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Asthma and COPD Care Pathways.ppt

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Asthma and COPD Care Pathways.ppt

  1. 1. 1 All rights reserved Asthma and COPD Care Pathways  Libyan National Care Pathways
  2. 2. 2 All rights reserved 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. 3 All rights reserved Asthma and COPD Care Pathways  The responsibilities of the PHC doctor  The responsibilities of the Nurse  Referral
  4. 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. 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. 6 All rights reserved 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. 7 All rights reserved 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. 8 All rights reserved 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. 9 All rights reserved 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. 10 All rights reserved 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?

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