Medicine Sun Peaks Navigating the Practice Maze Sun Peaks Grand, February 6-8 th, 2015 Dr. Shannon Louise Walker, MD, FRCPC Clinical Associate Professor,

COPD CLINICAL PEARLS:NAVIGATING THE

COMPLEXITIES OF AECOPDMedicine Sun Peaks

Navigating the Practice MazeSun Peaks Grand, February 6-8th, 2015

Dr. Shannon Louise Walker, MD, FRCPCClinical Associate Professor, UBC

Medical Director Community Respiratory Services, Penticton Regional Hospital

Honorarium or sponsorship received from:◦ Almirall◦ Astra Zeneca◦ Boeringher-Ingelheim◦ GSK◦ Intermune◦ Pfizer◦ Takeda◦ College of Family Physicians◦ Doctors of BC: PSP and Shared Care◦ Interior Health

No conflicts of interest to declare

Disclosures

1. The Acute Exacerbation of COPD◦ How do we recognize it?◦ Acute management◦ Controversies

2. AECOPD Readmission or Outpatient ‘Failure’◦ Realities◦ Strategies

Shared Care Experience with the AECOPD PATHWAY

3. Prevention of AECOPD◦ Updated recommendations from CTS/ACCP

guidelines: 2014

Learning Objectives

The Acute Management of an

AECOPD

Definition:1. More DYSPNEA2. Increased COUGH3. Increased and/or purulent PHLEGM compared to baseline

Differentiate from other causes of worsened dyspnea in the COPD patient with co-morbidities

◦ Eg. Arrythmia, CHF, anemia, PE, Pneumothorax, pneumonia, lung cancer

◦ May need to do CXRAY, ECG, Hb, BNP to differentiate

What is an AECOPD?

AECOPD Usual upper airway

organisms including:◦ H.Influenza◦ Morexella◦ S.pneumonia

Treatment can be any choice of broad spectrum antibiotic

Treatment is 5 days Combined with oral

steroid common

PNEUMONIA Need to always cover

for atypical organisms including:◦ Chlamydia◦ Mycoplasma◦ (Legionella)

First line treatment is Macrolide or Fluoroquinolone

Treatment 7 – 10 days

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How is an AECOPD different from Pneumonia?Major differentiating feature is XRAY ABNORMALITY

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Impact of Exacerbations in COPD

Wedzicha JA, et al. Lancet. 2007;370:786-796.

Patients With Frequent Exacerbations

Higher Mortality

Faster Declinein Lung Function

Poorer Qualityof Life

Greater AirwayInflammation

Increased Health Care

Utilization

Risk of exacerbation increases with COPD severity

1. Treat Current AECOPD optimally◦ Prevent treatment failures◦ Prevent admission or re-admission

2. Prevent Future AECOPD◦ Delay and/or◦ Reduce severity◦ Reduce frequency

Treatment Goals

Antibiotic treatment recommendations for purulent AECOPD

Group Simple exacerbation

Basic clinical state

COPD without risk factors

Symptoms and risk factors

Increased sputum purulence and dyspnea

Probable pathogens

Haemophilus influenzae, Haemophilus species, Moraxella catarrhalis, Streptococcus pneumoniae

First choice (in alphabetical order)

Amoxicillin, second- or third-generation cephalosporins, doxycycline, extended-spectrum macrolides, trimethoprim/sulfamethoxazole

O’Donnell et al. Can Respir J 2008; 15 Suppl A:1A

Antibiotic treatment recommendations for purulent AECOPD

Group Complicated exacerbation

Basic clinical state COPD with risk factors

Symptoms and risk factors

As in simple plus one of:FEV1 <50% predicted; ≥4 exacerbations per year; ischemic heart disease; use of home oxygen; chronic oral steroid use

Probable pathogens As in simple plus:Klebsiella species and other Gram-negativesIncreased probability of beta-lactam resistancePseudomonas species

First choice (in order of preference)

Fluoroquinolone, beta-lactam/beta-lactamase inhibitor

O’Donnell et al. Can Respir J 2008; 15 Suppl A:1A

Shorter Term Systemic Steroid Treatment is Effective

Short-term group(prednisone 40 mg; 5 days)

Conventional group(prednisone 40 mg; 14 days)

HR (short-term vs. conventional): 0.95 (90% CI,0.70-1.29; p=0.006)

100

75

50

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0 50 100 150 200

Time from Inclusion (days)

Pati

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HR: hazard ratio; REDUCE: reduction in the use of corticosteroids in exacerbated COPD.1. Leuppi et al. JAMA. 2013;309:2223-31

Systemic (oral or IV) corticosteroids are recommended in most patients with moderate to severe AECOPD, especially those needing ER or hospital care¹

But we just don’t have enough data to clarify recommendations for : ◦ Outpatient AECOPD treatment◦ Mild patients with an AECOPD◦ Mild exacerbations◦ Patients with documented bacterial infection or non-

eosinophilic exacerbations may even do worse²’³

Use of Systemic Steroids in AECOPD

1.1. O'Donnell et al. Can Respir J. 2007;14 Suppl B:5B-32B; 2. Wilson et al. Eur Respir J. 2012;40:17-27; 3. Sethi S. COPD 2015

COPD Exacerbations: An Update. CHEST 2014. https://www.pathlms.com/chest/events/176/video_presentations/4704; 4. Bafadhel et al. Am J Respir Crit Care Med. 2012;186:48-55.

30 Day Readmissions and Clinical Failure of AECOPD

Table 1: IH Hospitals: Top 10 CMGs for Readmissions within 28 Days, 2009/10 – 2011/12

Case Mix Group (Original Hospitalization) *2009/10 2010/11 2011/12Chronic Obstructive Pulmonary Disease 164 209 213Symptom/Sign of Digestive System 131 112 164Heart Failure without Coronary Angiogram 135 134 111Non-severe Enteritis 72 65 82Viral/Unspecified Pneumonia 68 59 81Arrhythmia without Coronary Angiogram 77 66 73General Symptom/Sign 64 61 68Gastrointestinal Obstruction 57 81 63Lower Urinary Tract Infection 33 42 61Myocardial Infarction/Shock/Arrest without Coronary Angiogram 84 62 58Other CMGs 2,813 2,768 2,876Total Readmissions 3,698 3,659 3,850

# of Cases with Readmissions

Gaps Identified by Chart Review of 4 patients admitted and readmitted with AECOPD

All 4 received antibiotics. 3 received prednisone. None had a follow up appointment scheduled

before discharge and the onus was on the patient to make follow up appointment.

None had contact with an RT Educator in the hospital.

Patient social conditions were poor: high stress, isolated. Rural patients more vulnerable.

Each had 2-4 clinic or ER visits between readmissions.

Preventing 30 Day COPD Exacerbation ReadmissionCHEST 2014 Original Investigations:Only 24% of patients reported symptoms to a

provider prior to readmission1 ◦ Patient-centered education on symptom reporting

and COPD action plans◦ Improved discharge planning for earlier follow up

Lower risk of readmission for patients who visited their primary care provider within 2 weeks of hospital discharge for COPD exacerbation2

◦ Hospital interventions which improve follow-up rates 1. Barks et al.

Chest. 2014;146(4_MeetingAbstracts):59A;

2. Akpa et al. Chest. 2014;146(4_Meeting

Abstracts):57A.

AECOPD Transitions ProjectGoal

To improve the health and quality of life of patients experiencing Acute Exacerbation COPD (AECOPD) and to reduce the burden of COPD on the healthcare system through an inter-disciplinary team focused on patients and their optimal transition back to the community.

Tools

AECOPD Pathway: acute care back to community

Pre-printed orders:◦ ER discharge◦ AECOPD admission◦ Ward discharge◦ Special Authority forms

Improved community resources and access for Family Physicians

COPD CARE Model

AECOPD Pathway

1. Identify patients being seen in ER or admitted to hospital with AECOPD

2. Patient seen promptly in hospital by AECOPD Pathway Educator or referred to see Educator ASAP as outpatient

3. AECOPD preprinted orders if requires admission to hospital

4. Discharge CHECKLIST that forms Discharge PRESCRIPTION from ER or WARD

5. Specialist referral if indicated

AECOPD Pathway Transition

Discharge CHECKLIST that forms Discharge PRESCRIPTION

◦ Discharge medications: Steroids , Abx, Inhalers◦ Education and Action Plan◦ Follow-up phone call within 1 week by AECOPD

Pathway Coordinator and appointment with Primary Care Provider within 1-2 weeks

◦ Community COPD CARE placement Rehab Home visit Breathe Well with Case Manager Group Medical Visit

COPD ‘CARE’ Model:“Continuing Assessment and Respiratory Education”

COPD WITH DECOMPENSATION

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CONFIRMED AECOPD

32 of 56

STARTED ON PATHWAY

23 of 32

NOT STARTED ON PATHWAY

9 of 32

NON-CONFIRMED AECOPD

24 of 56

ALERNATIVE TREATMENT

AECOPD CASE FINDING

AECOPD PATHWAY ADHERENCE

PATHWAY PARAMETERS NUMBER %

Inpatient COPD Education and Handout 23/23 100

AECOPD Pre-Printed Orders initiated 19/23 83

Received Antibiotics and / or Prednisone 23/23 100

Received RT phone call within 72 hrs of discharge

19/23 83

Received RT visit within 2 weeks of discharge 12/23 52

Had Family Doctor follow up visit within 2 weeks

19/23 83

Community Respiratory Program referral 23/23 100

Evaluation of the AECOPD Pathway1. Patient Outcomes

◦ Use of Antibiotics and Steroids◦ Hospital LOS◦ Admission/Readmission

2. Use of Pathway◦ # Patients identified◦ Components of pathway completed◦ Use of PPOs◦ Follow up completed

3. Stakeholder satisfaction

Self-Management Education: Reduces Hospitalization

Self-Management Education: substantial Cost Savings

Disease Management Programs Reduce Hospital Admissions

Rice et al. 2010; Am J Respir Crit Care Med

p=0.03

Usual care

Disease Management

Usual management

AECOPD Prevention Strategies

Prevention Strategies for AECOPD:Non-pharmacologic

Smoking Cessation Vaccinations Pulmonary Rehabilitation Self-Management Education

◦ Case Manager◦ Written Action Plan (in selected patients?)

◦ Inhaler Education Disease Management Programs

O’Donnell DE, et al. Can Respir J 2007;14(Suppl B):5B-32B

Prevention Strategies for AECOPD:Pharmacologic

Long-acting Bronchodilators◦ Both LAMAs and LABAs or combinations of LABDs

Anti-inflammatory agents◦ ICS/LABA◦ PDE4 inhibitors (roflumilast)◦ Macrolide therapy

Vaccinations Mucolytics

◦ NAC 600 mg po bid

LAMA (long acting long-acting muscarinic antagonists),LABA (long-acting b-agonist) LABD (long-acting bronchodilator), ICS (inhaled corticosteroid), PDE (phospho-diesterase), NAC (N-acetyl-cysteine)

O’Donnell DE, et al. Can Respir J 2007;14(Suppl B):5B-32B. GOLD guidelines. 2014 Update.

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ICS and Risk of Pneumonia ICS have been associated with an increased risk of

pneumonia1

Differences likely due to PK/PD properties and effect on human pulmonary host defence2

No association with increased risk of mortality1,3

CI: confidence interval; ICS: inhaled corticosteroids; PK/PD: pharmacokinetic/pharmacodynamic.1. Crim et al. Eur Respir J. 2009;34:641-7; 2. Suissa et al. Thorax. 2013;68:1029-36; 3. Kew and Seniukovich. Cochrane

Database Syst Rev. 2014;3:CD010115.

fluticasone

budesonide

• Risk of pneumonia is greater with fluticasone vs. budesonide2

• Risk of pneumonia with fluticasone is dose related2

90% CI

◦Use your RT department to help with this task

◦Online education tools for you and your patients www.bc.lung.ca www.livingwellwithcopd.comhttp: www.gpscbc.ca/psp-learning/system-of-

shared-care-copdheart-failure/tools-resources

Patients need to know how and when to use their inhaler devices properly to ensure effectiveness

1. AECOPD is a clinical entity of worsened dyspnea, cough and phlegm in persons with COPD

◦ Pneumonia is differentiated by Xray abnormality and treatment is different

◦ Beware lone dyspnea in the patient with co-morbidities

2. Bronchodilators, Antibiotics and Oral Steroids3. Non-pharm and pharm strategies are required to

prevent recurrence or readmission

4. AECOPD PATHWAY, ACTION PLAN and EDUCATION

5. Resources are available with PSP and Shared Care and follow CTS guidelines for best practice

Summary

CTS = Canadian Thoracic Society

What is one thing you would take away from this session?

Is there a need for an AECOPD PATHWAY in your community?

What can you do?◦ Know when your patient is being discharged from

AECOPD◦ See your patient in1-2 weeks post AECOPD◦ Refer them to a community program for education and

self management

Questions

Hands-on INHALERS: