Medicine Sun Peaks
Navigating the Practice Maze
Sun Peaks Grand, February 6-8th, 2015
Dr. Shannon Louise Walker, MD, FRCPC
Clinical Associate Professor, UBC
Medical Director Community Respiratory Services, Penticton
Regional Hospital
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Honorarium or sponsorship received from:
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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
The Acute Exacerbation of COPD
1.
How do we recognize it?
Acute management
Controversies
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AECOPD Readmission or Outpatient ‘Failure’
2.
Realities
Strategies
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Shared Care Experience with the AECOPD PATHWAY
Prevention of AECOPD
3.
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Updated recommendations from CTS/ACCP
guidelines: 2014
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Definition:
1. More DYSPNEA
2. Increased COUGH
3. Increased and/or purulent PHLEGM
compared to baseline
Differentiate from other causes of worsened
dyspnea in the COPD patient with comorbidities
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Eg. Arrythmia, CHF, anemia, PE, Pneumothorax,
pneumonia, lung cancer
May need to do CXRAY, ECG, Hb, BNP to differentiate
Major differentiating feature is XRAY ABNORMALITY
AECOPD
 Usual upper airway
organisms including:
◦ H.Influenza
◦ Morexella
◦ S.pneumonia
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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)
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First line treatment is
Macrolide or
Fluoroquinolone
Treatment 7 – 10
days
6
Patients With Frequent Exacerbations
Faster Decline
in Lung Function
Greater Airway
Inflammation
Poorer Quality
of Life
Higher Mortality
Increased Health Care
Utilization
Wedzicha JA, et al. Lancet. 2007;370:786-796.
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Treat Current AECOPD optimally
1.
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Prevent treatment failures
Prevent admission or re-admission
Prevent Future AECOPD
2.
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Delay and/or
Reduce severity
Reduce frequency
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, extendedspectrum macrolides,
trimethoprim/sulfamethoxazole
O’Donnell et al. Can Respir J 2008; 15 Suppl A:1A
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-negatives
Increased probability of beta-lactam resistance
Pseudomonas species
First choice (in
Fluoroquinolone, beta-lactam/beta-lactamase
order of preference) inhibitor
O’Donnell et al. Can Respir J 2008; 15 Suppl A:1A
100
Short-term group
(prednisone 40 mg; 5 days)
Patients without
Exacerbations (%)
75
Conventional group
(prednisone 40 mg; 14 days)
50
HR (short-term vs. conventional): 0.95
(90% CI,0.70-1.29; p=0.006)
25
0
0
50
100
150
Time from Inclusion (days)
HR: hazard ratio; REDUCE: reduction in the use of corticosteroids
in exacerbated COPD.
1. Leuppi et al. JAMA. 2013;309:2223-31
200
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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 noneosinophilic exacerbations may even do worse²’³
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.
1.
Case Mix Group (Original Hospitalization)
Chronic Obstructive Pulmonary Disease
Symptom/Sign of Digestive System
Heart Failure without Coronary Angiogram
Non-severe Enteritis
Viral/Unspecified Pneumonia
Arrhythmia without Coronary Angiogram
General Symptom/Sign
Gastrointestinal Obstruction
Lower Urinary Tract Infection
Myocardial Infarction/Shock/Arrest without Coronary Angiogram
Other CMGs
Total Readmissions
# of Cases with Readmissions
*2009/10
2010/11
2011/12
164
209
213
131
112
164
135
134
111
72
65
82
68
59
81
77
66
73
64
61
68
57
81
63
33
42
61
84
62
58
2,813
2,768
2,876
3,698
3,659
3,850
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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.
CHEST 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_Me
etingAbstracts):59A;
2. Akpa et al.
Chest. 2014;146(4_Me
etingAbstracts):57A.
Goal
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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 interdisciplinary team focused
on patients and their
optimal transition back to
the community.
Tools
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AECOPD Pathway:
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Pre-printed orders:
care back to community
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acute
ER discharge
AECOPD admission
Ward discharge
Special Authority forms
Improved community
resources and access
for Family Physicians
COPD CARE Model
1. Identify patients being seen in ER or admitted
2.
3.
4.
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to hospital with AECOPD
Patient seen promptly in hospital by AECOPD
Pathway Educator or referred to see Educator
ASAP as outpatient
AECOPD preprinted orders if requires
admission to hospital
Discharge CHECKLIST that forms Discharge
PRESCRIPTION from ER or WARD
Specialist referral if indicated
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
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Rehab
Home visit
Breathe Well with Case Manager
Group Medical Visit
COPD WITH
DECOMPENSATION
56
CONFIRMED
AECOPD
NON-CONFIRMED
AECOPD
32 of 56
24 of 56
STARTED ON
PATHWAY
NOT STARTED
ON PATHWAY
23 of 32
9 of 32
ALERNATIVE
TREATMENT
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
Patient Outcomes
1.
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Use of Pathway
2.
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3.
Use of Antibiotics and Steroids
Hospital LOS
Admission/Readmission
# Patients identified
Components of pathway completed
Use of PPOs
Follow up completed
Stakeholder satisfaction
p=0.03
Usual care
Usual management
Disease Management
Rice et al. 2010; Am J Respir Crit Care Med
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Smoking Cessation
Vaccinations
Pulmonary Rehabilitation
Self-Management Education
◦ Case Manager
◦ Written Action Plan (in selected patients?)
◦ Inhaler Education
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Disease Management Programs
O’Donnell DE, et al. Can Respir J 2007;14(Suppl B):5B-32B
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Long-acting Bronchodilators
◦ Both LAMAs and LABAs or combinations of LABDs
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Anti-inflammatory agents
◦ ICS/LABA
◦ PDE4 inhibitors (roflumilast)
◦ Macrolide therapy
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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 (phosphodiesterase), 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 have been associated with an increased risk of
pneumonia1
fluticasone
90% CI
• Risk of pneumonia is
greater with fluticasone vs.
budesonide2
budesonide
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• Risk of pneumonia with
fluticasone is dose related2
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.
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◦ 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/systemof-shared-care-copdheart-failure/toolsresources
AECOPD is a clinical entity of worsened dyspnea,
cough and phlegm in persons with COPD
1.
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Pneumonia is differentiated by Xray abnormality and
treatment is different
Beware lone dyspnea in the patient with co-morbidities
3.
Bronchodilators, Antibiotics and Oral Steroids
Non-pharm and pharm strategies are required to
prevent recurrence or readmission
4.
AECOPD PATHWAY, ACTION PLAN and EDUCATION
2.
5.
Resources are available with PSP and Shared Care
and follow CTS guidelines for best practice
CTS = Canadian Thoracic Society
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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