Respiratory Guidance & Information Page
Somerset LMC Nurse Adviser - Information and Contact details
Breathless Algorithms - These documents/algorithms you may find useful when assessing breathlessness (for interest).
Please see below the latest COPD guidance & Protocol. The icons showing documents are embedded documents within the guidance, so click on them and they should open.
The aim of the protocol is to provide a framework for qualified nurses to care for patients who have been diagnosed with COPD within general practice. This advice is based on NICE1 and the Somerset respiratory networks guidance and should be used in conjunction with this protocol as patients present or via formal COPD clinics. Please also bear in mind this document is aimed at processes and that it does not reflect the individual care and expertise you need to provide for your patient group.
- Asthma step down guide -
- Summary of inhalers and equivalents
- Inhaled Corticosteroids
Examples/Templates of Good Practice
David would like to send you information that he thinks is helpful and appropriate. as not everyone attends meetings and conferences and is exposed to new products/information. They will be non-promotional and to make it clear he does not endorse any particular product only wants to share information and changes that he thinks may be helpful in your practice, for you to use as you will. This does not take away from your own judgment, experience and skill.
Somerset Respiratory Adviser (David Long) News
NEWS 24 JANUARY 2019
Re: vaping advice
Please read letter regarding vaping and new resources/information.
NEWS 3 January 2019
There is currently some confusion over asthma management plans. One would hope this brief item will help diffuse any concerns you may have. Please note this item relates to the Asthma UK Action plan but may be pertinent to other plans in circulation. The main questions are:
Q1 Do I have to fill in all the action plan ie percentage drop in peak flow?
A1 In short, No. There is no evidence to suggest a symptom driven plan is any better or worse than using peak flow measurements to gauge deteriorating asthma control. So you can cross out the peak flow boxes if you wish and any other part that is not pertinent to the patient for that matter. Using symptom recognition to initiate patient action if you and the patient agree.
Q2 The plan still includes spaces to allow patient to increase their ICS, this has normally meant doubling ICS dose (amber section) is this still used?
A2 In short No. Evidence suggest that doubling does not help patients and quadrupling may be helpful. However if you quadruple the dose you need to be aware of not giving very high doses of ICS and LABA. The advice is that if the patient is not taking their preventer it should be started at this point. If they deteriorate then seek help sooner as detailed in the plan.
At the Respiratory Clinical Programme Group in Somerset, self management plans (Asthma and COPD) are being reviewed and one would hope a Somerset wide plans will be forthcoming in the new year and embedded into EMIS thereafter. "
Not sure if we need to evidence this but my hunch is practices nurses just need to have the guidance.
NEWS 6 December 2018
Firstly I would like your help. At the recent Respiratory Clinical Programme Group it was agreed that a SOMERSET wide self management plan for both asthma and COPD would be a good idea. With this in mind could you send me your self management plans if they are different to the asthma UK plan or the Somerset COPD plan. We would like to update our current plans and would dearly like to see what is actually in use currently. If you could send them to me at email@example.com I will forward them to the group. I will of course send you all the updated plans once the exercise has been completed.
The next item again is about sharing good practice and I would dearly love to understand what mechanism you use to inform you of a discharge of a respiratory patient from hospital to allow you to put in place the appropriate follow up. Not every practice has a mechanism in place and it would be good to hear what works elsewhere and share this. If you could email me as above I would be very grateful.
Most of you now know about “right Breathe” website and the app. However I was informed of an excellent way in which it can benefit patients.
Within the app you have the opportunity to set a profile. If you chose the patient profile it allows the patient to choose their own inhalers. this gives them information about the inhaler, inhaler technique video and a way of setting diary entries/alarms to remind them to take the drugs.
I am currently at the Winter BTS and the SIGN/BTS asthma guidance was presented and a consultation document produced for consultation and updating in 2019. Available is NICE COPD partial update https://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245
More information on this in later news but if you want to read them they are available online currently.
The last item concerns the launch of a five year plan to improve lung health which was launched on the 5th December. This is a welcome document and is good to see respiratory disease coming to to the fore at a national level. It covers many recommendations to improve outcome for patients with lung disease. I will not list here but you can read the report https://cdn.shopify.com/s/files/1/0221/4446/files/Taskforce_Report_FINAL_low-resv2.pdf?_ga=2.120965640.1028659838.1544109930-2145669372.1544109930 .
I started my new role in September of this year and the time has flown by. The nurses I have come into contact with during this time have been exceptional and I would like to thank you all for engaging with this new initiative and look forward to working with you in the coming year to improve outcomes for respiratory patients in Somerset.
As this will be the last communication of the year from me I would like to wish you all a very Merry Christmas and a Happy New Year.
News 16 November 2018 - GOLD Strategy Update 2019 published
The strategy has updated two main areas:
- ABCD INITIAL assessment model has been simplified. This model was never intended for follow up therapy . It also includes using eosinophils (= 0.3 taken when patient is in a stable state) as a biomarker for patients who would likely respond to ICS.
- It has developed a follow-up treatment guide based on symptoms as a way to decide which treatment to consider for patients who present with either predominant breathlessness or exacerbations. It also includes consideration of deescalating treatments.
Another area that I feel needs highlighting and should form part of any clinical assessment is the management cycle (pp 28 of the pocket guide), a simple but effective aid memoir.
The consensus is that we continue using local and GOLD strategies until the NICE guidance is published (Dec 2018). We can then advise and inform once digested.
News 12 November 2018 - Good Practice Information
I thought it might be a good idea to share good practice when I come across it. This is a simple but effective way of ensuring that patients understand what medication they are taking and for what disease. It also improves correct inhaler technique, compliance and can reducing consultation time.
This ‘top tip’ came about from a symposium discussion at this years PCRS conference. A GP when prescribing an inhaler will put on the prescription and subsequently medication label, something along the lines of ‘ Take salbutamol for relief of your asthma”. If it is a new prescription for an inhaler and they have not had time to do the inhaler technique a request is also put on the script “please can the pharmacist show inhaler technique”. This will help you, the pharmacist and patient alike.
The patient knows why and how to take their medication. The pharmacist knows why they need the medication and can inform the practice of over or under use of medications. For the busy clinician they can be assured the medication is being used correctly and this will be subsequently reinforced on subsequent visits. Have a discussion with your team.
You may be doing something similar, if you are, I would love to know how its working, or any other initiative you feel has impacted positively on your respiratory patients ( firstname.lastname@example.org ) I know it may not be acceptable for all, for numerous reasons but think this is an excellent small measure which has had a positive impact.
News 25 October - New Products of Note
I can hear you say “not another inhaler to add to the 109 already out there!”. Its here, and why do I think its worth a mention? It adds another useful combination therapy to our ‘bag of tricks’ for asthma patients only.
It is a pMDI, ICS/LABA that is the only breath-activated device available in this combination. So this will allow you to consider this device and drug combination for patients who have ASTHMA and are already using breath-activated devices or those you feel would benefit due to poor technique. with their current device. Needless to say it has to be used in accordance with the SIGN/BTS asthma guidance for ICS/LABA.
Briefly it is for 12yrs and older on lower dose fluticasone propionate 50 mcg/ 5mcg formoterol the medium dose being fluticasone propionate 125 mcg/ 5mcg formoterol. If the research is to be believed it has a very good deposition on the lungs of a mean of 43%, compared to the usual 30%.
AeroChamber plus Flow-Vu
Nothing new here? We are all very familiar with the AeroChamber spacer device and why we use it. The company have produced a spacer device that although 15p-30p more depending on style type prescribed, has in my mind significant benefits over the older device we are familiar with. First and fore most its anti-static, so no need to waste drug priming the device and more drug is delivered to the patient. It has been demonstrated to reduce hospital admission (19%) and ED attendance (13%) compared to other conventional non-antistatic devices. How often do we forget to tell patients to wash the device regularly in soapy water and leave the soap on the device to air dry (helps reduce anti-static)? This device is dishwasher safe which is a big bonus for practicality. It is more cost effective as it needs to be replaced every year as opposed to the current version every 6 months. There are other improvements such as an outlet valve that blows away from the patients face. However for me the above is enough for me to consider prescribing this above the normal Aerochmaber. If you want more detailed current information about Spacer device why use them and how? Follow this link http://openres.ersjournals.com/content/erjor/4/2/00065-2018.full.pdf
You may have had all this information already, if you have I apologise but for those who haven’t I think these productsare worth keeping in mind when you review patients. You can look on the products website or ask for visit by the representative if you want further information.
News 5 October - Opinion News Slot
Cough in COPD
We all know of patients that despite the traditional methods to help their cough such as:
· Stopping smoking
· Optimal inhaler therapy
· Correct treatment for exacerbation i.e. extending antibiotic course length (see Somerset COPD guidance)
· Cold, pollution and other irritant avoidance
· Keeping hydrated
· Flu & pneumonia vaccinations
· Pulmonary rehabilitation
· Mucolytic therapy (remembering to reduce frequency from tds to bd after successful 3/12 trial)
COPD patients still have difficulty expectorating and clearing phlegm causing an increase in exacerbation frequency. One physiotherapy technique is the Active Cycle of Breathing this is one technique usually used in cystic fibrosis or Bronchiectatic patients. It is however very useful technique to help clear sputum in a less explosive and traumatic way for your COPD patients. This technique used effectively can help patients significantly, however when patients find this ineffective other methods can be used. Therapeutic devices, which help the removal of mucous from the airways such as, flutter devices. One new product that can be prescribed is the Aerobika it should only be considered after all the previous methods have failed. Why I think this helps more than others is due to the way it works at the earliest part of expiratory phase, no metal parts. On a more practical level it can be cleaned in a dishwasher and microwave bag as well as the usual methods and last a year (approx. £46).
Sputum clearance is an important and integral part of treatment for your COPD patients especially if they are productive and have frequent exacerbations. By employing the above methods you will reduce the impact on patients and the health service.
As always I would welcome and constructive feedback Dlong1@nhs.net , I realise this is not a comprehensive review of interventions but want to highlight areas that in my experience make a big difference to patients.
News 25 September - Spirometry National Register a Local Perspective
It is hoped that by April 2021 anyone involved with undertaking or producing a report / interpretation for a clinician on spirometry will need to be assessed and deemed competent by a nationally approved assessment led by ARTP and be approved for entry onto a national register.
A key point is that you do not need to receive training via an ARTP accredited provider but assessed. So training needs can be met in other ways. Once registered you will need to be reassessed every 3yrs. At the current time this is not an expectation - but with boundaries of professional competence it is important the those undertaking, producing a report for a clinician should have the appropriate skills necessary. The clinician should be assured the spirometry is good quality - and interpret the spirometry report in a clinical context (much like xrays and other tests) to decide on diagnosis.
Things to consider:
• The register is hinted at but not formalised by the CQC
• If you train and register now you will need to be reassessed soon after the scheme starts.
• There are substantial costs involved for the training and registration and no funding stream has been negotiated via NHS England. This central funding should be provided, as it is a Quality Assurance Initiative.
• Spirometry training is always ongoing due to the turnover of the workforce. Whatever training is made available it needs to be readily accessible.
• There may be a local solution to the initiative; this will be discussed at the CCG Respiratory Clinical Program Group.
The advise for now, is that you need not worry for the next couple of years about registration - but you should be able to indicate why you believe that you are competent to perform / report on spirometry. We should have a better understanding of the educational and financial landscape by then. We will of course keep you all informed of any changes or local initiatives.
More information can be obtained : https://www.pcc-cic.org.uk/article/quality-assured-diagnostic-spirometry
News 20 September - New Respiratory Dashboard available
New Respiratory Dashboard is available!
The rationale being: "Given the complexity of prescribing in respiratory care and the plethora of medicines available, it was agreed by a national group of respiratory specialists that it would be useful to help see the variation in prescribing of respiratory medicines across England.
The aim of this dashboard is to highlight the variation in prescribing across the CCGs in England so that CCGs and local health economies can utilise this data at local level to decide if this variation is warranted or unwarranted and if and how they may wish to address this.”
Undoubtedly it will take time to review and formulate opinions we will of course keep you updated of any initiatives or thoughts. It might for the time being be of interest to you and your practice.
News 12 September - Cost Effective Prescribing of Inhaled treatments for Asthma
There is a need for a simple document that outlines first line choices of inhaled treatment to be used in respiratory care. The rationale is to simplify matters for those who are not that familiar with the newer options available from the 100 plus choices, reduce cost, improve ‘brand prescribing’ and patient safety.
To help in this matter, David Long has put together a matrix of choices which you can adapt to your own Medical Centres preferences. It is intended for the whole practice to agree and adopt. If another choice is required, the patient is sent to the respiratory specialist in the practice for instruction and inhaler choice dependent on the class or classes of drug required.
News 3 Sept 2018 - Primary Care Respiratory Society 'interesting bits’...
A study looking at the patients perception of asthma control, highlighted how and why patients do not use ICS. Also why there is a lack of patient engagement in asthma reviews. This article certainly provided an interesting insight. I think this is something that as a group we need to think about and work on, counteracting the patient perception. Read the summary by following this link http://www.respiratoryacademy.co.uk/journals_club/understanding-patients-perceptions-of-asthma-control-a-qualitative-study/
click on the July button at the bottom of the PCRS webpage to see other interesting respiratory articles.
I would be interested to hear your opinions on how we could improve this perception of not engaging the patient. I for one advocate using health status questionnaires such as the asthma control test. This helps not only engage the patient and improve consultation satisfaction but helps you as a clinician pinpoint problems the patient is experiencing and discuss solutions. It will also tell you if you repeat the scoring after an intervention if the patient has had any benefit. Hence having to see the responses to both the pre and post intervention questionnaires is important, as certain domains may well have changed from the previous questionnaire but have the same total score.
This is a brief update as I have only just commenced my new role. I do hope this is helpful and will of course keep you updated in due course as to the events and news happening within the respiratory specialty.