athma and copd

1. 1
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Asthma and COPD Care
Pathways
 Libyan National Care Pathways

2. 2
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Two different diseases, but with some
overlap
 Asthma
 Usually in younger people
 Not a progressive disease
 Aim is complete control of symptoms
 COPD
 Usually in older people
 Progressive
 Aim is to reduce symptoms and slow progression

3. 3
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Asthma and COPD Care Pathways
 The responsibilities of the PHC doctor
 The responsibilities of the Nurse
 Referral

4. PHC – GP
Diagnosis of Asthma
 By history alone in most patients
 Testing for reversibility(15-20%)
in patients where there is doubt
about the diagnosis (Use Peak
Flow meter)
Care Pathway – Asthma
Investigations
 No routine investigations: no routine blood tests,
chest X-ray or allergy testing (unless clinically
indicated in selected patients)
 Pulse oximeter desirable but not essential
Lifestyle Education:
every care provider
 Focus on
behaviour
change –
smoking,
nutrition,
exercise, fasting
during Ramadan
(motivational
interview)
 Specific
education about
Asthma &
complications
 Tailored
education to
patient’s needs
 Role of MoH &
Community
(social
campaigns,
leaflets, social
medias, support
groups, etc)
201
8
Test of reversibility
 In clinic for
symptomatic
patients: peak
flow (PF) before &
after inhaled
Salbutamol
 Trial of oral
steroids with
improvementof
chest symptoms
 Patient records PF
at home (GP
responsible to
check patient’s
technique)
Treatment (Adults)
Use stepwise approach
Step 1:
 intermittentuse
of short acting
Bronchodilators
(Salbutamol)
 Preferablyusing a
spacer (can be
home made:
bottle or
availablein local
pharmacies)
 Follow up: check
inhaler technique
Step 2: add standard
dose of inhaled steroids
Step 3: add long acting
beta2agonist
Step 4: increase inhaled
steroids to high dose
Step 5: refer – if referral
not possible, GP starts
oral steroids
Medical Management
Adults
Refer to Specialist
Using referral form
Medical Management
Children <5
years
Acute Asthma Management
 Assessment of
severity
 Treatment in PHC
1. Inhaled Salbutamol
using either a spacer
or nebulizer
2. Oxygen (if available)
3. Oral Prednisolone
(unless patient cannot
swallow)
Reassess & decide
whether to transfer
 Search for
cause/trigger,
investigate & treat
infections (chest X-ray
only if clinically
indicated)
 Continue oral steroids
for 5 days
 Review patient,
consider stepping up
treatmentof chronic
asthma
PHC - Nurse
Awareness,Prevention &
Education (see below)
Patient education is
essential
Keeps disease register with
list of all Asthmatic patients
(Asthma Patients Register)
Responsibility to teach Peak
Flow (PF) monitoring&
inhaler technique to patient
Give asthma plan & PF
meter to each patient
(desirable)
 Trial of treatment
using inhaled
Salbutamol with
inhaler & spacer
 Children <2 years:
do not label as
asthma (keep
under review)
 Remember post-
viral wheeze is
not asthma
Treatment (<5yrs)
Use stepwise approach
Step 1:
 intermittentuse
of short acting
Bronchodilators
(Salbutamol)
 Always using a
spacer (can be
home made:
bottle or
availablein local
pharmacies)
 Follow up: check
inhaler technique
Step 2: add standard
dose of inhaled steroids
Step 3: refer – if referral
not possible, GP
increases dose of
inhaled steroids

5. PHC – GP
Diagnosis of COPD
 By history & examinationalone in
most patients (typicalpositive
features & absence of important
symptoms of alternative
diagnosis)
Care Pathway – Chronic Obstructive Pulmonary Disease
(COPD)
Investigations
 Every patient must have: chest X-ray, CBC
 Desirable to test for reversibilityin all newly
diagnosed cases (with Peak Flow meter)
 If in doubt on diagnosis, refer for Spirometry
(desirable)
Lifestyle Education:
every care provider
 Focus on
behaviour
change –
smoking,
nutrition,
exercise, fasting
during Ramadan
(motivational
interview)
 Specific
education about
COPD &
complications
 Tailored
education to
patient’s needs
 Role of MoH &
Community
(social
campaigns,
leaflets, social
media, support
groups, etc)
2018
Treatment
Treatment to reduce symptoms
Step 1:
short acting inhaled Bronchodilators (Salbutamolor
Ipratropium),use one for one month, if not effective,
change to the other
Step 2:
long acting inhaled Bronchodilators (either long acting
Beta2agonist: Salmeterol/Formoterol OR long acting
antimuscarinic)OR use a combination with Steroids
Step 3: refer
Medical Management
 Stop smoking at all steps (only measure
slowing disease progression!)
 Annual Influenza vaccine,
Pneumococcalvaccine every 5 years (if
available)
 Pulmonary rehabilitationby trained
nurse
Refer to Specialist
Using referral form
COPD Exacerbation
Management
 Assessment of
severity
 Treatment in PHC
Low dose Oxygen,
Beta2agonist by
inhaler or spacer,
antibiotics
Continue oral prednisolone
for 10 days
 Considerneed for
chest X-ray, CBC
 Reassess & decide
transfer or not
transfer
PHC – Trained Nurse
 Responsible to deliver
pulmonary
rehabilitation
(physiotherapy
exercises)
Follow up
 Every 6 months in early stages
 Assess according to symptoms and increase
frequency as disease progresses
Palliative Care:
multiple care provider
 Long-term home
Oxygen if possible
 High Protein Diet
 Home support:
Adaptation of
physical
environment
 Provide support to
patient & family
 Mental health
(depression)
 Psychological
support (end of life
support with
appropriate
communication
skills)
 Social services
involvement

6. 6
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How will patients with asthma
and COPD present?
 For the first time with an acute exacerbation
 For the first time with mild symptoms
 On occasions when the diagnosis has not been
made during previous consultations

7. 7
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The responsibilities of the PHC doctor
 Being alert to the different ways in which asthma and COPD can
present
 Taking a good history, especially of symptoms in the past
 Examining the patient to look for signs of asthma or of other diseases
 Excluding other diagnoses
 Using investigations as available and as necessary in order to assess
reversibility and to confirm diagnosis
 Using a stepwise approach to treatment, in both adults and children
 Giving appropriate health education messages, especially about
stopping smoking

8. 8
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The responsibilities of the PHC Doctor
( continued)
 Helping patients to understand how to use inhalers and spacers
correctly
 Managing exacerbations, and knowing when to refer patients with
severe exacerbations
 Understanding the availability and cost of different inhalers to ensure
that patients are prescribed the least expensive medicines that are
available
 Making appropriate referrals when patients are still symptomatic
despite stepwise treatment
 Supervising the clinic nurse to ensure that they satisfy their
responsibilities

9. 9
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The responsibilities of the nurse
 Maintaining a supply of health education materials
 Keeping registers of patients with asthma and COPD
 Teaching patients how to measure their peak flow and how to use
inhalers
 Using motivational interviewing to help patients to stop smoking
 Teaching patients simple breathing exercises ( pulmonary
physiotherapy)
 Helping patients to make asthma plans
 Knowing signs of serious exacerbations when detected during triage

10. 10
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Referrals
 Urgent referrals- treat and stabilise the patient before sending. Use
referral form
 Routine referrals. Use referral form. Write on the form WHY you are
referring the patient and WHAT you want the specialist to do
 Who is going to deliver them?
 How are they going to deliver them?