Just the Facts: Management of patients with an acute exacerbation of chronic obstructive pulmonary disease in the emergency department.

Improving Quality of Asthma Care After Emergency Department Discharge: Evidence Before Action

Introduction: Vocal cord dysfunction (VCD) causes vocal cord narrowing during inspiration resulting in airflow obstruction and breathlessness. In asthma VCD can be found in up to 20% of stable asthmatics but few studies have examined coexisting VCD in exacerbated asthma and none in COPD. We hypothesised that VCD may occur frequently during acute asthma and COPD exacerbations. Method: Overall 34 patients with asthma exacerbations and 37 patients with exacerbations of COPD were studied in the emergency department (ED). All patients had a previous diagnosis of asthma or COPD confirmed by lung function. Asthma chronic disease severity was based on GINA and exacerbation severity based on a validated score. COPD chronic disease severity was based on GOLD criteria and exacerbation severity was based on BAP-65. Dynamic computerised tomography (CT) imaging was done as soon as possible after ED admission and VCD was diagnosed using 320-slice CT of the larynx. Results: In the overall group (n=71) VCD was detected in 20 cases (28%). Patients with COPD had VCD more often (14/37, 37.8%) than asthmatics (6/34, 17.6%, p=0.03). There were no associations between asthma or COPD, acute disease severity and presence of VCD. Patients with COPD had more VCD if they had severe/very severe chronic COPD (10/14, 71%) as opposed to mild/moderate (4/14, 31%). Conclusion: Surprisingly VCD was more frequently detected in COPD than in asthma. VCD should be considered a contributing factor during exacerbations of both diseases. Further studies are needed to determine how much VCD contributes to acute symptoms and to examine effective treatments for VCD in these clinical contexts.

Object: The purpose of this study was to determine the effect of follow-up reminder phone calls for scheduled clinics on the patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) after an emergency department (ED) visit. Methods: Consecutive patients older than 55 years who presented at the ED from March through October 2001, with a chief complaint consistent with COPD with acute exacerbation were eligible for inclusion. All patients received a scheduled, timely follow-up by our specialist who visited after 7 days. The intervention group received a follow-up reminder phone call of their appointment to visit the specialist within 48 hours of ED release. The main outcome was to compare whether patients kept their appointment with their COPD specialist during the two months following ED treatment and readmission to the ED. ED visit and specialist visit logs for the two months following the ED visit were checked from the charts. Readmission to the ED was defined as any ED visit for acute exacerbation of COPD. Results: 88 patients (84 males and 4 females) who met the inclusion criteria were enrolled (47 in the intervention group and 41 in the control group). The age of the 88 patients ranged from 56 to 80 years, with a mean age of 66.8±5.7 years. The intervention group of follow-up reminder phone calls had a significantly lower number of ED visits (0.2±0.5 vs 0.4±0.7, p=0.05) and higher number of outpatient department visits (1.8±1.0 vs 1.2±1.0, p＜0.01) in the first month, but not in the second month. Conclusions: Follow-up reminder phone calls seemly had some effect in the decrease of the ED readmission rate and increase specialist visits in the first month following an ED visit for acute COPD exacerbation.

Are corticosteroids effective in acute exacerbations of chronic obstructive pulmonary disease?

Nutritional status and long-term mortality in hospitalised patients with chronic obstructive pulmonary disease (COPD)

Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease

IntroductionThere has been a widespread antibiotic prescription in the Emergency Department (ED) among patients presenting with acute exacerbation chronic obstructive pulmonary disease (AECOPD) irrespective of the causative agent of the disease. The viral respiratory panel (VRP) test is designed to detect viral pathogens in the respiratory tract, which may contribute to the exacerbation of chronic obstructive pulmonary disease (COPD), as the upper and lower respiratory tract infections are caused by a broad range of microbes and not only bacteria. The aim of this study is to weigh the benefits of obtaining a VRP in patients presenting with isolated symptoms pertaining to well-defined criteria of an AECOPD with preexisting COPD or reactive airway disease to find out how such test impacts patient throughput time in the ED and also investigate how obtaining a VRP affects the use of antibiotics in this patient population. It is important that ED physicians accurately diagnose the main cause of AECOPD to help optimize the use of health care resources, including antibiotics, antivirals, inpatient, and ED beds. VRP testing must be taken into consideration as it helps eliminate the need of administering antibiotics to every patient who presents to the ED with AECOPD.Design and methodThis is a case-control observational study using retrospective chart review to obtain patients’ data from our hospital data warehouse. Data on patients with the primary diagnosis of AECOPD in the past two years were retrieved. A comparison between those who had VRP on arrival in the ED and those who did not have a VRP obtained was performed. We also compared ED throughput time for patients with AECOPD who received antibiotics to those who did not receive antibiotics. Only patients between the ages of 18 and 64 were included in the study. Patients with other preexisting health conditions such as cardiac diseases, neurological problems, and abdominal complaints were excluded. Patients who required hospitalization and pregnant patients were excluded from the study.ResultsWe collected the data of 340 patients who met the study criteria. Of the 340 patients enrolled, 65 (19%) received the VRP test and 275 (81%) did not receive VRP test. Among the 65 patients who received the VRP test, 45 (70%) had a virus etiology detected and reported in the ED (p=0.001). Also, 138 (50.2%) did not receive VRP test and were not given antibiotics, and 137 (49.8%) did not receive VRP test but were treated with antibiotics; 11 patients received antibiotics despite haven tested positive to a virus. The result showed that those who received antibiotics with no VRP test on arrival in the ED had a shorter throughput time compared to patients who did not receive antibiotics but received VRP test.ConclusionThe study is a quality improvement study to help determine the efficacy and appropriateness of ordering a VRP prior to ED disposition and the impact of overall ED throughput time for each patient presenting with AECOPD. The study showed that antibiotics did play a significant role in the duration of the throughput time in patients with AECOPD. However, rapid VRP testing was indeed associated with a trend toward decreased antibiotic use in the ED.

Introduction

How Viral Infections Cause Exacerbation of Airway Diseases

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can be caused by viral, bacterial, or environmental factors. Recent studies have suggested that procalcitonin serum levels may help reduce unnecessary antibiotic use without statistically significant differences in rates of treatment failure for AECOPD. The purpose of this quality improvement project was to create a procalcitonin-based algorithm to aid emergency department (ED) clinicians in the management of patients with AECOPD who do not require hospitalization and to evaluate its efficacy and practicality. The primary outcome of this project was the rate of antibiotic prescriptions before and after the initiation of the algorithm. This study used an observational, retrospective, pre-and posteducation/intervention design. Clinicians were educated individually on the use of procalcitonin, and a copy of the algorithm was made available to each clinician and posted in the ED. Patients who were discharged from the ED with a diagnosis of an AECOPD were identified using International Classification of Diseases, Tenth Revision codes. Patient charts were reviewed from November 2018 to March 2019 for the preimplementation period and November 2019 to March 2020 for the postimplementation period. The rate of antibiotic prescriptions and the number of procalcitonin tests ordered before and after the introduction of the algorithm were analyzed. In addition, information on COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) grouping and 30-, 60-, and 90-day reexacerbation rates were collected. It was estimated that a sample size of 146 patients (73 patients/group) would provide 80% power to detect a between-group difference of 10% in the percentage of patients who were prescribed antibiotics. Categorical variables were expressed using estimates of their frequency and percentages. Percentages were compared using Fisher exact tests. For all tests, the significance level was set at 0.05. Seventy-three patients were included in the preintervention group, and 77 patients were included in the postintervention group. Patients in the preintervention and postintervention groups had similar representation in GOLD categories: 52% and 51% for D, 17.8% and 23.4% for C, 21.9% and 16.8% for B, and 8.2% and 7.8% for A, respectively. The rate of antibiotic prescriptions decreased by 20% after implementation from 83.6% before to 63.6% after implementation (P = .01). The differences in reexacerbation rates between the preintervention and postintervention groups were similar: 19.2% vs 23.4% at 30 days, 12.3% vs 11.7% at 60 days, and 4.1% vs 9.1% at 90 days, respectively. Prior to education and introduction of the procalcitonin algorithm, procalcitonin was ordered for 1.4% of AECOPD cases. Postimplementation, procalcitonin was ordered for 28.6% of AECOPD cases and used in clinical decision making 81.8% of the time. In this study of the implementation of a treatment algorithm for patients with mild and moderate AECOPD who present to the ED, procalcitonin was shown to reduce the rate of antibiotic prescriptions without an observable difference in reexacerbation rates 30, 60, and 90 days after presentation.

No More Equivalence Trials for Antibiotics in Exacerbations of COPD, Please

Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs. To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive. A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression. Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack-years of smoking (45 pack-years versus 53 pack-years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta-agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001). Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

Design a risk model to predict adverse outcome (AO) 30 days after discharge in adult patients treated for acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) in emergency departments (EDs). PREURG was a prospective, observational, multi-purpose, multicenter cohort registry. Phone calls were made as part of a 30-day follow-up. The main variable was the presence of any AO (recurrence of COPD AE, ED revisit, hospitalization, institutionalization, or death) 30 days after being discharge from the ED. The study included a total of 931 patients with COPD AE (23.4% women and 76.6% men) discharged from the ED with follow-up data; 322 (34.6%) had an AO 30 days after being discharge from the ED. The REPOCUR model included the variable sex (OR for men of 1.50 [95%CI, 1.06-2.15]), severe COPD AE type (OR, 3.15 [95%CI, 2.02-5.04]), $ 2 COPD AE/year (OR, 1.64 [95%CI, 1.20-2.24]), and $ 4 ED visits/year (OR, 2.15 [95%CI, 1.52-3.04]). Each item is worth 1 point. The risk of experiencing an AO at 30 days with a score of 1 is 22.5%; 35.0% with a score of 2; 50.0% with a score of 3; and 65.1% with a score of 4. The area under the curve is 0.67 (95%CI, 0.64-0.71). The REPOCUR model could be a useful prognostic tool to identify adult patients with COPD AE and a high risk of exhibing AO at 30 days after being discharged from the emergency department.

Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD. A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO(2)), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h. Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P = 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P = 0.001). SpO(2) > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO(2) < 90% were not given oxygen (61.8%; 30%; 45.5%). A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence-based supporting oxygen use and better understanding of clinicians' oxygen decision-making in patients with COPD.