From assessing symptoms to choosing the right inhaler, there are a lot of things we consider as healthcare professionals looking after patients with COPD.
As a Consultant Respiratory Physician predominantly looking after patients with COPD, I am involved in multiple aspects of their treatment. In this series of 4 short videos, I am answering some frequently asked questions that you might have heard or asked yourselves in your healthcare professional life.
Note: if you would rather read my answers instead of watching the videos, you can find a text version further down the page.
Here is an overview of the questions I covered:
- How do you assess the symptoms of a patient who you know has COPD?
- How does this lead to treatment decisions?
- How common is the overlap between asthma and COPD?
- How do you differentiate between asthma and COPD diagnosis?
- What is important to consider when selecting an inhaler for COPD patients?
- How do you confirm a patient has the correct inhaler?
- How do you teach a patient how to use their inhaler?
1. Assessing symptoms and treatment decisions
The first thing I do with symptoms is associate people's symptoms relative to their lung function.
2. COPD and asthma overlap
The most important thing when trying to differentiate between the two is to take a really good clinical history.
3. Inhaler choice
What's really important is making sure that they've practised and you go through good inhaler teaching techniques with them so they understand how to use their inhaler.
4. Teaching a patient to use their inhaler
As healthcare professionals, it is important to remember that just because this might be their 200th prescription for that particular drug, we still check it is exactly what they are expecting to receive and that they know exactly how to use it.
If you would rather read than watch, here are the video transcripts.
1. What do you do to assess the symptoms in somebody you know has COPD and how does this lead to treatment decisions?
If we start with the assumption that we know that somebody's got an underlying diagnosis of COPD, there's multiple pathways that people take with their disease. Some patients have frequent exacerbations, lots of symptoms, lots of co-morbidities, sometimes recurrent hospital admissions. Other patients, for example, have a much more stable course of disease and might only be seen once a year in a routine annual review visit for example, rather than having day to day symptoms.
The patients that I see in clinic tend to be at the more severe end of the spectrum, with being a secondary care physician. But the first thing I do with symptoms is associate people’s symptoms relative to their lung function.
So, is somebody’s breathlessness out of proportion with their lung function, for example? Are they having lots of exacerbations irrespective of the severity of their COPD? And then make judgments based upon what their symptom burden is, relative to what the underlying reason for that symptom burden is.
So sometimes it's about making a new diagnosis in a COPD patient, it's about discovering they have heart failure on top of their COPD diagnosis. Sometimes it's about realising that their lung function has declined and maybe they need a step up in terms of their treatment. And sometimes it's about trying to treat frequent exacerbations and that might be long term antibiotics, for example as prophylaxis rather than making a change in inhaler management.
2. How common is the overlap between asthma and COPD and how do you differentiate between asthma and COPD diagnosis?
There’s controversy around how much overlap there is between asthma and COPD. Some studies would say that the overlap is as high as 40%. We've done some work that suggests that it's much lower than that, that it’s more like 14% overlap between the two diseases. One of the problems is because the symptoms are very similar for both, and there's overlap of symptoms with both that people get misdiagnosed as having one or the other. And I think some of that misdiagnosis, then leads to some of the higher prevalence figures in terms of overlap.
The most important thing when trying to differentiate between the two, is to take a really good clinical history. So, for COPD for example, in the UK, you are highly unlikely to develop COPD if you've not smoked. The COPD in this country that we can attribute to not smoking is around 5%. So that's a really good starting point for confirming the diagnosis of COPD.
The next thing then is to look at how those day to day symptoms have changed or what triggers people have in terms of their symptoms. So, somebody with asthma, for example, may well not have had a significant smoking history, if they've smoked at all, might be more likely to have a family history of asthma symptoms like reflux or rhinitis, for example, certain seasonal triggers that trigger their symptoms. So history taking is absolutely key.
Then it's about confirming the diagnosis with spirometry. So you expect to see obstructive spirometry in somebody who has COPD, you expect normal spirometry in somebody who has asthma, unless they've got really severe asthma with fixed airflow obstruction, but again, you should be able to differentiate that clinically.
And then the other important test for asthma is looking at peak flow variability and also looking at inhaled nitric oxide.
3. When selecting an inhaler for COPD patients, what’s important to consider and how do you confirm it’s the correct inhaler for that patient?
It's really difficult sometimes to get the exact inhaler right for the patient the first time you prescribe it. So over the years, I found that some patients do really well on a particular inhaler. And others just cannot get to grips with using a particular device for one reason or another. And sometimes there's no way of predicting that in advance of trying the inhaler.
What's really important is making sure that they've practised and you go through good inhaler technique, teaching with them so that they understand how to use their inhaler. And also to remember in terms of repeat prescriptions, I've had patients who've had a particular inhaler, and then it's been switched to a different device on repeat prescription and they come back and they've not known how to use it because the device has changed on repeat prescription.
So it's about education around making sure they know exactly how to use that particular device and remembering that not every single device works brilliantly for every single patient.
4. When teaching a patient how to use their inhaler, what steps would you go through with them?
The most important thing is that they understand exactly how to use that particular device they've been given. And as healthcare professionals, I think it's important for us to remember that just because this might be their 200th prescription for that particular drug, that we still check that it's exactly what they're expecting to receive and that they know exactly how to use it.
Particularly now that there are sometimes variations with the same drugs in terms of the device that things can be given in. And so I think it's important to always check that they know exactly what to do with that particular device; be that through demonstration of showing them with the placebo, or just talking them through how they're going to use their inhaler.