Asthma is a common and complex syndrome, and a major cause of morbidity and healthcare costs. Clinicians have an array of evidence-based investigations and effective interventions at their disposal, but outcomes have not improved as much as trial evidence would suggest they could. This article discusses drivers behind this discrepancy using illustrative examples to highlight information gaps and barriers that impair the delivery of community and emergency asthma care and appropriate referral to specialist asthma services. It highlights organizational issues in the current system that lead to disjointed care that varies in quality. It also explores problems such as the adequacy of training for healthcare professionals, divergence from best practice guidance, and an acceptance amongst patients and practitioners of poor asthma control. This, along with inherent problems in the diagnosis of this heterogeneous disease, facilitates and perpetuates suboptimal care and outcomes. To help address the outcome gap, we discuss the potential for relatively simple, achievable and cost-effective actions that could potentially be taken by clinicians together with commissioners and managers of healthcare systems.

Jane Scullion looks at the latest evidence linked to prescribing for COPD patients

Background: Switching inhaler regimens for clinical or non-clinical reasons can incur variable consequences and damage patient–healthcare professional (HCP) relationships (Usmani, et al. JACI IP 2022;10:2624). Objective: To develop a global expert consensus quality standard on how and when to implement appropriate inhaler regimen switches. Method: A nominal group technique was used, comprising primary care, secondary care, payer and patient respiratory disease experts. Ideas were generated in response to research questions on appropriate switching, who should be involved and the best practice. Each response was independently rated or scored. Results: Experts generated 80 ideas to the questions (excluding duplicate/overlapping ideas). Error/s in inhaler technique, and inadequate disease control due to symptoms or exacerbations rated as 'very important' reasons for an inhaler regimen switch. No patient consultation and no training/ education rated as 'extremely important' reasons for preventing a switch. Activities rated as 'considerably', 'very' or 'extremely important' when implementing a switch and time required, are outlined in Figure 1. It was agreed that HCPs should initiate and implement switches. Conclusion: Clinical and patient-led factors are the most important reasons for prompting or preventing an inhaler regimen switch. To implement an inhaler switch requires a median 35 minutes per patient.

Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.

BACKGROUND:Inhaled medications are central to treating asthma and chronic obstructive pulmonary disease (COPD), yet critical inhaler technique errors are made by up to 90% of patients. In the clinical research setting, recruitment of subjects with poor inhaler technique may give a false impression of both the benefits and the necessity of add-on treatments such as biologic therapies.OBJECTIVE:To assess the frequency with which inhaler technique is assessed and reliably optimized before and during patient enrollment into randomized controlled trials (RCTs) addressing the efficacy of topical therapy, and the escalation of therapy for asthma and COPD.METHODS:Systematic searches were conducted of PubMed and Embase for RCTs published in the past 10 years involving patients with a diagnosis of asthma or COPD undergoing escalation of baseline inhaled therapy (stepping up, changing, adding, switching, increasing, etc) or the introduction of biologic agents.RESULTS:Searches highlighted 1,014 studies, 118 of which were eligible after the removal of duplicates as well as screening and full text review. Of these, only 14 (11.9%) included accessible information in the methods section or referred to such information in online supplements or protocols concerning assessment of participants' inhaler technique. We therefore developed the proposed Best Practice Inhaler Technique Assessment and Reporting Checklist.CONCLUSIONS:Our study identifies a concerning lack of checking and correcting inhaler technique, or at least reporting that this was undertaken, before enrollment in asthma and COPD RCTs, which may affect the conclusions drawn. Mandating the use of a standardized checklist in RCT protocols and ensuring all published RCTs report checking and correcting inhaler technique before enrollment are important next steps.

Background:Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. A comprehensive and detailed understanding of COPD care pathways from pre-diagnosis to acute care is required to understand the common barriers to optimal COPD care across diverse health systems.Methods:Country-specific COPD care pathways were created for four high-income countries using international recommendations and country-specific guidelines, then populated with published epidemiological, clinical, and economic data. To refine and validate the pathways, semi-structured interviews using pre-prepared discussion guides and country-specific pathway maps were held with twenty-four primary and secondary care respiratory healthcare professionals. Thematic analysis was then performed on the interview transcripts.Results:The COPD care pathway showed broad consistency across the countries. Three key themes relating to barriers in optimal COPD management were identified across the countries: journey to diagnosis, treatment, and the impact of COVID-19. Common barriers included presentation to healthcare with advanced COPD, low COPD consideration, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted disease management across the pathway but presents opportunities to retain virtual consultations. Structural factors such as insurance and short duration of appointments also impacted the diagnosis and management of COPD.Conclusion:COPD is an important public health issue that needs urgent prioritization. The use of Evidenced Care Pathways with decision-makers can facilitate evidence-based decision making on interventions and policies to improve care and outcomes for patients and reduce unnecessary resource use and associated costs for the healthcare provider/payer.

Respiratory disease is one of the leading causes of both mortality and morbidity, causing a significant burden on healthcare resources, the economy, and on individual patients and their carers. Respiratory conditions are managed in many different settings, from home and residential care through the full range of primary to tertiary care. The multifaceted nature of both diseases affecting respiration and the care options is comprehensively covered in this second edition of the Oxford Handbook of Respiratory Nursing. Offering a systematic description of the main respiratory diseases found in adults, the Handbook covers the assessment, diagnosis, and nursing management of each condition. With a special focus on the role of the multidisciplinary team in meeting the multiple care needs of respiratory patients, the Handbook covers both physical and psychosocial concerns, and both pharmacological and non-pharmacological therapies.

Introduction: COPD is a major cause of morbidity and mortality worldwide. There is an immense burden on patients and the healthcare system associated with COPD care. Contributing to this is the lack of a holistic view of how COPD care is delivered in diverse health systems. Aims: 1. Use quantitative and qualitative data to develop comprehensive COPD care pathways in Japan, Canada, England and Germany. 2. Understand similarities and differences across national COPD care pathways, including the impact of COVID-19, to identify where to target health system policy reform. Methods: Country-specific COPD care pathways using the GOLD recommendations and country specific guidelines were created and populated with published economic, epidemiological, and clinical data, identified from a pragmatic literature review. A semi-structured discussion guide and COPD care pathway were used to interview 13 respiratory healthcare professionals in primary and secondary care to build and validate the pathway. Results: Availability of data varied across countries, with a distinct lack of published data in Japan. Overall, 22 barriers to optimal care (grouped into 5 main themes: pre-diagnosis, diagnosis, management, exacerbations, and COVID-19) were identified. Common issues included presentation to healthcare with advanced COPD, low levels of COPD awareness, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted COPD care across the continuum of the pathway. Conclusions: Analysis of COPD care pathways highlighted current gaps in optimal care and identified common areas for global health policy reform. Implementing policy change may improve patient outcomes and reduce COPD mortality.

Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder that causes considerable morbidity and mortality throughout the world. COPD is predominantly caused by smoking. COPD is characterized by fixed airflow obstruction. Significant airflow obstruction may be present before the individual is aware of it. Airflow obstruction is slowly progressive, with minimal or no reversibility to bronchodilators. This chapter covers the causes and risk factors, epidemiology, investigations, differential diagnosis, and assessment. It then goes on to describe management strategies (pharmacotherapy, drug delivery systems, other therapies), the management and treatment of acute exacerbations of COPD, oxygen, and assisted ventilation, the role of the nurse and the nurse specialist, complications, and palliative care.

Asthma is a significant problem in the UK reported to affect approximately 5.2 million people; and occurring in 21% of children and 15% of adults. Allergy is an important component of asthma, and most people with asthma are sensitive to one or more common aeroallergens. Approximately 80% of people with asthma also have rhinitis (essentially a runny, blocked nose), which is associated with a significant impact on quality of life. This chapter covers asthma and its assessment and management, patient education, and an introduction to allergy. This also includes the allergic response, diagnosis, anaphylaxis, immunology, and care algorithms as other important aspects.

Selecting the most appropriate inhalation device from the wide range available is essential for the successful management of patients with chronic obstructive pulmonary disease. Although choice is good for healthcare professionals, knowing which inhaler to prescribe is a complex consideration. Among the key factors to consider are quality of disease control, inhaler technique, inhaler resistance and inspiratory flow, inhaler design and mechanisms of drug delivery, insurance and reimbursement restrictions, and environmental impact. In this article, we offer a simple, practical tool that brings together all these factors and includes hyperlinks to other published resources from the United Kingdom, Belgium, and The Netherlands.

Spacers are pressurized metered-dose inhaler (pMDI) accessory devices developed to reduce problems of poor inhaler technique with pMDIs. Spacers that feature a 1-way inspiratory valve are termed valved holding chambers (VHCs); they act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a 2-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. Both spacers and VHCs have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce corticosteroid-related side effects such as throat irritation, dysphonia, and oral candidiasis commonly seen with the use of pMDIs alone. Spacers and VHCs are not all the same, and also are not interchangeable: the performance may vary according to their size, shape, material of manufacture and propensity to become electrostatically charged, their mode of interface with the patient, and the presence or otherwise of valves and feedback devices. Thus, pairing of a pMDI plus a spacer or a VHC should be considered as a unique delivery system. In this Rostrum we discuss the risk potential for a patient getting switched to a spacer or VHC that delivers a reduced dose medication.

Introduction Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD. Methods A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like. Results The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required. Conclusion There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required.

As global citizens, we have a duty to reduce the serious threats posed to planetary well-being and population health by environmental degradation and climate change. These now unquestionable threats to our future are due to human population growth and the resource consumption patterns of the human race. In tandem, as healthcare professionals, we should seek the best possible outcomes of our treatment for our patients and we need to consider equity between different groups of patients. In the speciality of respiratory medicine, the current controversy over how to deal with the role in global warming of the propellants used in pressurised metered dose inhalers (pMDIs) is a very pressing example of how these sometimes conflicting imperatives confront us in our daily practice. Uncritical implementation of policy risks deterioration in patient inhaler choice

OBJECTIVE:To assess the incidence of hip fracture and all major osteoporotic fractures (MOF) in patients with chronic obstructive pulmonary disease (COPD) compared with non-COPD patients and to evaluate the use and performance of fracture risk prediction tools in patients with COPD. To assess the prevalence and incidence of osteoporosis. DESIGN:Population-based cohort study. SETTING:UK General Practice health records from The Health Improvement Network database. PARTICIPANTS:Patients with an incident COPD diagnosis from 2004 to 2015 and non-COPD patients matched by age, sex and general practice were studied. OUTCOMES:Incidence of fracture (hip alone and all MOF); accuracy of fracture risk prediction tools in COPD; and prevalence and incidence of coded osteoporosis. METHODS:Cox proportional hazards models were used to assess the incidence rates of osteoporosis, hip fracture and MOF (hip, proximal humerus, forearm and clinical vertebral fractures). The discriminatory accuracies (area under the receiver operating characteristic [ROC] curve) of fracture risk prediction tools (FRAX and QFracture) in COPD were assessed. RESULTS:Patients with COPD (n=80 874) were at an increased risk of fracture (both hip alone and all MOF) compared with non-COPD patients (n=308 999), but this was largely mediated through oral corticosteroid use, body mass index and smoking. Retrospectively calculated ROC values for MOF in COPD were as follows: FRAX: 71.4% (95% CI 70.6% to 72.2%), QFracture: 61.4% (95% CI 60.5% to 62.3%) and for hip fracture alone, both 76.1% (95% CI 74.9% to 77.2%). Prevalence of coded osteoporosis was greater for patients (5.7%) compared with non-COPD patients (3.9%), p<0.001. The incidence of osteoporosis was increased in patients with COPD (n=73 084) compared with non-COPD patients (n=264 544) (adjusted hazard ratio, 1.13, 95% CI 1.05 to 1.22). CONCLUSION:Patients with COPD are at an increased risk of fractures and osteoporosis. Despite this, there is no systematic assessment of fracture risk in clinical practice. Fracture risk tools identify those at high risk of fracture in patients with COPD.

Chronic obstructive pulmonary disease (COPD) is a long-term condition characterised by persistent respiratory symptoms and airflow limitation. It is preventable and treatable, but still results in high levels of morbidity and mortality. This affects health service costs, but more importantly it affects the person with COPD, and their relatives and carers.If healthcare services continue to focus on managing the disease process rather than the person living with the disease itself, they may continue to produce the same outcomes and fail to substantially reduce the burden of the disease. Helping people live with COPD requires clinicians to communicate effectively with people, families and carers and share multidisciplinary team decisions with patients. Clinicians must consider the physical, psychological, social and spiritual implications of the disease.This article explores how nurses can have a positive effect on the lives of people with COPD, and provides practical strategies and suggestions on giving them effective support.

We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

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