Diagnosing COPD without being able to objectively demonstrate airflow limitation
Hi everyone, just wondering thoughts of how we are going to approach respiratory diagnosis over the coming months without being able to do spirometry. Asthma not such an issue as we can use PEF, trial of treatment and suspected asthma codes but not so easy for COPD ! Look forward to hearing your thoughts.
Hi Sally. Really important to raise this. Tracey and I as policy leads are trying to come up with a PCRS position on this and will need everyones thinking here as there will definitely need to be some going against the grain I think and some novel approaches I hope . We are waiting for ARTP , PHE , NHSE and others too but I think the more discussion we have here the better. We as PCRS already say Spiro or FENO not necessary if high probability asthma - so we can restate that as I think still many not getting trial of rx and waiting weeks / months for Spiro despite with high prob. We as PCRS already support networked resp diagnostic approach so only those that really need Spiro get it and if done is done safely and well. Maybe as part of that hub approach there is two person or multi person decision making ? We have all started to get used to that in recent weeks. Is FENO just a big no for now - so many not using anyway? More PEFR diaries at home? Daryl Freeman darush attar-zadeh Steve Holmes Carol Stonham Duncan Keeley Val Gerrard BEVERLEY BOSTOCK Vikki Knowles Leon O'Hagan Joanne King Tracey Lonergan
It is indeed back to basics, and only using AGPs when we need to, then doing it safely. I chair the diagnosis group of the LTP and we are about to pick the work stream back up post Covid but the recommendations are all here I am sure. The one thing I think we might see is that, much like virtual consultations, we will be able to progress much more quickly with diagnostic hubs to meet the challenge.
We have an older GP in my practice who was never quite enamoured with wasting time using Spirometry for diagnosis - preferred patient history and symptoms. Especially when some patients scored above the magic 70% ratio!
Basically any long term smokers over 60yrs with Dyspnoea, and no Hx of Asthma were classed COPD and treatment started. He wasn't often wrong.
In the absence of confirmation with Spirometry we have been trialling LAMA's & LAMA/LABAs for response with any suspected patients and and anecdotally those started on treatment have been reporting feeling improvement - one told me "My chest hasn't felt this good in years!".
Is there a place for regular validated questionnaires such as CAT scores similar to Peak Flow Diaries?
I am following this with interest as we have been addressing this in our Group Practice . Thank you for the webinar Beverley, was interesting and has steered further conversation for our little team. We have been running remote reviews for a while, but the idea of diagnosis is much more challenging. We are taking the approach of history, history, history (to quote Beverley!) & providing a 'suspected' diagnosis based on this. If the suspicion is of any Asthma elements, I use peak flow monitoring & have MyAsthma app to support me with remote monitoring. For those without the necessary IT, we have managed to use paper copies sent into surgery or even the patient reciting the results by telephone while I plot my end. If I suspect COPD without any indication of asthma elements, I will code as suspected COPD, initiate treatment with monitoring follow-up calls, then add the patient to my waiting list for post-BD spirometry post pandemic. Much as Leon described above. We are privileged in our service to be able to offer quality assured spirometry & we had just launched our pilot diagnostic hub in our locality prior to lockdown, so I am hoping to see this reinstated, in a likely different format, once we resume a type of normality! Some formal guidance around starting diagnosis & initiating management without spirometry in COPD would be very reassuring as I fear there may be many patients denied treatments as they do not have a formal diagnosis yet!
Thanks for the replies some great ideas
As has been said on many of the other topic posts this is a real opportunity to really bring home the message about the importance of taking a comprehensive respiratory history. My concern is that for some this maybe an alien subject - it would seem pragmatic to start with promoting the message about respiratory history taking then the rest may start to fall into place for people! Good opportunity to get people to revisit the pathophysiology as well - I really like this easy to read paper on Pathophysiology of COPD by MacNee 2006
I followed this feed with interest last week, some really interesting points. Someone recently showed me the SpiroBank Smart which is a really interesting idea. Andrew Booth on another feed was talking about cleaning down O2 sats meters and handing them out for people to use at home. I wonder if you used Video Consultation and a simple hand held spirometer it would be possible to do spirometry at home? Not perfect but in these times perhaps better than having no values for lung function?
I think this is one of the things that I struggle with the most at the moment. But it is very reassuring in reading all the comments above, as this is exactly what I have been doing.
History and symptoms are key. This has always been the case: make your diagnostic hypothesis, and then prove / disprove through objective measurements. "Do no harm" is the other voice inside my head, and on the balance of probability, giving a SABA or LABA/LAMA trial is probably going to do more good than harm. Treatment trial success will be largely subjective, but hey, this is respiratory care!
I'm not sure about handheld Spiro (Get thee behind me, Satan!) Rob Daw , as I'm not sure if it would increase my confidence, or increase my anxiety, but desperate times call for desperate measures. And we do need to think outside the box. I guess it all depends on when we can have Spiro back? Answers on a postcard...
I would still like to add a note of caution as someone who has practiced before and after spirometry in primary care.
History can be deceiving, as any of us oldies who went through cleansing long lsts of COPD patients in the late 90s and early noughties will tell you. It must be done with an open mind and no assumptions- you just need to count the patients with 'normal' spirometry on our COPD registers.
The coming months will be challenging, not sure about home spirometry- there was some discussion about portable spirometers with ipads delivered to peoples homes so thy can be observed and then brought back to Practice, it sounds expensive. Any move to home spirometry would need some quality control and pilots. Possibly something like COPD6 could help point you in the right direction as a temporary measure, but again cost, need for observation of technique and how it would be cleaned?
Maybe a research proposal is needed, we could be here for sometime.
GPs should not try to detect mild COPD
Paul Enright1 and Carlos Vaz Fragoso2
npj Primary Care Respiratory Medicine (2020) 30:20 ; https://doi.org/10.1038/s41533-020-0176-0
Just looking at this with these references?
Jithoo, A. et al. Case-finding options for COPD: results from the burden of
obstructive lung disease study. Eur. Respir. J. 41, 548–555 (2013).
Thorat, Y., Salvi, S. & Kodgule, R. Peak flow meter with a questionnaire and minispirometer
to help detect asthma and COPD in real-life clinical practice: a crosssectional
study. NPJ Prim. Care Respir. Med. 27, 32 (2017).
Covid19 is not going to go away any time soon. Yes the prevalence will reduce , but it will not be eradicated until we have robust , accurate, rapid test track and trace systems. It will continue to exist, and thrive in other less fortunate parts of the world & will evolve into COVID-20 , COVID-21 etc .
i see this thread as being more about how we can adapt to live alongside Covid , vs wait for it to go .
diagnostic hubs are certainly likely to be part of the solution , alongside the sort of pre-op admin work up that we will see hospitals introduce in order to ensure that their elective procedures can restart ( eg patients isolating for 2 weeks plus testing prior to attendance / spiro etc to reduce risks. )
If we accept that spirometry is not always perfumed and interpreted correctly in primary care (my own survey of surgeries in Sheffield showed that only 25% of Spiro was performed correctly) then giving a patient a handheld, without a graph, doing it remotely maybe via video link, will surely decrease the quality even further. I appreciate you get false positives, but you get false negatives too. FeNO testing gets criticised as there are a fifth false positives / negatives. Reversibility testing is even worse at a third false positives and negatives. So if we go down the route of initiating something that hasn't been proven, in a therapy area that doesn't have especially good diagnostic tests in the first place, then aren't we heading for a hiding to nowhere? Wouldn't it be better to have a respiratory hub, with proper testing, proper PPE, proper decontamination, and proper results?
Or am I living in cloud cuckoo land?
It sounds very sensible to me. I find that the origins of people's breathlessness being correctly diagnosed agonisingly slow. All the time these people are breathless, they are loosing condition and quality of life. Having just done my ARTP spirometry course, I feel that although it was very good and thorough , it was very time consuming. I wonder what the long term uptake will be for general practice nurses.
Hi all... I’ve been reading this thread this morning.. and it’s all the things that are spinning through my head right now. I work in a 35,0000 pop inner city practice and I am currently the only nurse doing asthma/copd diagnostics reviews generally.
My biggest problem.. is time!!! It’s all so time consuming. I love it, I do it all day every day and enjoy the process. But it’s the constant time pressure vs trying to do the job properly that’s the struggle.
I’m definitely in the camp of history taking is the key. And then trial of treatment and review, and review, and review again!!! Then when you get fixed on a treatment... issuing an appropriate care plan (that they actually understand and therefore will/can use) and Education exercise/ACB techs etc etc... TIME!!!!
Im about to have a meeting Tom about how we can be more Streamline in our processes of diagnosis and review for these patients. Ie ? using tech to gather information prior to their appt with me etc.. history take done before by tech.
Generally practices allow 20mins (if ya lucky) for each asthma review per person per yr. but yet the reality is I speak to someone possibly 2-3 times ie for changing treatment and reviewing producing a pt specific relevant APlan that the patient understands and will use!!! etc etc... so this inbalance is an issue. Discussion is felt to be best when getting the patient engaged and educated to self manage and avoid AA’s etc.. but discussion again takes time. Supposedly better templates being set up to complete reviews but actually this discourages discussion I find. Being advised to be more succinct but yet there is so much info that’s relevant.
Any thoughts on how we get round this?? How do we reduce asthma deaths with 20m spent once yearly?? How does everyone else do it?? Any good ideas for me??