Pathway for Diagnosing Visit 1 Registry Clients at Risk Patient presents with symptoms suggestive of Exertional breathlessness Chronic cough Regular sputum production Frequent bronchitis ; wheeze Occupational risk factors No clinical features of asthma Tool #1 is different from Asthma Patient presents opportunistically to Physician Smoker/Ex-Smoker (> 10 pack years) 40 years old No clinical features of asthma Tool #1 is different from Asthma Have you used tobacco in the last 30 days? Tool #2 Quit Now 3 Questions Never smoked May still have if symptomatic but consider alternate diagnosis OR Ex-smoker 1. Congratulate! 2. Record pack years & quit date Tool #3 Calculating pack years Tool #4 Chart marker 3. Tool #5 Lung Health Questionnaire NO Non YES PATIENT AT RISK OF Smoker 1. Assess readiness to quit: Tool #2 Quit Now 3 Questions 2. Record pack years Tool #3 Calculating pack years Tool #4 Chart marker 3. Tool #5 Lung Health Questionnaire Ready to quit 1. Tool #6 QuitNow Referral Form 2. Tool #7 Kick the Butt patient pamphlet 3. Tool #8 Penticton Integrated Health Centre (PIHC) Nicotine Intervention referral form #802603
Non Investigation of Possible OPTIONAL Visit 2 Screening Consider trial of short acting bronchodilator Tool #9 Respiratory Inhaler Quick Reference Guide Tool #10 Package of inhaler device teaching sheets Screen with 6 Tool #11 6 Quick Start Guide Normal Abnormal Refer for Pre & Post Spirometry Tool #12 PF Lab Referral Form #809054 Consider 6 Annually Prn Smoker 1. Assess readiness to quit: Tool #2 Quit Now 3 Questions 2. Record pack years Tool #3 Calculating pack years Tool #4 Chart marker 3. Tool #5 Lung Health Questionnaire Not Ready To Quit Reassess next visit Offer help when ready Ready to quit 1. Tool #6 QuitNow Referral Form 2. Tool #7 Kick the Butt patient pamphlet 3. Tool #8 Penticton Integrated Health Centre (PIHC) Nicotine Intervention referral form #802603
Pathway for Diagnosing Visit 3 Confirmation Spirometry Results Normal result: Post Bronchodilator FEV1 > 80% FEV1/FVC > 0.7 + normal flow-volume loop Not Confirmed A normal result does not exclude the diagnosis of Asthma Tool #1 is different from Asthma Abnormal result: Post Bronchodilator FEV1/FVC < 0.7 Confirmed Exclude other potential diagnoses Arrange further investigations: Physical Examination, Detailed lung function, Chest X-Ray, Echocardiogram, Sputum, etc Follow Management Pathway Dr. Shannon Walker MD, FRCPC Patricia Rattee RRT, CRE Francis Hensen RN, BScN, M.Ed
Pathway for the Management of Suspected Investigation of Suspected Patient has confirmed Tool #13 Patient Care Flow Sheet Education Regarding Tool #14 Understanding Tool #15 Patient Education Resources MRC Level 3 Pulm Rehab: Tool #12 PF Lab Referral form If pt. unable to attend: Tool #18 Community Resp. Therapist Referral form Assessing Disability and Severity in Tool #16 Classification by Symptoms and Disability - MRC Dyspnea Scale Tool #17 Classification by Impairment of Lung Function MRC Level 2 Explore concerns Provide info re: Exercise, smoking and Self-management Canadian Thoracic Society Guidelines for Management Tool #19 CTS recommendations for management of - 2008 Update -highlights for primary care
Canadian Thoracic Society Guidelines for Management Tool #19 CTS recommendations for management of - 2008 Update -highlights for primary care Optimal Pharmacotherapy Tool #20 Optimal Pharmacotherapy Action Plan Tool #22 IH Flare-Up Action Plan Additional Interventions for Tool #21 Interventions for Annual Review by Physician Explore patients concerns Smoking cessation if appropriate Annual spirometry Review MRC scale & severity by spriometry Advise re: flu & pneumococcal vaccination Review patients pharmacological regime Check Inhaler Technique Review flare-up action plan Document exacerbation history Home oxygen assessment/abg if FEV1 < 50% or Oxygen saturation < 92% at rest on room air Assess for comorbidities Tool #23 Comorbidities Associated with Calculate BMI Annual Billing Code Tool # 42 Payment Description
Pathway for the Management of Acute Exacerbation of Patient has an acute exacerbation Increased dyspnea Increased cough and sputum Change in the colour of sputum for 24 hours or more Patient/family/caregiver starts Action Plan Contacts Physician for assessment appointment Tool #22 IH Exacerbation Flare-up Action Plan for antibiotics/prednisone use Factors to consider when determining whether to treat at home or in hospital: General condition Degree of breathlessness Ability to cope at home Level of consciousness Presence of cyanosis Worsening peripheral edema O2 saturation levels <92% on room air Go to ER or call 911 YES Concerning factors? NO Manage at home Patient admitted to in-patient care Condition deteriorates Monitoring by: Family Physician: Telephone F/U Tool #42 Payment Description Community Respiratory Therapist: Tool #18 Referral form #802604 Discharge after treatment to: Family Physician Community Respiratory Therapist Respirologist prn Go to Stable Management Pathway Condition improves
Start at step appropriate to symptoms Tool 9 Respiratory Inhaler Quick Reference Guide Mild Optimal Pharmacotherapy Step 1 SABA - Salbutamol 100 mcg 2 puffs QID prn with spacer and/or SAAC - Ipratropium Bromide 20 mcg 2-4 puffs QID with spacer Step 2 Tool #20 Mild Persistent Dyspnea LAAC - Tiotropium Bromide 18 mcg od + SABA Salbutamol prn or LABA - Salmeterol 50 mcg 1 puff BID or Formoterol 6 or 12 mcg BID + SABA Salbutamol prn Step 3 Moderate-Severe Infrequent AE LAAC Tiotropium Bromide 18 mcg od + SABA Salbutamol prn < 1/year or LABA Salmeterol 50 mcg BID or Formoterol 12 mcg BID + Salbutamol prn If Persistent Dyspnea LAAC Tiotropium + LABA Salmeterol or Formoterol + SABA Salbutamol prn If Persistent Dyspnea LAAC Tiotropium + ICS/LABA Advair 250/50 mcg BID or Symbicort 200/6 mcg 2 puffs BID + SABA Salbutamol prn Moderate-Severe Step 4 LAAC Tiotropium bromide 18 mcg OD Frequent AE + 1/year ICS/LABA Advair 500/50 mcg BID or Symbicort 200/6 mcg 2 puffs BID + SABA Salbutamol 100 mcg 2 puffs QID prn If Persistent Dyspnea Consider adding oral Theophylline OR Consider adding PD4 Inhibitor Derived from the 2008 Update CTS Guideline for Step 5 If still symptomatic and/or in addition to pharmacotherapy at any time Options include one or more of the following: Referral for Pulmonary Rehabilitation Tool #12 PF lab Referral Form 809054, if not already done Referral to Respirologist Tool #28 When to refer to a Respirologist - CTS Guidelines Referral for Home Oxygen Assessment Tool #12 PF Lab referral form 809054 Tool #34 Home Oxygen Program Subsidy Application Form 807800 Advanced Care Planning Tool #29 End of Life Care in CTS Guidelines Tool #30 GPAC Guidelines for Advanced Care Planning Tool #31 Comprehensive Approach to Management of Refractory Dyspnea in Advanced CTS Guidelines Tool #32 My Voice Patient Pamphlet Tool #33 Dr. Ann Gordon End of Life Video
REQUIRED Vaccinations Offer Annual Influenza Vaccine Offer Pneumococcal Vaccine Tool # 24 Vaccinations CTS Guidelines ADDITIONAL Annual Spirometry/Assess Oxygen Spirometry Tool #12 PF Lab Referral Form 809054 Home Oxygen Assessment if FEV1 < 50% Tool #12 PF Lab Referral Form 809054 Tool #34 Home Oxygen Program Subsidy Application Form Tool #21 Self Management/Education Education, collaborative goal setting, treatment plans Tool #25 Patient Self-Management Pamphlet Respirology Referral Tool #28 When to refer to a respirologist CTS Guidelines Exercise Advice If Patient MRC Scale Grade 2 Tool #26 Maintain an active lifestyle CTS Guidelines If Patient MRC Scale Grade 3 Pulmonary Rehabilitation Tool #12 PF Lab Referral Form 809054 Assessment of Disability & Severity Annual and prn assessment Tool #16 MRC dyspnea scale CTS guidelines Tool #17 Impairment of Lung Function CTS guidelines Interventions For Screen for Cardiovascular Risk Factors Primary and Secondary Prevention Calculate Body Mass Index (BMI) Tool #36 Body Mass Index Nomogram Screen For Osteoporosis Tool #35 Osteoporosis Risk Factors Action Plan Complete and Review Annually Tool #22 IH Flare-up Action Plan Identify & Manage Anxiety/Depression prn Tool #37 Patient Health Questionnaire (PHQ-9) Tool #38 Generalized Anxiety Disorder (GAD 7) Tool #39 Bounce Back Referral Form Tool #40 Bounce Back Patient Pamphlet Medications & Inhaler Technique Tool #9 Respiratory Inhaler Quick Reference Guide Tool #10 Package of Inhaler Device Teaching Sheets Screen for Obstructive Sleep Apnea (OSA) Tool #41 Epworth Sleepiness Scale Tool #12 'PF Lab Referral Form 809054' Smoking Cessation Tool #6 Quitnow.ca referral form Tool #7 Kick the Butt Patient Pamphlet Tool #8 PIHC Referral Form #802604 Advance Care Planning Tool #29 End of Life Care in Tool #30 GPAC Guidelines for Advanced Care Planning Tool #31 Dyspnea Management Guidelines Tool #32 My Voice Tool #33 Dr. Ann Gordon s End of Life Video