Severe Acute Asthma in the Emergency Department: CTS Symposium.

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Severe Acute Asthma in the Emergency Department
CTS Symposium.

• Brian H. Rowe, MD, MSc, CCFP(EM)
• Canada Research Chair in Emergency Airway
  Diseases
• Associate Dean (Clinical Reseaerch), FoMD
• Professor, Department of Emergency Medicine
• University of Alberta

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Conflicts

• Support for the studies reported in this talk
• CIHR (ON)
• Physician's Services Inc. (PSI) Foundation (ON)
• Medical Services Inc. (MSI) Foundation (AB)
• University of Alberta Hospital Foundation (AB)
• Canadian Assoc. of Emergency Physicians (CAEP)
• Emergency Health Services - RAC (ON)
• Department of Emergency Medicine, U of Alberta
• Drugs supplied AZ, GSK
• Partial study funding GSK.
• The presenter is not a paid employee or
  consultant for any sponsor except the University
  of Alberta.

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Outline

• Epidemiology of acute/ED asthma.
• Severity assessment.
• Predictors of admission and relapse.
• CTS-CAEP asthma guidelines.
• In-ED management
• After-ED management.
• Summary.

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Pathophysiology - Asthma

• Definition relapsing chronic disease
  characterized by symptoms of dyspnea.
• Pathophysiology
• Primary Airway inflammation (heterogeneity)
• Secondary broncho-constriction (most symptoms)
• Long-term may produce inflammatory scarring and
  fixed obstruction.
• Summary treatment addresses primary inflammation
  and secondary bronchospasm.

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ED Asthma

• Asthma exacerbations are common ED presentations.
• Exacerbations result in significant
• Costs to the health care system
• Impairments in quality of life for patients
• Lost time from work, school or activities.
• Potential for serious sequelae
• Hospitalizations and complications
• Rarely - death.

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Asthma how it should be treated
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Asthma how it is treated
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ED Asthma Visits in Alberta

• ACCS methods
• Data on 104 EDs in Alberta
• All ED encounters
• Trained and supervised medical records
  nosologists code each chart.
• Validity of ED diagnosis of asthma
• Comparison of respiratory presentations by
  multiple ED physicians asthma gt COPD gt LRI gtgtgt
  URI reliability.

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A person visits an Alberta ED every 16 minutes
with asthma

• Over 6 yrs, 200,000 visits
• 93,150 people
• Adults
• 105,813 visits
• Children
• 94,187 visits
• 1.8 to 2.4 of all ED visits
• 2.1 visits/person, 63 only one visit

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Age specific ED visit rates/1000
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2.6 times higher rates

In 2004/5, Welfare group (lt65yr) had
Age group and gender directly standardized rates
(DSRs) per 1000
24.8 per 1000 (22.9 to 26.6)
19.2 per 1000 (17.9 to 20.5)
12.4 per 1000 (11.7 to 13.1)
9.5 per 1000 (9.3 to 9.7)
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Summary

• ED asthma in Alberta is declining but still
  common
• Confirmation Teresa To/ICES data.
• Admission rates remain stable.
• Children present more frequently than adults.
• There is considerable room for improvement in
  acute asthma care in Canada!
• Confirmation Diane Lougheed et al.

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Severity assessment (CAEP/CTS)
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ED (simple) Approach
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90

of visits resulted in discharges from EDs in
2004/2005
Discharged 179,585
Discharged from program of clinic 757
Left against medical advice 902
Admitted to CCU or OR 511
Admitted to other area 16,930
Admitted to another facility 1,205
Expired in ambulatory care service 21
Expired on arrival to ambulatory care service 5
Left without being seen 84
Rowe BH, et al. Chest. 2009
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Translational model
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Finding the evidence
2011
Especially productive EM group Cochrane Airways
Group.
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Cochrane in-ED asthma treatments

• Beneficial effect confirmed
• MDI spacers vs nebulization (Cates)
• Early systemic corticosteroids (Rowe)
• Inhaled CS (Edmonds)
• Anticholinergics (Plotnick)
• Early systemic magnesium sulfate (Rowe).
• Beneficial effect lacking
• Antibiotics (Graham)
• Heliox (Rodrigo)
• Aminophylline (Belda).
• Insufficient evidence NIV.

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CTS-CAEP Asthma Guideline

• Inhaled SABA
• Recommends salbutamol.
• Inhaled SAAC
• Recommends IB to reduce admission.
• Systemic corticosteroids
• Recommends SCS to reduce admission.
• Adjunctive care
• IV MgSO4, ICS, IM epinephrine, NIV?

Hodder R, et al. Can Med Assoc J. 2010
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Nebulizers vs MDI Spacers?

• Evidence
• Cochrane Review (high quality)
• Wide search updated 2009
• Search identified 27 trials (2295 children and
  614 adults) from ED and community settings.
• Variable spacer devices (doesn't seem to make a
  difference) and doses (higher doses dont seem to
  be more efficacious).
• Outcomes sub-grouped into peds and adults.

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Nebulizers vs MDI Spacers?
Cates CA, et al. CL 2010. Outcome admissions.
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Nebulizers vs MDI Spacers?
Cates CA, et al. CL 2010. Outcome LOS in ED.
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Nebulizers vs MDI Spacers?
Cates CA, CL 2010. Outcome Rise in pulse rate (
baseline).
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Canadian data

• Survey of the use of nebulizers and spacers in
  Canadian Pediatric EDs (83 response).
• Overall, 21 of emergency physicians used MDI and
  spacer.
• The largest perceived barriers amongst non-users
  included safety and costs, and the lack of a
  physician champion for change.
• Gradient from East (more use) to West (less use)
  in Canada.

Osmond M, et al. Acad Emerg Med 2007
1411061113.
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Summary

• Patients with life threatening asthma
  exacerbations were excluded from the studies, so
  the results cannot be assumed to apply to this
  group.
• Analysis of the data regarding lung function
  tests in many papers was complicated by a lack of
  standardized reporting.
• MDI spacer conclusion
• Children - superiority proven
• Adults no differences vs. equivalence.

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CTS-CAEP Asthma Guideline

• Inhaled SABA
• Recommends salbutamol.
• Inhaled SAAC
• Recommends IB to reduce admission.
• Systemic corticosteroids
• Recommends SCS to reduce admission.
• Adjunctive care
• IV MgSO4, ICS, IM epinephrine, NIV?

Hodder R, et al. Can Med Assoc J. 2010
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Anticholinergics (ipratropium bromide)

• During the ED stay
• P 2189 patients, gt 18 years of age
• D 7 high quality RCTs
• I single/multiple IB compared to placebo
• O 26 reduction to hospital (RR 0.74 95 CI
  0.60 to 0.89, with a NNT of 9)
• O increase in early FEV1 modest with single (ES
  0.34) large with multiple (ES 0.78).
• Summary use often and early.

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IB SABA in the ED
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CTS-CAEP Asthma Guideline

• Inhaled SABA
• Recommends salbutamol.
• Inhaled SAAC
• Recommends IB to reduce admission.
• Systemic corticosteroids
• Recommends SCS to reduce admission.
• Adjunctive care
• IV MgSO4, ICS, IM epinephrine, NIV?

Hodder R, et al. Can Med Assoc J. 2010
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Systemic Corticosteroids

• During the ED stay
• Mainstay of ED asthma treatment.
• CAEP AIR study
• 96 SABA (3)
• 85 SAAC (3)
• 78 of ED patients received SCS.
• Whats the evidence?

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Systemic CS to prevent admission

• During the ED stay
• P 863 patients (435 corticosteroids 428
  placebo)
• D 12 variable quality RCTs
• I systemic CS compared to SOC
• O reduction in admissions (RR 0.75 95 CI
  0.64, 0.85 NNT 8)
• O earlier treatment, earlier effects observed.
• Summary use often and early.

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SCS - admissions
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CTS-CAEP Asthma Guideline

• Inhaled SABA
• Recommends salbutamol.
• Inhaled SAAC
• Recommends IB to reduce admission.
• Systemic corticosteroids
• Recommends SCS reduces admission.
• Adjunctive care
• IV MgSO4, ICS, IM epinephrine, NIV?

Hodder R, et al. Can Med Assoc J. 2010
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In-ED use of MgSO4 (admissions)
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In-ED use of ICS (admissions)
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Treatment after discharge

• Preventing relapses

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Alberta data - Relapse to ED
6.4 individuals had a repeat ED visit at 7 days.
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Alberta Data - next MD visit
35 had at least one (non-ED) follow-up visit
within 7 days for any reason time to first F/U
19 days (95 CI 18 to 21).
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Follow-up

• Relapse occurs following discharge and other
  evidence suggests treatment plays a role.
• Guidelines recommend follow-up for reassessment
  and educational reinforcement.
• Follow-up after ED remains less than ideal and so
  ED MDs need to ensure patients are covered during
  the sub-acute phase.

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Cochrane post-ED asthma treatments

• Beneficial effect confirmed
• Early PO corticosteroids (Rowe)
• Inhaled CS (Edmonds)
• Non-pharmacological approaches
• Action plans and regular follow-up (multiple).
• Beneficial effect lacking
• Antibiotics (Graham)
• Non-pharmacological approaches
• Nutritional supplementation.
• Insufficient evidence LABA, LKTs.

Hodder R, et al. Can Med Assoc J. 2010
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CTS-CAEP Asthma Guidelines

• Systemic corticosteroids
• Recommends SCS to reduce relapse.
• Inhaled corticosteroids
• Recommends ICS to reduce relapse.
• Adjunctive care
• Close follow-up, asthma education, smoking
  cessation, immunizations, AAP.

Hodder R, et al. Can Med Assoc J. 2010
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Cochrane Review

• Following the ED stay
• D Randomized controlled trials (7 ?quality
  RCTs)
• P acute asthma discharged (374 pts, all ages)
• I SCS (oral/IM) for 7-10 days
• C vs standard care
• O reduction in relapse (RR 0.39 NNT 5)
• O reduction in use of beta-agonists (2/day).

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Systemic CS preventing relapses
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Summary

• Unless contra-indicated, systemic corticosteroids
  should be prescribed for acute asthma at
  discharge.
• IM corticosteroids as effective as oral agents
  (advantage compliance disadvantage injection
  pain/bruising).
• Tapering corticosteroids, not generally felt to
  be necessary (several trials to support this).

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CTS-CAEP Asthma Guidelines

• Systemic corticosteroids (SCS)
• Recommends SCS to reduce relapse.
• Inhaled corticosteroids
• Recommends ICS to reduce relapse.
• Adjunctive care
• Close follow-up, asthma education, smoking
  cessation, immunizations, AAP.

Hodder R, et al. Can Med Assoc J. 2010
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Flow chart CS ICS vs CS alone
Emergency Department discharge
?
Budesonide 1600ug/day X 4 weeks
Emergency DepartmentTreatment
SABA 2 puffs QID Prednisone 50 mg OD
R
Placebo Turbuhaler/day X 4 weeks
SABA 2 puffs QID Prednisone 50 mg OD
Visit 1 Telephone Clinic
Visit Week 0 10-14
days 4 weeks
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Relapse
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ICS

• Following the ED visit
• D 10 high quality RCTs
• P patients discharged from ED, all ages
• I ICS for 7-21 days
• C /- oral prednisone ?-agonists
• O relapse to additional care
• Comparisons
• Primary ICS CS vs CS
• Secondary ICS vs CS.

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ICS CS vs CS Evidence
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CTS-CAEP Asthma Guidelines

• Systemic corticosteroids
• Recommends SCS to reduce relapse.
• Inhaled corticosteroids
• Recommends ICS to reduce relapse.
• Adjunctive care
• LABA?, close follow-up, asthma education, smoking
  cessation, immunizations, AAP.

Hodder R, et al. Can Med Assoc J. 2010
51
Flow chart - ICS vs ICS/LABA
Emergency Department discharge
?
Fluticasone 1000ug/day X 4 weeks
Emergency DepartmentTreatment
SABA 2 puffs QID Prednisone 50 mg OD
R
Fluticasone 1000ug/Salmeterol per day X 4 weeks
SABA 2 puffs QID Prednisone 50 mg OD
Visit 1
Telephone Telephone Week 0
10-14 days 4 weeks
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Relapse
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Relapse by Prior ICS Use
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Relapse predictors - AIR Sub-Study

• Design Prospective cohort.
• Patients Consecutive patients with acute asthma
  enrolled in ED by trained research nurses at
  following informed consent.
• Setting 20 ED sites across Canada (2004-2005)
• Assessment Pre-ED, in-ED and post ED (discretion
  of the treating MD) care documented.
• Outcome assessment 2-week telephone contact.
• Primary outcome relapse.

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Multi-variate LR relapse model
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Summary

• ED visits are common, vary by region and
  treatment varies.
• In ED
• SABA/SAAC SCS IV MgSO4, ICS and ? NIV.
• Post-discharge
• SCS, ICS /- LABA
• Follow-ups
• Delays common and methods of connecting under
  studied.
• Delivery of non-drug treatments important.

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Thanks for the invitation!

• Questions.?

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Acute Asthma Management Adults In-ED management
NIV
IV MgSO4, inhaled corticosteroids
Adjust therapy based on history/response
Systemic corticosteroid (SCS)
Fast-acting beta-agonist and ipratropium bromide
Treat complications
Confirm Diagnosis
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Acute Asthma Management Adults Post-ED
management
?
Add a LABA
Adjust therapy based on severity/response
Inhaled corticosteroid (ICS)
Systemic corticosteroid (SCS)
Fast-acting bronchodilator
Written Discharge Plan
Control environment, education, referral(s)