The primary care audit is currently only run in Wales due to its IT infrastructure being better suited to an automated pull of data directly from GP systems. The expansion of audit into England is being explored by NHS England. GP practices in Wales will be approached in the lead up to the next round of audit (winter 2023) to ‘opt in’, therefore if you are a Welsh GP we encourage you to opt in at that point to be involved. English GP practices can use the audit information located at GitHub – NationalAsthmaCOPDAudit/primary_care2021: 2021 Welsh Primary Care Audit to set up and run their own asthma and COPD audit(s) until which point the audit is formally commissioned in England.
The respiratory toolkit has been commissioned by various ICSs and NHS organisations across the UK. If this applies to you, you will have a bespoke platform for your health service and you can sign up for free and access the respiratory toolkit. If you aren’t sure whether there has been provision in your area, get in touch with ICST and we will offer that support firstname.lastname@example.org
The patients do not pay for the apps, Asthmahub, COPDhub and Asthmahub for parents – they are commissioned centrally which means they are free at the point of access
Yes, this is very common, as well as patients being discharged from hospital with an exacerbation of COPD without any confirmation of that diagnosis. If you are aware of this cohort, the diagnosis can be simply confirmed (or refuted) with a post-bronchodilator spirometry, but the problem occurs when these patients don’t have their diagnosis confirmed.
If practices are not sure which patients are in this cohort, they can be identified when practices run a search for patients coded with the codes for COPD diagnosis or suspected diagnosis, and then sort this cohort of patients into those who have the correct code for post-bronchodilator spirometry (339m or 407603001)
There shouldn’t really be a diagnosis of COPD without the bronchodilator evidence. However a diagnosis of emphysema could be made on CT scan and normal spirometry. These patients have a higher risk of lung cancer than non-emphysema patients and also of developing COPD so should be followed up annually with spirometry and sympromatic review.
A post bronchodilator FEV1/FVC ratio less than 0.7 confirms a diagnosis of COPD, but there are two scenarios that might explain the pattern that you are describing:
If this was a young person, you may consider a diagnosis of COPD if they were symptomatic (and they have an abnormal chest xray) because what’s considered “normal” FEV1/FVC ratio for their age might be considerably higher than 0.7 (or 70%).
If there was an issue with the quality of the spirometry trace – it’s very easy to achieve poor quality spirometry that falsely elevates the FVC, and therefore normalises the FEV1/FVC ratio above 0.7 (70%). Repeat the spirometry, making sure that the patient takes a maximal inspiration to ‘full’ and then ‘empties’ their lungs forcefully.
The difficulty here is that the FEV1/FVC deteriorates with age, so using one fixed cut-off for everyone can be a bit tricky. There is a risk that this fixed cut-off could cause significant under-diagnosis in young people, and over-diagnosis in old people (who don’t have any disease, but just old lungs!).
As a simple rule of thumb, using 0.7 as a cut off for ‘normal’ lung function is perfectly acceptable for everyone EXCEPT young people (<35 years) and old people (>70 years). The group in the middle, who are likely to be the ones who are being diagnosed with COPD, it is probably acceptable to use 0.7, and this is why most guidelines will advise that we use 0.7.
The Lower Limit of Normal (LLN) <b>directly compares</b> your patient to a group of normal people with healthy lungs of the same age and height as your patient. This is the <b>gold standard way to interpret spirometry</b> test results. If your patient has results lower than their LLN, this suggests that there is a disease process which is causing this abnormality.
BTS/SIGN for asthma recommended LLN but GOLD/NICE for COPD and NICE for asthma have stuck with fixed ratio. The evidence that LLN correlates any better with a diagnosis of asthma or COPD isn’t really there in spite of the points raised above and the fixed ration is simpler to explain and measure and reference population figures aren’t always available for all populations so by and large the powers that be have stuck with the fixed ratio (For now!).
Yes – if you aren’t sure if this is asthma or COPD, the best thing to do is to perform a reversibility test.
If the pre-bronchodilator spirometry test is normal, this rules out COPD but does not rule out Asthma. Use another objective test to try and find evidence of Asthma, like a PEF diary.
If the pre-bronchodilator spirometry test is abnormal, it could be either Asthma or COPD.
If the post-bronchodilator spirometry improves significantly from the baseline, AND it returns to normal parameters, this supports a diagnosis of Asthma.
If the post-bronchodilator spirometry does not improve significantly from the baseline, AND the FEV1/FVC remains abnormally reduced <0.7, this confirms a diagnosis of COPD.
If the post-bronchodilator spirometry improves significantly from the baseline, but the FEV1/FVC remains abnormally reduced <0.7, this supports a diagnosis of both Asthma and COPD, called Asthma/ COPD overlap syndrome (ACOS).
Spirometry is only one part of the diagnosis in children and if you are not trained to do it/don’t have availability for tests then you need to look at other options i.e. History, examination, PEFR when symptomatic, PEFR diary, FeNO and or trial of treatment. All clinicians in England working with children with asthma are encouraged to do training which is available on the ICST Respiratory Toolkit, or here https://www.e-lfh.org.uk/programmes/children-and-young-peoples-asthma/
(Highest PEFR – Lowest PEFR) / Highest PEFR over a 5 day period
Traditionally the peak flow readings are carried out over a two week period with Highest-lowest /mean but there is research which shows that 5 day, twice-daily readings where variability =highest-lowest/highest is as good.
Variability = >20% in UK although GINa says >10% !
Thanks for your comment – we agree this is the best way to explain to your patients what you are referring them to
Thank you for your question and I’m sorry to hear that you don’t have a pulmonary rehabilitation service. It sounds like you have approached your local commissioning group. If you haven’t involved patients in that request, you may want to consider submitting another but including support from a patient group e.g. Asthma and Lung UK, Action for Pulmonary Fibrosis, your local pulmonary rehabilitation network and possibly national pulmonary rehabilitation groups e.g. British Thoracic Society PR Advisory group. This may help strengthen your bid. In the meantime, you could see whether your most local service would be able to provide any support e.g. online or home-based PR programmes (the patients would still need an in-person assessment, so this may not be a realistic option if patients have to travel very far).
Wishing you the best of luck.
Patients should be encouraged to be as active as possible with COPD, and there are lots of exercise referral schemes run by trained exercise practitioners that are designed for people with long-term conditions. These offer patients some support and guidance to exercise safely and give them the confidence to improve their activity levels. Perhaps contact some of your local leisure centres to see what is available for people with respiratory conditions.
People with MRC 2 and functional limitation can be referred to pulmonary rehabilitation (BTS Quality Standards for PR), so you don’t need to wait until they are categorised as MRC 3. As well as local exercise referral schemes noted above, you could also share reputable online resources about keeping active: Keeping active with a lung condition | Asthma + Lung UK (asthmaandlung.org.uk)
Thanks for your comment – we agree!
Important to think of behaviour change. Just because somebody knows that not taking medication could lead to death does not mean they will take their inhalers unfortunately. Explore with them about what is stopping them taking them, the barriers, ensure they have the resources and that their environment is set up right i.e. inhalers next to the toothbrush/bedside table. Think about a prompt that they are already doing on a routine basis that they could link to taking their inhalers. I teach patients the Tiny Habits method https://tinyhabits.com/ and there are loads of resources on the PCRS Asthma Right Care page https://www.pcrs-uk.org/campaign/asthma-right-care
Thank you for your question. It is great to hear about the initiative but I’m sorry to hear about the difficulties experienced. In research exploring barriers to referral, one of the points that is frequently highlighted is referrer education. It’s not clear from your question whether you put in place the scheme as well as a programme/initiative to education referrers about PR i.e. what it involves, the benefits, who should be referred, when they should be referred etc. Good relations between the referring services and PR service are important as this can facilitate education, feedback and notification of inappropriate referrals.
Unfortunately, this is only going to get worse with the new QOF metric which has changed from offer to refer. Here is some wording you could use to support locally: We are writing to ask for your help in safeguarding services and preventing them from being overwhelmed with inappropriate referrals and or ‘batch’ referrals. Please will you ensure when referring a patient to PR that not only you, as the referrer, understand the merits of the referral but that the patient also does and are on board. There is no place for ‘blanket referring’ patients on the COPD register as this will lead to referrals being rejected and clogging up an already saturated system.
Diagnosis of COPD should be done as normal using post-bronchodilator spirometry. If the patient has had multiple harmful agents that could cause the COPD, it’s not possible to differentiate between them unfortunately.
Companies will say you can do from age 6 but it is very dependent on the child and the time you have available!
This will depend on whether or not your machine is set up to do spirometry on children and/or whether you are appropriately trained to do it. Children from 12 years should be able to perform good quality spirometry, as well as some younger children with lots of coaching!
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