6.04 Ageing Lungs

September 18, 2018

In this episode we look at the ageing lungs, both what’s normal as we age and what’s abnormal. We will talk through some of the commenest conditions we see qffectinathe lungs in older people.

Presented by: Dr Jo Preston, Dr Iain Wilkinson with prior recording from Professor Allen.

Faculty: Sarah Jane Ryan – Physiotherapist University of Brighton

Link to CPD log for series 6

Pdf of infographic here


Social media this week

Iain:

A Randomized Controlled Study of Art Observation Training to Improve Medical Student Ophthalmology Skills.

Jo: Tweet from Dan Thomas:


The Gallery:


Learning outcomes

Knowledge:

To be able to describe and understand the normal changes in older people’s lungs.

To understand the impact of frailty on an older persons response to an respiratory insult

Skills:

To be able to describe spirometry to a patient

To be able to signpost people to ways to improve their inhaler technique

Attitudes:

To promote smoking cessation for all patients with lung disease


Show Notes

Ageing lungs show notes pdf

1.     Introduction

This episode is based around an interview in did with professor Steven Allen back in 2013. As such we apologise for the sound quality being a bit less good than normal!

    • ‘Dyspnoea’
        • present in 32% of patients >70 yrs
        • Poorer functional status
        • Poorer physical and mental health
        • More likely to be anxious and depressed
      • Presence of LVF, airways disease and obesity were all higher in this group
  • 60% of all presentations with dyspnoea are age >65yrs
    • But… in older people it’s difficult to evaluate
        • Subjective
        • Small margin between disease and physical (FEV1 reduces with age)
        • deconditioning (due to age or fitness levels)
        • Gets more common as age increases
      • Vary according to severity
        • MRC >2 = 36%, >3 = 16% >4 = 4%

  • Cardiac and respiratory causes of SOB account for 70% of cases (others are neuro, anaemia etc)

COPD

Common:

    • 5% of all global deaths are due to COPD
    • Exposure to tobacco smoke is the main cause (some are due to long term asthma) [DON’’T talk about cessation – this comes later]
    • 1.2 million ppl living with COPD in UK
  • 4% ppl >40yrs old!

Main symptoms are:

Dyspnea: Progressive, persistent and characteristically worse with exercise.

Chronic cough: May be intermittent and may be unproductive.

Chronic sputum production: COPD patients commonly cough up sputum.

The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact on the patient’s health status, and the risk of future events.

COPD patients are at increased risk for:

    • Cardiovascular diseases
    • Osteoporosis
    • Respiratory infections
    • Anxiety and Depression
    • Diabetes
    • Lung cancer
  • Bronchiectasis

Global Initiative for Chronic Obstructive Lung Disease

    • The response to hypoxia or hypercapnia is markedly impaired in older adults (less respiratory reserve – frailty)
        • A 50% reduction in response to hypoxia
      • A 40% reduction in response to hypercarbia.
  • Aging is associated with loss of potentially protective mechanisms in a population that is more likely to be exposed to these states, making them more vulnerable.

Sharma G, Goodwin . Effect of aging on respiratory system physiology and immunology. Clin Interv Aging. 2006;1(3):253-60

Asthma

“Central to all definitions is the presence of symptoms (more than one of wheeze,  breathlessness, chest tightness, cough) and of variable airflow obstruction. More recent descriptions of asthma in both children and adults have included airway hyper-responsiveness and airway inflammation as components of the disease”

BTS/SIGN Guidelines

    • The diagnosis of asthma is a clinical one.
    • The absence of consistent gold-standard diagnostic criteria means that it is not possible to make unequivocal evidence-based recommendations on how to make a diagnosis of asthma.
  • There is the possibility that there will be people at high probability of asthma in whom a ‘monitored initiation of treatment’ is appropriate without necessarily awaiting further investigation.

Patients with asthma often had the condition in their younger years.

BTS Asthma guidelines

Spirometry

  • Spirometry is positioned as pivotal by both guidelines (BTS and NICE), but both caution that it is not useful for ruling out asthma because the sensitivity is low, especially in primary care populations (only 27% of people diagnosed as having asthma in the NICE feasibility work had obstructive spirometry which is similar to the estimate in BTS/SIGN of ‘a quarter having obstructive spirometry’).

BTS Asthma guidelines

“Spirometry is a method of assessing lung function by measuring the volume of air that the patient is able to expel from the lungs after a maximal inspiration. It is a reliable method of differentiating between obstructive airways disorders (e.g. COPD, asthma) and restrictive diseases (where the size of the lungs is reduced, e.g. fibrotic lung disease). Spirometry is the most effective way of determining the severity of COPD”

    • There are spirometers in about 70–80% of practices in the UK and their use is increasing, particularly since changes to the GMS primary care contract introduced in April 2004.
    • Practice nurses predominantly perform the tests but many lack confidence in carrying out the procedure or in the interpretation of the results.
    • Accurate spirometry can only be performed with appropriate training.
  • Most nurses and GPs request more help in carrying out and interpreting spirometry.

Spirometry in practice – A Practical Guide To Using Spirometry In Primary Care – BTC COPD Consortium

Smoking cessation

    • Link to evidence of health care intervention here (in wellbeing episode I think we did this a bit)
  • Death and ill health due to smoking-related diseases, particularly lung cancer, chronic obstructive pulmonary disease, and heart disease.
      • Stopping smoking at age 60, 50, 40, or 30 adds about 3, 6, 9, or 10 years of life expectancy respectively [Doll et al, 2004].
    • Less evidence in methods in the over 50s but all methods (pharmacological, non-pharmacological and multi-modal) worked significantly when compared with control groups.

Chen D. Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis .Drug Alcohol Depend. 2015 Sep 1;154:14-24.

  • There graphics are from the US clinical practice guideline for smoking cessation.

A Clinical Practice Guideline for Treating Tobacco Use and Dependence. A US Public Health Service Report JAMA. 2000;283(24):3244-3254

    • In England — the free Smokefree National Helpline on 0300 123 1044 or online www.nhs.uk. This offers support via a smartphone app, email programme, text messages and Facebook page.
    • In Wales — the free Help Me Quit Wales Helpline on 0800 085 2219, or online www.helpmequit.wales.

Inhaler useage

  • Evidence suggests a negative correlation between advancing age and correct technique across MDI and varying DPI devices when examined collectively.

Barbara S, Kritikos V, Bosnic-Anticevich S. Inhaler technique: does age matter? A systematic review .Eur Respir Rev. 2017 Dec 6;26(146).

    • Therefore think about who will be able to help them use the inhaler.
    • Use spacers
  • Less frequent medication delivery

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/


Curriculum Mapping

Curriculum Area
NHS Knowledge Skills Framework Suitable to support staff at the following levels:

    • Personal and People Development: Levels 1-3
  • Service Improvement: Level 1 – 2
Foundation curriculum Section

10. Management of long term conditions in the acutely unwell patient

11. Obtains history, performs clinical examination, formulates differential diagnosis and management plan

13. Prescribes safely

Core Medical Training Respiratory Medicine

Geriatric Medicine

HST Geriatric Medicine 3.2.1 Basic Science and Biology of Ageing

3.2.3 Presentations of Other Illnesses in Older Persons – Respiratory

11. Managing Long-Term Conditions and Promoting Patient Self-care

29. Diagnosis and Management of Chronic Disease and Disability

GPVTS program Section 2.03 The GP in the Wider Professional Environment

    • Core Competence: Managing medical complexity
  • Inhaler technique

3.03 Care of Acutely Ill People – Asthma

Section 3.05 – Managing older adults

    • Core Competence: Managing medical complexity
    • Core Competence: Working with colleagues and in teams
  • Core Competence: Practising holistically and promoting health

3.19 Respiratory Health

PA matrix of conditions Obstructive Pulmonary Disease

Infectious Respiratory Disorders

ANP (Draws from KSF) Section 7.16 Chronic Obstructive Pulmonary Disease (COPD)

Managing Long-Term Conditions and Promoting Patient Self Care

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