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