- Email: [email protected]
32 When to refer an acute exacerbation to hospital
16
Speaker abstracts, Saturday 3 March 2007
Patient education promoting self-management has been recommended as a strategy for early recognition and treatment of AECOPD. We are going to review whether there is evidence of benefit using a self-management program and an action plan. We will present data on the use of the action plan to aid the COPD patients to recognize and properly respond to their exacerbation through the self-initiation of medication such as antibiotics and prednisone. Finally, using the example of a written action plan, we will see how we can translate these results into the real world of clinical practice which is essential in order to impact on patient care. The self-management model does not require a new breed of health professionals but some revamping of the current health care delivery system and of current health professionals’ education and training. 32 When to refer an acute exacerbation to hospital R. Stevenson. Department of Respiratory Medicine, Glasgow Royal Infirmary, Scotland, UK Abstract not available at time of going to press. 33 Hospital at home community
COPD acute care in the
L. Davies. Aintree Chest Centre, University Hospital Aintree, Liverpool, UK Over the last few years there has been considerable interest in hospital based rapid assessment units and early discharge schemes for patients with exacerbations of COPD. Rapid assessment units aim to identify patients that can safely be managed at home with additional nursing and medical support rather than being admitted to hospital. Early discharge schemes aim to facilitate the early discharge of patients admitted with a COPD exacerbation. Both types of ‘hospital at home’ care generally involve a full assessment of the patients at the hospital by a multidisciplinary team and discharge to the community with a package of support including pharmacological treatment (nebulised bronchodilators, corticosteroids, antibiotics and oxygen as clinically indicated), nursing care and social support if required. There are different models for this type of care across Europe and the rest of the world with some schemes keeping patients under the care of the hospital respiratory physician during this period of exacerbations, and others returning clinical responsibility to the primary care physician. Good communications between primary and secondary care teams is essential for their success. The purpose of this talk will be to: Summarise the evidence for rapid access and early discharge schemes; Review which patients are most suitable for this type of management; Describe the different, successful models of care; Summarise the available data relating to health care costs and potential ‘savings’ to be made with such schemes; Discuss the attitudes that patients and their carers hold towards hospital at home schemes. 34 End of Life at home J. Scullion. Glenfield Hospital, Leicester, UK The palliative care of patients with respiratory disease has been a sadly neglected area reflecting both that there has been little thought given to patients’ needs in this area and also that there has been little financial support or incentives to develop services in this area. In common with many chronic diseases many patients with respiratory diseases face months or years of progressively deteriorating health. Historically palliative care/end of life provision has been the preserve of those providing services for patients with a cancer diagnosis. Currently the NHS is providing
increasing resources for palliative care, but the majority of these resources are focused within the cancer services. National Service Frameworks (NSFs) confirm that end-of-life decisions and terminal care need to be addressed for many conditions, not just cancer, but this does not happen for the majority of respiratory patients. Similar numbers of patients die of COPD as from lung cancer, but patients with COPD experience worse health status and receive less supportive care than those with lung cancer. Similarly patients with parencyhmal lung disease have a prognosis similar to that of lung cancer, but again few receive the support they need. The principles and practices of palliative care apply as much to end-stage respiratory disease as they do for patients with cancer. Health care professionals and service providers need to address the issue of how best to deliver end-of-life care to all patients with life-limiting disease irrespective of diagnosis, and where possible this should be in the place that the patient would wish to be. Track 2
Secondary Care Focus
35 Definition of exacerbations R. Rodriguez-Roisin. Hospital Clinic, University of Barcelona, Spain The natural history of obstructive pulmonary disease (COPD) is one of a progressive lung function reduction, poor health status and systemic effects, all interspersed with varying frequency of episodes of COPD exacerbation. Exacerbations have a serious impact on patients in terms of lung function decline or disease progression, morbidity and mortality, and poor quality of life, and involve huge economic costs. The precise definition of an exacerbation is a controversial issue. The 2006 Update of GOLD has defined a COPD exacerbation by “a sustained worsening of respiratory symptoms and beyond normal day-to-day variations that is acute and warrants a change in regular medication in a patient with underlying COPD”. In addition to this definition using respiratory symptoms (symptom-driven), an exacerbation has been also defined using symptoms plus an event, such as a specific change in medication, namely prescription of systemic corticosteroids and/or antibiotics, or both, by a physician or hospital admission for a severe episode of exacerbation (action-based). There is a need for understanding more about whether events defined by a change in symptom intensity for a specified period are consistent within patients, relate to different clinical outcomes and are similar in patients in countries. This work will stimulate a better therapeutic approach, categorized by severity classification, and aid the search for biologicalfunctional outcomes/biomarkers by redefining diagnostic and therapeutic strategies. 36 Surgical and non-surgical volume reduction P. Shah. Royal Brompton Hospital and Chelsea & Westminster Hospital, London, UK Severe emphysema is associated with a high morbidity and mortality. Patients have significant symptoms despite maximal medical therapy and pulmonary rehabilitation. Single lung transplantation is a possible treatment option but organ availability is limited. Lung volume reduction surgery (LVRS) has been shown to be a potential option in patients with significant upper zone disease and poor exercise capacity. Improvements in quality of life, reduction in breathlessness and improvements in exercise capacity have been reported in a large randomised control study (NETT study group. N Engl J Med 2003; 348: 2059 2073). Overall mortality was similar in the two groups but significantly better in the surgical group in patients with
Speaker abstracts, Saturday 3 March 2007
Patient education promoting self-management has been recommended as a strategy for early recognition and treatment of AECOPD. We are going to review whether there is evidence of benefit using a self-management program and an action plan. We will present data on the use of the action plan to aid the COPD patients to recognize and properly respond to their exacerbation through the self-initiation of medication such as antibiotics and prednisone. Finally, using the example of a written action plan, we will see how we can translate these results into the real world of clinical practice which is essential in order to impact on patient care. The self-management model does not require a new breed of health professionals but some revamping of the current health care delivery system and of current health professionals’ education and training. 32 When to refer an acute exacerbation to hospital R. Stevenson. Department of Respiratory Medicine, Glasgow Royal Infirmary, Scotland, UK Abstract not available at time of going to press. 33 Hospital at home community
COPD acute care in the
L. Davies. Aintree Chest Centre, University Hospital Aintree, Liverpool, UK Over the last few years there has been considerable interest in hospital based rapid assessment units and early discharge schemes for patients with exacerbations of COPD. Rapid assessment units aim to identify patients that can safely be managed at home with additional nursing and medical support rather than being admitted to hospital. Early discharge schemes aim to facilitate the early discharge of patients admitted with a COPD exacerbation. Both types of ‘hospital at home’ care generally involve a full assessment of the patients at the hospital by a multidisciplinary team and discharge to the community with a package of support including pharmacological treatment (nebulised bronchodilators, corticosteroids, antibiotics and oxygen as clinically indicated), nursing care and social support if required. There are different models for this type of care across Europe and the rest of the world with some schemes keeping patients under the care of the hospital respiratory physician during this period of exacerbations, and others returning clinical responsibility to the primary care physician. Good communications between primary and secondary care teams is essential for their success. The purpose of this talk will be to: Summarise the evidence for rapid access and early discharge schemes; Review which patients are most suitable for this type of management; Describe the different, successful models of care; Summarise the available data relating to health care costs and potential ‘savings’ to be made with such schemes; Discuss the attitudes that patients and their carers hold towards hospital at home schemes. 34 End of Life at home J. Scullion. Glenfield Hospital, Leicester, UK The palliative care of patients with respiratory disease has been a sadly neglected area reflecting both that there has been little thought given to patients’ needs in this area and also that there has been little financial support or incentives to develop services in this area. In common with many chronic diseases many patients with respiratory diseases face months or years of progressively deteriorating health. Historically palliative care/end of life provision has been the preserve of those providing services for patients with a cancer diagnosis. Currently the NHS is providing
increasing resources for palliative care, but the majority of these resources are focused within the cancer services. National Service Frameworks (NSFs) confirm that end-of-life decisions and terminal care need to be addressed for many conditions, not just cancer, but this does not happen for the majority of respiratory patients. Similar numbers of patients die of COPD as from lung cancer, but patients with COPD experience worse health status and receive less supportive care than those with lung cancer. Similarly patients with parencyhmal lung disease have a prognosis similar to that of lung cancer, but again few receive the support they need. The principles and practices of palliative care apply as much to end-stage respiratory disease as they do for patients with cancer. Health care professionals and service providers need to address the issue of how best to deliver end-of-life care to all patients with life-limiting disease irrespective of diagnosis, and where possible this should be in the place that the patient would wish to be. Track 2
Secondary Care Focus
35 Definition of exacerbations R. Rodriguez-Roisin. Hospital Clinic, University of Barcelona, Spain The natural history of obstructive pulmonary disease (COPD) is one of a progressive lung function reduction, poor health status and systemic effects, all interspersed with varying frequency of episodes of COPD exacerbation. Exacerbations have a serious impact on patients in terms of lung function decline or disease progression, morbidity and mortality, and poor quality of life, and involve huge economic costs. The precise definition of an exacerbation is a controversial issue. The 2006 Update of GOLD has defined a COPD exacerbation by “a sustained worsening of respiratory symptoms and beyond normal day-to-day variations that is acute and warrants a change in regular medication in a patient with underlying COPD”. In addition to this definition using respiratory symptoms (symptom-driven), an exacerbation has been also defined using symptoms plus an event, such as a specific change in medication, namely prescription of systemic corticosteroids and/or antibiotics, or both, by a physician or hospital admission for a severe episode of exacerbation (action-based). There is a need for understanding more about whether events defined by a change in symptom intensity for a specified period are consistent within patients, relate to different clinical outcomes and are similar in patients in countries. This work will stimulate a better therapeutic approach, categorized by severity classification, and aid the search for biologicalfunctional outcomes/biomarkers by redefining diagnostic and therapeutic strategies. 36 Surgical and non-surgical volume reduction P. Shah. Royal Brompton Hospital and Chelsea & Westminster Hospital, London, UK Severe emphysema is associated with a high morbidity and mortality. Patients have significant symptoms despite maximal medical therapy and pulmonary rehabilitation. Single lung transplantation is a possible treatment option but organ availability is limited. Lung volume reduction surgery (LVRS) has been shown to be a potential option in patients with significant upper zone disease and poor exercise capacity. Improvements in quality of life, reduction in breathlessness and improvements in exercise capacity have been reported in a large randomised control study (NETT study group. N Engl J Med 2003; 348: 2059 2073). Overall mortality was similar in the two groups but significantly better in the surgical group in patients with