Identification and management of acute exacerbations

1
Identification and management of acute
exacerbations - admission avoidance

• Marc Rodriguera RGN MSc
• COPD Nurse Specialist
• Tower Hamlets CHS

2
Case Study

• Mrs S is a 75 year old lady with COPD who has
  just phoned the practice saying she is breathless
  which stops her from doing her daily shopping and
  she seemed to be having increased difficulty in
  coughing up sputum and at times have yellow
  sputum.

3
DEFINITIONS

• SYMPTOMATIC
• (based on Anthonisen et al Ann Intern Med 1987)
• At least two of increase in SOB, sputum
  purulence, sputum volume
• Or any one above and one of URTI, Wheeze, Cough,
  Increase in resp. / pulse rate
• HEALTH CARE UTILIZATION
• (Rodriguez-Roisin Chest 2000)
• Sustained worsening of COPD patients condition
  from stable state necessitating a change in
  regular medication
• Used by most studies of therapies in COPD

4
INSPIRE STUDY Exacerbation rates HCU and
Symptom defined
5
Strategies in reducing impact of COPD
exacerbations

• Reduction in triggers
• Optimising inhaled therapy (use of LABA/ICS
  combinations and/or LAMA)
• Self-management
• Pulmonary rehabilitation

6
COPD EXACERBATION TRIGGERS AND PATHOPHYSIOLOGY
REDUCTION ON EXACERBATION TRIGGERS Smoking
cessation Vaccination Anti virals Pollution
control Occupational factors? Long term
antibiotics? Stress/anxiety management
From Wedzicha, JA, Seemungal T Lancet 2007
7
TORCH STUDY DATA - RATE OF MODERATE AND SEVERE
EXACERBATIONS OVER THREE YEARS
Mean number of exacerbations/year
25 reduction
1.2
1.13
0.97
0.93
1
0.85
0.8
0.6
0.4
0.2
0
Placebo
SALM
FP
SFC
Treatment

• Calverley et al. NEJM 2007

p lt 0.001 vs placebo p 0.002 vs SALM p
0.024 vs FP
8
EFFECT OF TIOTROPIUM ON EXACERBATIONS Powrie et
al ERJ2007
9
INSPIRE STUDY - SFC and TIO have similar
magnitude of effect on exacerbation frequency
6
4
Rate of Healthcare Utilisation Exacerbations
2
0
SFC 50/500
TIO 18
Wedzicha JA, et al. AJRCCM 2008
10
Case Study Abdul

• Abdul has COPD (FEV 16 predicted) and is
  housebound due to breathlessness. He uses
  antibiotics and oral steroids monthly. He also
  has been complaining of thick sputum and
  difficulty expectoration.
• How would you address this issue of frequent COPD
  exacerbations?

11
ECLIPSE - DISTRIBUTION OF OBSERVED
EXACERBATIONS DURING YEAR 1 BY PRIOR EXACERBATION
HISTORY FOR GOLD STAGES 3-4Wedzicha et al
Presented at ATS 2009
RATES OF COPD EXACERBATIONS
12
Written Management PlanRescue packs

• Use of Antibiotics
• If your sputum colour turns green, yellow or
  brown, or you have new or increased coughing, you
  need to start taking the antibiotics as
  prescribed
• Use of Steroids
• If the breathlessness is affecting your ability
  to perform your usual activities (for example,
  your usual walking distance is shortened OR you
  are unable to do dress or wash when you
  normally can), you need to start taking the
  steroid tablets as prescribed

13
SIGNIFICANCE OF TREATMENT DELAY AND RECOVERY
TIME Wilkinson et al AJRCCM 2004
14
SYMPTOM ONSET AND EARLY START OFTHERAPY
24

Plt0.001
18
12
Symptom recovery time (days)
6
0
0
7
14
Delay between onset and treatment (days)
Patients who receive prompt therapy after symptom
onset are likely to recover more rapidly than
are patients whose treatment is delayed
Wilkinson et al. Am J Respir Crit Care Med.
20041691298-1303.
15
Chest Clearance Technique Huffing
16
Breathing Techniques and Positions of Ease
17
Anxiety, Dyspnoea And Relaxation

• Many people who experience dyspnoea also
  experience anger, frustration, guilt, dependency
  and embarrassment.
• Screen for anxiety and depression and offer
  treatment if needed

Emery and Lebowitz 2000307 Rachel Garrod
Pulmonary Rehabilitation
18
Case Study Admission Avoidanc

• Mr B is 77 year old with very severe COPD and
  bronchiectasis. He lives alone, on long term
  oxygen and has 3X daily carers. He has been
  coughing up green sputum. He is able to move
  around his flat with difficulty and has access to
  a telephone and a telecare alarm. He has just
  started to take his own rescue pack and adamant
  he does not want to go to hospital. What is your
  plan of action?

19
NICE COPD GUIDELINES (2010)
20
Reviewing a COPD Patient?

• 1. Need urgent support during a COPD exacerbation
  (seen same/next working day) OR
• 2. Had 2 or more COPD hospital admissions in the
  past 12 months (seen in 1 week) OR
• 3. On oxygen and/or non-invasive ventilation due
  to COPD (seen within one month)
• .. Consider referring to the Community
  Respiratory Team

Further contact/information Community
Respiratory Team 2nd Floor Burdett House, Mile
End Hospital, Bancroft Road E1 4DG Phone
0208121 4168 (Open Mon - Fri 830 AM to 430 PM)
Direct Fax [phone] Leads (LAP 1-4)
Kara Renno 07506 709 696 kara.renno_at_thpct.n
hs.uk (LAP 5-8) Marc Rodriguera 07949 073 924
marc.rodriguera_at_thpct.nhs.uk
21
Questions