto a pulmonary rehabilitation program, if her daughter is able to take her, i know it would improve her qualityof life and her exercise capacity. so i'd certainly strongly berecommending both of those things. a questionfrom rural new south wales -

'what's the current thinkingon the amount of marijuana smoking needed to cause copd?' how many bong yearsare we talking about here? i don't know how many bong years. - it's a good question.- no, it is. i think it must be from the north coastof new south wales, actually. we're seeing more and more patientspresenting with copd who have really nastycystic lung disease. norman: the ageing hippiesare coming home to roost?

it really is very severe. the chest x-rays and ct scansare really quite characteristic. as you know, it's quite difficultfor these patients to stop using. often the marijuanais mixed with nicotine. it's a difficult management situation. we are seeing quite a lot of it. rhinitis - treating the nosewith nasonex to help the asthma? - yes.- what is nasonex? mometasone.

it's another nasal corticosteroid. are there copd plans,like asthma plans? yes, there are. looking atthe australian lung foundation website, there are plans available. cochrane meta-analysis suggeststhat the use of these plans isn't quite as helpful as they have beenin asthma, but i suspect that we just don't havethe evidence about them. talking about a holistic approachand a self-management approach

to management of eitherof these disease, it makes common sense to have a patientunderstanding and using a plan, for example,for flare-ups of their copd. what are your take-home messages?vanessa? one of the take-home messages is that the needs of older peopleare quite different, that we do need to definean integrated approach to the management of older peoplewith either asthma or copd, and changing our approachto be more holistic.

- toni?- i have to agree with that. i particularly think it's very importantin a rural area. the limited number of healthprofessionals there are in that area need to work together. for pharmacists, it's really important that you get to knowwho else is in your area. the other thing is thatpharmacists, i think, have a huge role in medication complianceand adherence. we probably havea more complete record.

potentially, in country areas, where there may only be one pharmacyin a town, they'll know everythingthat person is taking. there needs to be open communicationwith the prescribers. gary? errors in medicine are generallybecause of not looking rather than not knowing. we would certainly want to encouragegreater use of spirometry, particularly in rural settings,

where you may not have accessto tertiary institutions. performing office spirometrycan be very effective in helping to tease outwhat's going on with these patients. the other thing that's been mentioned,and i'd like to reinforce, is the team-based approach. this is an ideal situation for the useof a gp management plan and team-care arrangement. gps are often pressed for time. where you do a gp management planand team-care arrangement,

you are getting adequately remuneratedfor the time and effort spent, and you're involving the necessaryallied health professionals, pharmacists and so on. - christine?- they've said everything, haven't they? i really would suggest that peoplehave a look at the copd-x guidelines. they're very useful. the first step in those guidelinesis to confirm the diagnosis, so, reiterating the importanceof doing spirometry. it's hard to treat someone properlyif you don't know what you're treating.

it may be mixed disease,but it's important to know that, and educate the patient. thank you all very much. i hope you've enjoyed tonight's programon breathlessness and the older adult. if you're interested in obtaining moreinformation about the issues raised, there are a number of resource available don't forget to complete and send inyour evaluation forms, and please register for cpd points by completing the attendance sheet.

our thanks to the nationalasthma council of australia for making the program possible, with funding from the government'sdepartment of health and ageing. thanks to you for taking the timeto attend and contribute. i'm norman swan.from all of us, bye for now. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�