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COPD/Heart Failure
Learning Session 1
www.pspbc.ca
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Housekeeping
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Agenda
Welcome and Introductions (15)
Video Clip or Patient Story (15)
COPD 101 (70)
Local respiratory services
COPD-6 training
QuitNow
Integrate into Practice Workflow
Break (15)
Heart Failure 101 (65)
Local HF clinic services and cardiologist referral
Integration of HF into practice workflow
Action Planning Expectations (5)
Planning for action Period (25)
7 7
CME Accreditation
Choice of:
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Module Structure
9
How is a collaborative different than CME?
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AIM
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How will we achieve this aim?
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Action Period 1 Measurement
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Patient Story
(15 minutes)
Our Aims
To foster a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
and Heart Failure by:
› Identifying subjects with COPD and Heart Failure earlier
› Using a team-based approach
› Improving communications between patients and care team
as well as within the care team
› Developing strategies to prevent progression of COPD or
Heart Failure as well as its optimal Improving management
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How will we achieve this aim?
In the FP practice:
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Approach to Dyspnea: COPD/HF
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COPD/Heart Failure
25-30% HF patients have COPD
20-40% COPD patients have HF
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Look for clues!
1. Initial clinical judgement
2. Risk factors for heart increase likelihood of HF
3. Symptoms of PND, orthopnea or edema increase likelihood
of HF
4. Signs for HF include:
› 3rd heart sound, arrythmia or murmur
› ↑ JVP
› Crackles
› Edema
5. Signs for COPD or AECOPD
› Air-trapping, wheezing, quiet lungs, prolonged expiration
› Worsened cough with increased or purulent phlegm
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A Case of Dyspnea
Post-
bronchodilator
FEV1/FVC 48%
FEV1 55%
Echo 2
years prior
showed EF
45%
Shortness of breath has worsened in past
week
WHY?
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Approach to Dyspnea: Diff Dx
Respiratory Cardiac Systemic
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Approach to Dyspnea
Onset of symptom
› Gradual vs sudden, rest or exertion?
Think:
CARDIAC,
RESP,
SYSTEMIC
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Approach to Dyspnea
Associated symptoms
› Cough, sputum, wheeze
› Chest pain: pleuritic versus exertional
› Palpitations, dizziness Think:
› Edema, orthopnea, PND CARDIAC,
› Bleeding causing anemia RESP,
SYSTEMIC
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Approach to Dyspnea
Associated signs
› Pallor
› Tachycardia or arrhythmia Think:
CARDIAC,
› Crackles vs wheeze
RESP,
› Hyperinflation vs chest restrictionSYSTEMIC
› Edema
› ↑JVP, S3, murmur
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Examination in 2 minutes
General appearance
Heart Rate
Rhythm
BP
(O2 sat)
Listen to chest
Listen to heart
JVP assessment
Edema
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Diagnostic Tests
O2 sat: rest and on exertion
EKG
CXR
Hb, BNP, LYTES with anion gap, TSH, troponin,
renal, liver,
PFTS
ECHO
Other tests:
› PE Protocol CT
› High resolution CT
› Stress test or MIBI, MUGA
› ABG
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Case continued
Current inhalers include an lone ICS inhaler and short
› Has not followed up with you recently
› Renews her prescriptions intermittently
Other Rx: rosuvastatin, HCTZ, amlodipine, metformin,
daily ASA
Exam reveals decreased breath sounds bilaterally,
wheeze,
Heart rate of 90, JVP of 4 cm, pitting edema to shins
and BMI 36
How would you proceed with this case?
ICS (inhaled corticosteroid), LABA (long-acting ß-agonist), LAMA (long-
acting muscarinic antagonists),
JVP (jugular venous pressure), HCTZ (hydrochlorothiazide)
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What tests could be ordered from your office to sort
this patient out?
(25 minutes)
Definition of COPD
COPD is a preventable and treatable disease
with some significant systemic effects
that may contribute to the severity in
individual patients.
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Asthma
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Clinical Course of COPD
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Prevalence and Burden of COPD
Global Disease Burden
1990 : COPD was 6th leading cause of death
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COPD is Under-diagnosed in Canada
Patients >40 yrs + 20 pack-year history
of smoking visiting a primary care
physician for any reason
1,003 patients underwent spirometry:
Diagnosis of
Spirometry COPD
results
Criteria Yes
for COPD 32.7%
Normal 20.7%
79.3%
No
67.3%
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Diagnosis
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Key Message
“Most patients with COPD are not diagnosed until the
disease is well advanced. Spirometry targeted at
individuals who are at risk for COPD can establish an
early diagnosis.”
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Fletcher Curve - the Effect of Smoking on FEV1
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Local respiratory services
COPD-6 training
The COPD6
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If FEV1/FEV6 is low ,<0.7 ,then refer to accredited
lab for definitive diagnosis
Walk in spirometry clinics
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COPD-6
Accurate enough for FEV6 & Ratios
(And multi-patient use. Exceeds ATS/ERS guidelines)
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COPD-6 (continued)
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Entering subject data continued
C - Caucasian
AA - African-American
HA - Mexican-American
Note: use C for all other races
9. Press Enter
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Copd-6 is now ready for blow
• Place the Mouthpiece into the
Copd-6
• Hold your head up, breathe in as
deeply as possible, place the
mouthpiece in your mouth, biting
it lightly while sealing your lips
firmly around it.
• Blow out as HARD and FAST as
you can for a full 6 seconds.
• Repeat 2 more times when the
blow icon appears.
• Hold down the enter key to bring
up the last session results
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Results of blow
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Test results after three blows
Press Enter to display the best of the
session
Press enter to display the best FEV1
and percent predicted of all blows
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The Copd-6 USB version’s printed report
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Training
http://www.youtube.com/watch?v=syXXEgZSTOQ
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1 (877) 455-2233
Progress in British Columbia
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Progress in BC
Intention to Quit
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Intention to Quit
Physicians discussing quitting
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Physicians Discussing Quitting
Effect of Physician intervention
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Effect of Intervention
What can Physicians do?
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What can Physicians do?
Strategies to help your patients quit
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Strategies
What is QuitNow?
Behavioural quit smoking support
Provincially Funded
Evidence-based
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What is QuitNow?
Fax Referral Forms
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quitnow@bc.lung.ca
Online Referral
online 69
Integrate into the workflow
discussion
End
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Heart Failure 101
(40 minutes)
Definitions and Nomenclature
Heart Failure
A clinical diagnosis
Inability for the heart to deliver sufficient blood/oxygen to
meet the demands of the peripheral tissues, or to do so at
abnormally high filling pressures, or both
Characterized by signs and symptoms of decreased
cardiac output and/or volume overload
Does not suggest a cause or underlying pathological state
Cardiomyopathy
Disease of the heart muscle due to any number of causes
Clinically characterized by heart failure
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Definitions and Nomenclature
Heart Failure with Decreased Ejection Fraction
Poor systolic performance of the heart resulting in
decreased cardiac output and increased venous pressures
Typically occurs in association with impaired left ventricular
systolic function due to any number of causes
Left ventricular ejection fraction (LVEF) of <40%
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Prevalence of Heart Failure
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10.0 Incidence:
8
550,000 new cases/yr
Patients in Millions
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Prevalence:
2% in 40 – 60 year olds
4 4.8
10% in those aged 70+
3.5
2
Year
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Percentage Alive
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50% survival at 30 months
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40
20
0
0 5 10 15 20 25 30 35 40 45 50
Months
http://www.healthservices.gov.bc.ca
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NYHA Classification of Heart Failure
1 Year
Classes Description
Survival Rate
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Important Causes of Cardiomyopathy and
Heart Failure
SYSTOLIC DIASTOLIC
Alcohol Hypertension
82 82
Local HF Clinic Services
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Referral Resources
Indications for
Referral
to a HFC
Heart
Function
Clinic
Referral
Form
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When and Who Should I refer to an
HF Clinic?
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Local Heart Failure services
Integrate into the workflow
discussion
Action Period Planning
(20 minutes)
Action Period 1 Measurement
90 90
Questions