Treating acute exacerbations of COPD and asthma in 2019 - what's different? - Dr Paul Walker University Hospital Aintree and University of Liverpool
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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 Trust your clinical assessment – change in phlegm required: colour > volume and thickness Antibiotic Treatment for AE COPD First line Amoxycillin 500mg tds for 5 days Doxycycline 200mg then 100mg daily for 5 days Clarithromycin 500mg bd for 5 days Second line Any first choice alternative above Alternative antibiotic Coamoxiclav 625mg tds for 5 days Levofloxacin 500mg daily for 5 days Cotrimoxazole 960mg bd for 5 days COPD AE Antimicrobial Prescribing; NICE 2018
Corticosteroids FEV1 improved 90ml/day active vs. 30ml/day Median length of stay 7 days active vs. 9 days placebo through day 1-5 (p
RCT Aminophylline vs. Placebo in AE COPD 80 subjects with no significant acidosis, loaded with 5mg/kg aminophylline then 0.5mg/kg/hr Treatment stopped by clinician (not researcher) and f/up 5/7 plus discharge day Aminophylline Placebo (n=39) (n=41) Deaths 0 2 NS Days of 1.7 2.3 p
COPD Home Care Models Patient Seen by GP Acute Exacerbation Admission Prevention Seen in A&E/Admissions Unit Early Immediate Supported Admission Discharge Discharge Supported Early Normal Discharge Discharge Community Support Community Support No 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 31% 32% readmissions 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 • 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 Odds ratio of receiving measures of ‘Good Care’ when receiving bundle vs. not receiving: 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
Poor inhaler usage associated with: Inhaler Technique • Activity limitation • More breathlessness • Greater use of reliever inhaler • 1664 subjects; COPD and asthma • Poor disease control • Mixture pMDI and DPI • Sleep disturbance • Inhaler misuse associated with: • Older age • Lower educational attainment • Lack of instruction from healthcare provider about inhaler technique 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
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