SCFT Chronic Obstructive Pulmonary Disease (COPD) Specialist Team & Dolby Vivisol Oxygen Service Albert Sundararaj, Specialist COPD Physiotherapist, SCFT Jo Hobbs, Clinical manager / Service Lead, Dolby Vivisol
Crawley, Horsham & Mid Sussex (Central) Monday to Friday 08.30 – 16.30 Based in Rose Wing, Horsham Hospital • specialist nurses – 2.8 WTE • specialist physiotherapists - 2.0 WTE • pulmonary rehabilitation assistant - 1.0 WTE • administrator – 1.0 WTE • Case load: 600 (50/50 clinical management / PR) - 86 receiving oxygen therapy ULTIMATE AIM: to prevent unplanned hospital admissions
Referral criteria (via One Call) Inclusion criteria - aged 18+ Be registered with a Crawley or Horsham & Mid Sussex GP. Have a diagnosis of COPD confirmed by spirometry or a respiratory physician. Clinical assessment: • POST EXACERBATION - and/or recent hospital admission due to COPD (will be contacted and triaged within 24 hours and seen within 2 weeks of receiving discharge summary) • ROUTINE - Patient requires a routine specialist assessment. (will be seen within 12 weeks of referral) Pulmonary Rehabilitation: • ROUTINE - Patient would benefit from a 12 session exercise and education programme (will be assessed and enrolled into a programme within 13 weeks) • FAST TRACK – Post exacerbation and / or recent hospital admission due to COPD (will be assessed and enrolled into a programme within 4 weeks )
Information & supporting documents required with referral • Current exacerbation • Specific reason for the medication referral • If the patient is being • Known risks regarding a referred due to frequent home visit exacerbations – include 6 months of antibiotic Px • Written evidence of COPD diagnosis • Recent exacerbation / hospital admission details • Last chest X-ray date & • Current oxygen therapy results • Last FBC date & results • Current nebuliser therapy
Routine Specialist Assessment • Assessment of frequent exacerbations of COPD – 2 or more a year. (Please attach at least 6 months of antibiotic & oral prednisolone prescription history) • Assessment due to severe disease – FEV1 < 50% • Already on long term oxygen therapy • Assessment for long term oxygen therapy (SPO2 <92% at rest, or < 94% if peripheral oedema, pulmonary hypertension, polycythaemia is evidenced) • Assessment for ambulatory oxygen assessment (SPO2 <92% on exertion) • Assessment for long term nebuliser trial (please ensure therapy is maximised & inhaler technique assessed & taught) The patient will be required to buy their own should the trial show a positive effect
Specialist COPD Exacerbation Assessment management Assessment Test Medication Smoking review / Education cessation Quality of life optimisation. advice BMI /symptom Inhaler Dietary assessmen t technique advice Clinical Dyspnoea observations Pulse management Self oximetry management Patient plan Activation Exercise End of Oxygen Measure advice life review MRC Chest Monitor clearance Depression / Immunisation peripheral techniques anxiety advice oedema management FBC Personalised Social care plan / Bone Travel Inform GP / suppor t lifestyle advice density advice referrer
Oxygen therapy in COPD A Cochrane review of randomised controlled trials of domiciliary oxygen therapy for COPD found; (Ref) • Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55mm Hg ( 8.0 kPa) • Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night • Aim for an SaO2 of 88-92% • Ref: Cranston JM, Crockett AJ, Moss JR, et al; Domcilliary oxygen for chronic obstructive pulmonary disease. Cochrane database Syst Rv. 2005 Oct 19 (4): CD001744
Oxygen assessment for LTOT • Definitive diagnosis • Patient clinically stable • Medically optimised • SPO2 <92% at rest, or < 94% if peripheral oedema, pulmonary hypertension, polycythaemia is evidenced • Risk assessment • Smoking status • Patient understands implications and process • Gain verbal and written consent (IHORM, HOCF, HOOF)
Capillary blood gases assessment • If PO2 ≤ 7.3kPa – repeat in 3 weeks – if result same – Px LTOT • If PO2 = 7.31 - 8kPa with no clinical evidence of secondary conditions - LTOT is not required • If PO2 = 7.31 – 8kPa with clinical evidence of secondary conditions - Px LTOT • Titrate O2 in 1Litre increments at 20 min intervals • Once stabilised at SPO2 >90% – perform blood gas to confirm pO2 = 8.1 – 9kPa Update HOOF and consider all equipment required and the need for ambulatory oxygen
Follow up after LTOT initiation • 1 week – telephone call • 4 weeks - Reinforce education and check S PO2 on O2 / Symptoms of hypercapnia / Adherence / Smoking status / Equipment • 3 months - reassessment and blood gas • 12 monthly blood gases for normocapnic patients • 6 monthly blood gases for hypercapnic or concerning patients
Nebuliser Trial – 3 weeks Nebuliser trial should consider: • A reduction in symptoms • An increase in the ability to undertake activities of daily living • An increase in exercise capacity • An improvement in lung function If the trial is positive, we will recommend the patient rents or purchases a device from a reputable company. We provide written information: • Buying a Nebuliser Guide • Details of nebuliser Suppliers • Care of your nebuliser booklet • Price list for rental or purchase agreements (£70 - £100 & £5 - £6)
Nebuliser Trial: • Check inhaler technique • Consider use of spacer device • Assess the individual and / or carer’s ability to use and clean etc • Only continue treatment if there is an improvement during trial • Offer choice of mask or mouthpiece • Consider which drugs require mouth piece only • Always provide education / written instructions / technical support details
Nebulised medications in COPD • Salbutamol 2.5mg / 5mg up to QDS Patients admitted with acute exacerbations of COPD requiring nebulised therapy should be considered for 2.5mg nebulised Salbutamol in place of 5mg (Ref) • Ipratropium Bromide 250mcg/1ml or 500mcg/2ml up to QDS • Saline solution - Sodium Chloride 0.9% w/v up to QDS • Colomycin antibiotic therapy 1 or 2 Million International Units (MIU) mixed with 4ml sterile water BD Ref: Nair S. A randomised controlled trial to assess the optimal dose and effect of nebulised Albuterol in acute exacerbations of COPD. Chest 2005; 128; 48 - 54
Pulmonary Rehabilitation • Programme of exercise and education • Individually designed • Benefits – improve muscle strength, cope better with breathlessness, improve fitness, improve mental health • 6 sessions a week – 3 centres • Commitment – 2 sessions week for 6 weeks • May need to be assessed for ambulatory oxygen
Pulmonary Rehabilitation pathway Initial assessment (History taking from patient, medical and drug history, Quality of Life Questionnaire, Incremental shuttle walk test) Included in Pulmonary Rehabilitation (Cardiovascular Training + Strength training+ Education) Final assessment (Quality of Life Questionnaire, Incremental shuttle walk test – improvement of 47.5m ) Patient discharged form the service
PR Venue and timings • Crawley – Physiotherapy gym, Crawley Hospital Time - Wed: 2.45pm Fri: 2.00pm • Mid Sussex – Dolphins Leisure centre, Haywards Heath Time – Tue: 1.30pm Thu: 1.30pm • Horsham – Physiotherapy gym, Horsham Hospital Time – Mon: 10.00am Wed: 11.45am
Time for a challenge Sit to Stand test Aim to stand up and sit down for 1minute.
Part A HOOF training • Jo Hobbs • Service Lead/ Clinical Manager • Dolby Vivisol
Dolby Vivisol Supporting Patients and Health Care Professionals 24/7 365 days a year • Major Home Healthcare provider in the UK • 20,000 active Patients across the UK • 250 Employees in the UK (all CRB checked & “Patient Ready”) • Long term contracts with the NHS – Home Oxygen – Scotland, South East Coast & South Central • Partner with all main manufacturers…
Guides • British Thoracic Society • National Home Oxygen Safety Group • NHS Improvement
Clinical assessment • Clinical assessment for correct home oxygen requirement with appropriate equipment
Forms! • Initial Home Oxygen Risk Mitigation (IHORM) form completed (National form) • Home Oxygen Consent Form (HOCF) completed • Home Oxygen Order Form (HOOF) completed
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