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. 
ths 

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  • 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

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  • Discussed this during a webinar I did last night chaired by Kevin Gruffydd Jones and our view was much as you have said here Noel - history, history, history, probability, peak flows and trial of treatment.  

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  • 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. 

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  • Of course, I was talking about asthma - just re-read the title of this message!  I think with COPD we can hold fire and perform post-bronchodilator spirometry when the time is right.  It's still going to be history and response to bronchodilator rx for COPD though.  Think I've covered my bases now! 

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  • 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?

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  • 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!  

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      • BEVERLEY BOSTOCK
      • Respiratory nurse
      • BEVERLEY_BOSTOCK
      • 6 mths ago
      • Reported - view

      Kerry Woodward  Leon O'Hagan    I love this approach. Sometimes we have to just be pragmatic... 

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  • 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

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463976/pdf/bmj33201202.pdf

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      • Michael
      • Michael
      • 6 mths ago
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      Sally Harris As a Buteyko Educator may I suggest the simple Buteyko Control Pause could be used. For those not acquainted to this measure, it is the maximum comfortable breath hold after a normal outbreath when at rest. For more information visit my website www.totalhealthmatters.co.uk . Recently a doctor discussed another method that can be used over the phone; ask the person to count aloud to as high a number as they can without taking any extra breaths. I believe this is called the Roth breath test. There is a correlation between the CP and the Roth measure.

      Most COPD sufferers will only manage a CO of between 10 and 15 seconds

      asthmatics 15 to 20

      75% of the population 20 to 30

      normal healthy breathing should be 45 to 60 seconds

      hope this is of interest.

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    • Rob Daw
    • Respiratory Nurse Practitioner
    • Rob_Daw
    • 6 mths ago
    • 1
    • Reported - view

    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?

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    • Rob Daw handheld spirometers cost < £100 . Providing new potential COPD patients with one could prove cost effective if it stops mid-labelling patients as COPD when they don’t have it. An idea to run past meds management team at CCGs .

      Also consider the cost of the individual components of the patient journey . Our patient referrals , unplanned admissions, urgent care visits etc 

      we will see an increase in anxiety symptoms ( increased perception of breathlessness ) across the population post covid , so expect to see more of these patients coming through the diagnostic funnel . 

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    • Stuart Berry We were discussing that yesterday cost of hand held v cost of avoided inappropriate treatment. There will still be costs associated with correct treatment but avoided harms too.

      Serial peak flows have also been mentioned as a way to excliude patients before moving on to other tests, as in the  article in npj. below

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    • Andrew Booth
    • Primary Care Respiratory Nurse and clinical tutor
    • Andrew_Booth
    • 6 mths ago
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    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...

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      • BEVERLEY BOSTOCK
      • Respiratory nurse
      • BEVERLEY_BOSTOCK
      • 3 mths ago
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      Andrew Booth I'm loving my Spirobank Smart - worth a look as you get traces, reproducibility data and numbers.  We are loaning one out and cleaning between patients.  They have a sealed portable, disposable turbine to use with the actual handheld unit.  This is a 21st century handheld device. 

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  • 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.

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      • Rob Daw
      • Respiratory Nurse Practitioner
      • Rob_Daw
      • 6 mths ago
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      Lisa Chandler Completely agree. I fear years of work to come, trying to review our decisions in the coming months. My thoughts on home spirometery were really around the sort of device you suggest i.e. COPD 6 or Carefusion Micro 1 with Video consultation to give some extra information to our history taking with a view that the long term goal would be re do these tests formally. I keep on hearing that we will only do PFT's when absolutely necessary but Im struggling to work out who these patients are? Naturally it is too risky to leave the patients with most severe symptoms untreated, but are these the patients that are absolutely necessary, you could argue that their diagnosis is more likely to be highly probably, whilst those with milder symptoms are either left without treatment or given treatment they may not need. Difficult and complicated times!! 

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  • 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).

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  • A great thread & comments 

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  • 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. ) 

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  • Do you think this may be the start of increasing breathlessness hubs?  If someone is going to self-isolate for spirometry, then it makes sense to carry out ECG, echo etc at the same time and then have reduced risk interactions with a number of health care professionals....

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      • Andrew Booth
      • Primary Care Respiratory Nurse and clinical tutor
      • Andrew_Booth
      • 6 mths ago
      • 1
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      Lizzie Williams I think this sounds like an amazing opportunity. Heart, lungs, and haematology all rolled into one super-hub!

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    • Andrew Booth
    • Primary Care Respiratory Nurse and clinical tutor
    • Andrew_Booth
    • 6 mths ago
    • 2
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    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?

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    • Andrew Booth That looks to be the way it will go.

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    • Andrew Booth not cloud cuckoo land... to get the proposal passed we would need to be mindful of the cost implications of not getting this right at the onset of diagnosis. 

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      • BEVERLEY BOSTOCK
      • Respiratory nurse
      • BEVERLEY_BOSTOCK
      • 3 mths ago
      • Reported - view

      Andrew Booth I'm loving the idea of perfumed spirometry although it could induce bronchospasm in some patients.   More seriously, though, see my comment above though, that Spirobank Smart does produce a graph.  Totally agree about hubs - mobile ones, in a van, to optimise accessibility!

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  • 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.  

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  • 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?? 

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    • Sally Turner 

      From one Sally to another I totally empathise and feel the same frustrations. Couple of thoughts I listened to a really good podcast on the Queens Nursing Insitute website by Suzanne Gordon on how as nurses we need to find our voices to articulate our profession and what we actually do. It made me think about how I might better approach articulating the importance of why we need time for reviews. Suzanne talks about the 'Paradox of Prevention' basically in undertaking chronic disease reviews we try to prevent things from happening , so its great that nothing happens to the patient, but the perception then is 'that nothing happened to make the nothing happen'. Really worth a listen she explains it much better than me. Promoting a whole team approach to diagnosis from the referring clinician who instigates the initial history  screening tests - CXR - bloods - PEF and symptom diary - means a large proportion of the assessment will already done. 

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    • Sally Harris 

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    • Sally Turner 

      I also think we need to implement some of the evidence we have around peer support and look at developing areas such as group consultation. Working with lay educators, third sector and wider team to provide some of the support around self care/ self management is crucial and moving forward we need to look at new ways of working, not just going back to the old ways of 20m appointments- this struggle has been the same for 30 years of my career and is very dependant on the set up in your area of work.

      A whole team approach using a whole and diverse team.

      PCNs should make this more viable, but thats another conversation

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  • Does anyone know what other countries do?  Does anywhere do a particularly good job?  

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    • Andrew Booth
    • Primary Care Respiratory Nurse and clinical tutor
    • Andrew_Booth
    • 3 mths ago
    • Reported - view

    Could something like the Spirobank Smart be utilised to perform Spiro in the car park, with the nurse observing either from the consulting room or a safe distance via Bluetooth. At least three people have suggested this type of technology / methodology to me recently (thank you Katherine Hickman  Rob Daw Sarahmcgarry ) which has caused me to rethink things considerably. I admit to having been a little resistant to this, but there is an adage that says: "If someone calls you a horse, then they are probably a horse. But if lots of people call you a horse, then you better get some straw."

    If we trial this technology, how would we know that it's worked (assuming we can't yet do a parallel study v usual Spirometry)? Is this as much about patient and professional confidence in diagnosis? And has anyone tried it yet? I'm starting to come round to the idea and feel a research project coming on! Now, where's that bale of straw...

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  • We were told on monday to expect guidance on Friday from ARTP. This wont solve all our prolems but was told that that while it will focus on secondary care (90 min COVID testing) it should help in primary care to inform practice.

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    • Lisa Chandler Thanks for the update - I was beginning to wonder if they were going to update us any time soon as not heard back from email I'd sent

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