Treating acute exacerbations of COPD and asthma in 2019 ...
Transcript of Treating acute exacerbations of COPD and asthma in 2019 ...
Treating acute exacerbations of COPD and asthma in 2019 –
what’s different?
Dr Paul Walker
University Hospital Aintree and
University of Liverpool
The biggest opportunity to improve acute respiratory care is to better implement
what we know
Organisation of care is vitally important to improving outcomes
COPD Exacerbation
“A sustained acute worsening of the person's symptoms from their usual stable state, which goes beyond their normal day-to-day variations”
Burton et al. J Telehealth Telecare 2015
Acute COPD Management
• Bronchodilators – pMDI plus spacer vs. DPI vs. nebulised: no difference (van Geffen WH, Cochrane review 2016) but nebulised may be easier for some patients
• Antibiotics – 5 day course adequate if clinically indicated (NICE 2018)
• Corticosteroids – oral, lower dose and 5-7 days now established as effective as higher doses, intravenous or 10-14 days
• Aminophylline – no evidence of efficacy, more side effects. Not recommended
Antibiotics
Antibiotic Treatment for AE COPD
First line
Amoxycillin 500mg tds for 5 daysDoxycycline 200mg then 100mg daily for 5 daysClarithromycin 500mg bd for 5 days
Second line
Any first choice alternative above
Alternative antibiotic
Coamoxiclav 625mg tds for 5 daysLevofloxacin 500mg daily for 5 daysCotrimoxazole 960mg bd for 5 days
COPD AE Antimicrobial Prescribing; NICE 2018
Trust your clinical assessment – change in phlegm required: colour > volume and thickness
Corticosteroids
FEV1 improved 90ml/day active vs. 30ml/day placebo through day 1-5 (p<0.05)
Median length of stay 7 days active vs. 9 days placebo (p<0.03)
Davies et al. Lancet 1999
There is rarely a need to slowly reduce the dose
RCT Aminophylline vs. Placebo in AE COPD80 subjects with no significant acidosis, loaded with 5mg/kg aminophylline then 0.5mg/kg/hrTreatment stopped by clinician (not researcher) and f/up 5/7 plus discharge day
Aminophylline (n=39)
Placebo (n=41)
Deaths 0 2 NS
Days of treatment
1.7 2.3 p<0.06
Theophylline level (mean)
73 2
Blinded evaluation - % helpful
49% 42% NS
IP stay (days) 7.1 8.2 NS
Nausea 46% 22% p<0.05
Duffy et al. Thorax 2005
COPD Home Care Models
Immediate Supported
Discharge
Supported Early
Discharge
Community Support No Community Support
Normal Discharge
Admission
Seen in A&E/Admissions Unit
Patient Seen by GP
Acute Exacerbation
Admission Prevention
Early Discharge
Community Support
ESD (100) Hospital (50)
Matched at baseline
192/583 (33%) patients eligible, 150/583 (26%) entered
50% on antibiotics and 37% on oral CS
Early readmissions 9% NA
Hospital Stay NA 5 days
Mean visits 11 NA
90-day
readmissions
31% 32%
90 day mortality 9% 8%
Davies et al. BMJ 2000
COPD Discharge Care Bundle
https://www.brit-thoracic.org.uk/document-library/audit-and-quality-improvement/cap-and-copd-care-bundle-docs-2016/copd-discharge-care-bundle/
BTS COPD Care Bundle Project
Odds ratio of receiving measures of ‘Good Care’ when receiving bundle vs. not receiving:
• 19 hospitals participated in admission care bundle and 17 discharge care bundle
• 659 / 2263 people admitted with AE COPD received discharge care bundle
• Completion rate rose throughout study
Calvert et al. Thorax 2016
Reducing the Hospital Burden of AE COPD
• Do your respiratory team change work plan between winter and summer?
• When you see people regularly hospitalised with COPD but impacted by social support, anxiety, depression what do you do about it? What services do you have available?
• Do you have an admission prevention and early supported discharge scheme locally – if not, why not?
• Are you meeting BPT for COPD? Do you have an effective COPD discharge care bundle?
• 195 people who died of asthma in Feb 2012 –Jan 2013
• Many patient had inadequate treatment and monitoring, no written SMP and excess SABA use (12+ inhalers/year)
• Increased death in the month following discharge from hospital
• Greater risk of death with severe asthma and one or more adverse psychosocial risk factor
Case Study• 37 year old woman with known asthma and worsening breathlessness and
chest tightness for 36 hours. Cough but little phlegm• Hospitalised with asthma last winter• Started rescue pack of prednisolone 40mg earlier today and using salbutamol
200mcg at least 8-10 occasions last 24 hours• Smoker 10/day. Works in bakery. Eczema and hay fever• Treated for depression, lives with 9 year old daughter• PEF at best 480 (predicted 400)• Prescribed salbutamol 200mcg PRN, montelukast 10mg nocte, symbicort
400/12 1 puff bd and tiotropium 18mcg daily• On examination weight 89kg, saturations 93% air, pulse 116, BP 150/80,
apyrexial, wheeze throughout chest but no crackles• Best PEF 200
1. Is she high risk for a fatal or near fatal asthma attack?2. Does she have acute severe asthma?
Asthma – high risk of fatal/near-fatal attack
SIGN/BTS Draft Asthma Guidelines 2019
Acute asthma severity • Admit anyone with any feature of life-threatening or near-fatal asthma
• Admit anyone with a severe feature after initial treatment
• If PEF >75% after treatment caution discharging:• Still have significant symptoms• Concerns about adherence• Lives alone/social isolation• Psychological problems• Physical disability or learning
difficulties• Previous near-fatal asthma• Attack while on steroids• Presentation at night• Pregnancy
SIGN/BTS Draft Asthma Guidelines 2019
Acute Asthma Management
• Oxygen – saturations 94-98%
• Bronchodilators – beta-agonist pMDI or nebulised with oxygen. Can use continuous. Ipratropium if severe or if poor initial response
• Corticosteroids – oral 40-50mg daily if can be swallowed and retained or hydrocortisone 100mg qds
• Aminophylline iv – no evidence of efficacy. Not recommended
• Beta-agonists iv – if unable to reliably use inhaled therapy or ventilated
• Magnesium – consider single dose if severe. Evidence inconclusive
• Continue usual inhalers
Magnesium
• 1109 people presenting to A&E with acute severe asthma
• Randomised to iv magnesium (2g), nebulised magnesium or placebo
• Primary endpoints breathlessness at 2 hours and admission within 7 days
• No effect of magnesium on breathlessness
• iv magnesium OR for hospitalisation 0.73 (CI 0.51-1.04; p=0.083)
Goodacre et al. Lancet RM 2013
Inhaler Technique
• 1664 subjects; COPD and asthma
• Mixture pMDI and DPI
• Inhaler misuse associated with:• Older age
• Lower educational attainment
• Lack of instruction from healthcare provider about inhaler technique
Poor inhaler usage associated with:• Activity limitation• More breathlessness• Greater use of reliever inhaler• Poor disease control• Sleep disturbance
Melani et al. Resp Med 2011
Discharge and Follow-up
• Written asthma action plan before discharge and medication optimised
• Primary care practice is informed within 24 hours of discharge from ED or hospital following - ideally to a named individual responsible for asthma care within the practice, by means of fax or email.
• Follow-up in primary care within 2 working days – GP or asthma nurse (NICE quality standard 4)
• Follow-up in secondary care in a month – doctor or nurse
Questions
Summary
• Treatment of AE COPD and asthma hasn’t changed dramatically but we have greater clarity about some aspects
• Admission prevention/early discharge, community support and discharge bundles are a key part
• Recognition of which asthmatics do badly matters
• Inhaler technique is vital for airway disease
• Follow-up of asthma patients may be the key to improving outcomes and reducing deaths