There's a Storm Brewing!
"The pandemic is not over": WHO chief urges Europe to brace for a second wave
As countries ease lockdown WHO official says now is the time for preparation, not celebration
COPD and its Comorbidities:
A Perfect Storm of Winter Pressures
COPD is a major cause of morbidity and mortality worldwide. Recurrent in the course of the disease, acute exacerbation's worsen baseline symptoms, impair lung function over time and increase the likelihood of new exacerbation.
Initially, increased mortality had been attributed to baseline disease severity but recent studies have shown that acute exacerbation's of COPD increase short term and long term mortality risk especially those exacerbation's requiring hospitalisation. Other prognostic factors include age, previous hospitalisation due to AECOPD, exacerbation severity and certain comorbidities.
COPD and Type 2 Diabetes
COPD is being increasingly recognised as a risk factor for the development of Type 2 Diabetes through different mechanisms including systemic inflammation, obesity, hypoxia and use of corticosteroids. Also, hyperglycaemia in diabetes patients is linked to the adverse impact on lung physiology, and a possible increase in the risk of COPD.
A recent review by Mamillapalli et al (2019) reported on multiple studies demonstrating the link between COPD and Type 2 Diabetes:
Regarding clinical outcomes in patients with co-existing COPD and T2DM they presented evidence to suggest that after adjusting for age, gender, and smoking pack history in patients with COPD, T2DM was associated with a 70% increase in 3-year mortality
In a study investigating the survival rates of patients with COPD, T2 DM was associated with a 300% increased 10-year mortality
Additional studies have shown that:
COPD patients with poor glycaemic control (HbA1c > 53 mmol/mol) had increased severity of COPD with increased symptoms, greater dyspnoea, increased hypoxia, more exacerbations, and increased length of hospital stay
Hyperglycaemia was associated with adverse outcomes in hospitalised COPD patients with severe exacerbation requiring non-mechanical ventilation
There is a positive correlation between high fasting glucose and increased risk of COPD exacerbation
COPD and Heart Failure
Patients with chronic obstructive pulmonary disease (COPD) are at greater risk of developing comorbid heart failure (HF) than the general population.
A paper by Kaszuba et al (2018) demonstrated that:
Previous studies have found large amounts of unrecognised HF in COPD patients
When recognised, HF is diagnosed later in COPD patients than in patients without COPD and cardiovascular medications are consistently under-prescribed in the COPD population
Evidence suggests that HF comorbidity increases COPD related secondary care utilisation and all-cause mortality in the COPD population
The mortality risk in patients with COPD in primary care was more than doubled when HF occurred as a comorbidity
Delayed diagnosis of HF in COPD patients and under-treatment of cardiovascular conditions in the COPD population may contribute to this increased morbidity and mortality
Studies have shown that around 20% of patients with COPD have undiagnosed HF whilst other studies have found that the odds of eight-year mortality in patients with COPD and coexisting HF were seven times higher than in patients with COPD alone
The authors concluded that:
"Heart failure has an important impact on mortality in patients with COPD. The mortality in patients with COPD and coexisting heart failure was strongly associated with age, male sex and other comorbidities. Of those three predictors, only other comorbidities can be influenced. Heart failure and other comorbidities should be recognised early and properly treated in order to improve survival in patients with coexisting COPD and heart failure"
Type 2 Diabetes and Heart Failure
Patients with diabetes mellitus have >2 times the risk for developing heart failure with reduced ejection fraction and HF with preserved ejection fraction.
Cardiovascular outcomes, hospitalisation, and prognosis are worse for patients with diabetes mellitus relative to those without.
One study by Faden et al (2013) looked at 386 patients with T2DM and no overt evidence of cardiac disease and found that 262 (68%) patients had evidence of LV dysfunction 5 years after diagnosis.
Another study by Boonman de winter et al (2012) looking at 605 patients with T2DM found that 28% had undiagnosed HF, 23% of which was HFpEF and 5% HFrEF.
COPD and COVID-19
A meta-analysis of 7 studies and 1592 COVID-19 patients by Lippi G and Henry B and published in Respiratory Medicine 167 (2020) concluded that:
COPD is associated with a significant, over five-fold increased risk of severe COVID-19 infection
Type 2 Diabetes and COVID-19
On the 19th May 2020 NHS England published two documents examining Type 1 and Type 2 Diabetes and COVID-19 related mortality and concluded that:
The overall death rate for people with diabetes has doubled since the beginning of the pandemic
A third of ALL COVID-19 deaths are associated with diabetes
Those with pre-existing kidney disease, heart failure and previous stroke are at higher risk
Even when all other known factors are taken into account, higher blood glucose levels and obesity are linked to higher risk
CVD and COVID-19
The European Society of Cardiology have published guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic and have stated that:
Severe COVID-19 infection is associated with myocardial damage and cardiac arrhythmia
Preceding coronaviruses outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were associated with a significant burden of CV comorbidities and complications
MERS was associated with myocarditis and HF
COVID-19 infection seems to have comparable cardiac manifestations.
Autopsies of patients with COVID-19 infection revealed infiltration of the myocardium by interstitial inflammatory cells
The myocardial injury is likely associated with infection-induced myocarditis and ischaemia
The Summer Review for Winter Resilience Initiative
A Program of Learning for General Practice Nurses
The Government are slowly but surely easing lockdown rules and have stated that they hope to return the country to 'near normality' by the end of July.
If this happens, and increased patient contact is possible, and you could invite 20 COPD patients in for a Summer Review with the intention of reducing their risk of a winter exacerbation, which patients would you invite and what would you do within that review given that a basic COPD QOF review is not set up to look beyond the lung?
Tracy Kirk spent 18 years working on large scale primary care based respiratory projects across the UK aimed at reducing unplanned COPD related hospital admissions and has written a short but specific webinar based program of learning specifically for General Practice Nurses. Tracy Kirk will be delivering each session.
The program aims to enhance and expand the nurses current knowledge, skills and understanding of what it is about COPD and its' common comorbidities that increases the risk of acute exacerbation, hospital admission and death.
We are able to offer 100 free places on this program of learning to nurses working at GP Surgeries across Greater Manchester. Places will be offered on a first come first served basis and there is an expectation that all 6 webinar sessions are completed.
The course content has been submitted to the CPD Standards Office for accreditation.
If you would like to apply for a place on this course please click here to register your interest.