A Previously Hospitalized Patient Who Is Having Frequent COPD Exacerbations Specialty House Calls Case 2

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1 The following is a transcript from a web-based CME-certified multimedia activity. This enduring activity is provided by Albert Einstein College of Medicine of Yeshiva University. This enduring activity is supported by an educational grant from AstraZeneca, LP. Jill A. Ohar, MD Professor of Medicine Director of Respiratory Care and Pulmonary Rehabilitation Wake Forest Baptist Medical Center Winston-Salem, NC Sanjay Sethi, MD Professor of Medicine Chief of Pulmonary, Critical Care and Sleep Medicine University of Buffalo School of Medicine and Biomedical Sciences Buffalo, NY DR. JILL A. OHAR: Welcome to Specialty House Calls Case 2. I m Jill Ohar, Professor of Medicine and Director of Respiratory Care and Pulmonary Rehabilitation at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. I m here with my colleague Dr. Sanjay Sethi, Professor of Medicine and Chief of Pulmonary, Critical Care and Sleep Medicine at the University of Buffalo School of Medicine and Biomedical Sciences in Buffalo, New York. Sanjay, you mentioned you have a previously hospitalized patient who is having frequent chronic obstructive pulmonary disease (COPD) exacerbations and is frequently readmitted. 1

2 DR. SANJAY SETHI: I do. So here is I have a 67-year-old woman who presents to the hospital for the second admission this year and has increased with this admission has increased cough, sputum, and a low-grade temperature and increased dyspnea, [and] has a past medical history of congestive heart failure (CHF). She has a 50-pack/year smoking history, and on examination her lungs show diffuse wheezing. This is her second admission, so there is a lot of concern, as we all know, about readmissions. So the question I was posed was, How would you reduce the chance of a 30-day readmission in this particular individual? DR. JILL A. OHAR: I think you can break it down into several different quadrants. First, do we know that this is indeed COPD? So, making a diagnosis of COPD do we have former pulmonary function tests (PFTs) that documents this clinical diagnosis, would be my first concern. Not all smoking people have COPD. Maybe as many as 40% of smokers will develop some lung-function abnormalities. Is this maybe just congestive heart failure that she has an exacerbation of that? Next, I think that it s important to think about, what is she doing that puts herself in harm s way? Does she continue to smoke? Does she take her medications? DR. SANJAY SETHI: I also find in my practice that many a time the spirometry or pulmonary function tests are missing in the patient s records. And they have been diagnosed and told that they have COPD purely on the basis of the fact that they smoked DR. JILL A. OHAR: Absolutely. DR. SANJAY SETHI: or are current smokers. So I totally concur that we should be looking for objective evidence of COPD and documenting it in these patients. But in this case, she was a bit better off. We knew her underlying forced expiratory volume in 1 second (FEV1) was about 45% predicted. DR. JILL A. OHAR: So that puts her in a fairly severe category. DR. SANJAY SETHI: Yes. So the first time she was admitted, she was prescribed a long-acting betaagonist/inhaled corticosteroid (LABA/ICS) to take home, and along with that was given a short-acting beta-agonist (SABA) and also put on a nebulizer. 2

3 This time when she came around, when questioned about her medication use, she was very good with using the nebulizer and the short-acting agent, but did not receive the same benefit with the LABA/ICS and was actually using it relatively infrequently. And for some reason, of course, [she] was not on a long-acting muscarinic agent (LAMA). Clearly though, there was some effort to put her on proper maintenance medication. Issues of adherence and really an understanding of what the medications do were not addressed adequately in this patient. DR. JILL A. OHAR: Absolutely. I think it s important to educate your patients and make their expectations congruent with reality. And clearly the drugs in the ICS/LABA combination class have been shown not only in the literature, but also have an indication from the Food and Drug Administration (FDA) to decrease exacerbation frequency. The same is true, though, of the long-acting muscarinic antagonist (LAMA) classification. And so these agents should be used together, especially in a frequent exacerbator. So clearly, she s probably not adequately medicated. She probably should be on a LABA, LAMA, and ICS. Second off, she is not using the medication primarily because she doesn t understand or doesn t have appropriate expectations. And then thirdly, assessing inhaler technique would be critical in this setting. Many patients don t understand that they actually run out of drug in the canister and that 1 inhaler won t be good for 3 or 4 years. I think some other issues that might be important in discussing her care would be: has she been effectively treated while in the hospital? DR. SANJAY SETHI: There was a large Medicare-based study and it showed about 80% of patients which actually looked at patients in the Medicare age who were admitted with COPD exacerbations; so a fairly large study, database-based, not a randomized trial. But in that study, what they showed was that about 80% of the 20% of patients who did not, for example, receive any antibiotics or the antibiotics were initiated 2 days after admission those patients had worse outcomes in terms of requiring late mechanical ventilation or still requiring additional treatment. So essentially, it was not optimal care in those situations. So clearly, there are deficiencies that were there. The other thing we use is steroids. What has been shown recently is that all you need is 40 mg a day for 5 days. And what I do find many times in the patients I get to see [is that] they are still treating them with this high-dose methylprednisolone (Solu-Medrol) for several days and then tapering them really slowly. 3

4 So, kind of the regimen that was tested 20 years more than 10 years ago in these patients but now we have moved to shorter regimens. And it s not just a matter of having [fewer] steroids on board. It is maybe that longer [use of] steroids can have other adverse outcomes. So that, I think, needs to be adhered to better in terms of getting shorter-term, medium-dose steroids to help with their exacerbations. DR. JILL A. OHAR: I can t agree with you more. As a matter of fact, I think it s important to put a box around that therapy in the hospital to include antibiotics broad-spectrum oral (PO) antibiotics really targeted in the group of patients that we see as frequent exacerbators at some of the gram-negatives and atypical, rather than the big 3 that we always think about in the textbooks for COPD exacerbation; you know, Moraxella, Haemophilus influenzae, and Streptococcus pneumoniae. By the time we have a frequent exacerbator, their FEV1 is lower. They tend to be colonized with the gramnegatives, the atypicals that we re going to need a stronger antibiotic for. So, fluoroquinolones, some of the second- and third-generation cephalosporins, etc, may be a better choice for them. Oxygen, which I think so often is lost; [and] bronchodilators in the form of both nebulizers early on, but a rapid transition to the long-acting dry-powder or metered-dose inhalers (MDIs) technology as soon as patients are able. Steroids in the new lower dose, as well, are all important. I, like you, see patients sometimes even a year later still on a low dose of prednisone. I get at least 2 or 3 patients a year in with atypical infections related to an immunosuppressed host from that steroid that has been left on, or the aseptic necrosis of the hip from patients who have seen repeated, extended bouts. I think it s so critically important to remember, yes, use those steroids but stop them. Five days, done. Are there any other problems you see with the inpatient course that may have been reflective in our case or other cases you ve seen? DR. SANJAY SETHI: Yes. So one of the things that I ve noticed, and one of the things that we tried to change in our hospital was, they come in. They stay on the nebulizers until the day they leave. I think what we should be doing is that, as soon as they are over the first the critical period put them on the dry-powder inhalers (DPIs), still have the nebulizer on PRN (as-needed) use, and maybe get a day or so in the hospital to see how they re doing on those. 4

5 DR. JILL A. OHAR: Absolutely. I think that also gives our respiratory therapists an opportunity to assess inhaler technique in the hospital and also to assess whether this patient can develop enough inspiratory force to use an MDI or a DPI. Because I think it s not really in the top of our thinking of, Wow, this debilitated, 67-year-old woman who weighs 110 lbs and also has osteoporosis and some congestive heart failure she can t draw that 30 L per minute that she needs to get in. [END OF SEGMENT 1] VIDEO SEGMENT 2 DR. JILL A. OHAR: You know, this case also throws in the congestive heart failure issue. And congestive heart failure is so incredibly common, especially among exacerbators and frequent exacerbators. I know that we have looked back over our frequent-exacerbator population and found that if you have 5 or more admissions to the hospital in the previous year, 82% of those patients will have concurrent congestive heart failure diagnoses. So I think it s important for us to help the doctors listening in on the House Call to understand, how do we differentiate between a CHF exacerbation [and] a COPD exacerbation, or is this both? And so I think one of the conundrums we often find ourselves in is the chest x-ray that is relatively nonspecific, the symptoms which are relatively nonspecific, and then you get a B natriuretic protein (BNP), hoping that that s going to be the deal breaker or tiebreaker here, and it s What do you do with that? Is there a number where you say, You crossed that line in the sand? You now have congestive heart failure, too? DR. SANJAY SETHI: I think that it comes down to a good assessment, bedside assessment and clinical judgment. The BNP I find useful if I have a baseline BNP. Not that I do it routinely, but if there is a baseline then you can see if there is a change from there. To me, the congestive heart failure story in COPD is related to 2 aspects. A) Is it right-sided failure, which is a consequence of their COPD getting worse? So they were hypoxic at home, and because of that, their cor pulmonale got worse. And that to me Because there, yes, I might use some diuretics, but my focus will be on treating the lungs and getting the COPD better. On the other hand, then there are other patients with either biventricular failure or predominant left ventricular failure. In them, it s a toss-up. It could be that the COPD exacerbation caused some ischemia and made things worse. So you could end up with concomitant COPD and CHF exacerbations. So if you treat a patient with steroids and antibiotics and bronchodilators and send them home, and there was concomitant CHF which you never addressed, the chances are that patient is going to be a bounceback. DR. JILL A. OHAR: Absolutely. And I think you ve brought up several issues with congestive heart failure. I know I have read that above 500, you can feel fairly confident that there is left ventricular dysfunction ongoing, that higher or abnormally high levels of BNP below 500 can easily be attributed to right heart strain related to the exacerbation. 5

6 I think also another issue you brought up with right heart strain is for us to begin to think about the differential diagnosis of what causes a COPD exacerbation. And while, far and away, infectious etiologies are important in terms of both bacterial and viral bronchitis and possibly pneumonia, when it is not an infectious etiology, the next most common thing is a pulmonary embolism (PE). You know, also in that differential is cardiac ischemia. Is this angina? Is this a myocardial infarction (MI)? So when we re working these patients up, I think a BNP can be helpful. I think troponins can be helpful. I think an echo[cardiogram] is important because it helps us understand: Is there cardiac pathology? Is there right heart strain from a big new PE? And also, just having your antennae up for having an expectancy set of something other than a bacterial infection as the cause. DR. SANJAY SETHI: For those patients, what I find the most instructive is, again, the clinical presentation of the exacerbation. So, [there s] nothing like a good history. So if they presented acutely, it s very uncommon for an exacerbation because of a bronchitic you know, what we think of the classic mechanism to be presenting acutely. Those are always things that develop over days, rather than minutes and hours. So whenever I hear the words, This started doc, I was fine and suddenly became short of breath, PE is way up on my list, many a time leading to a computerized tomography (CT) [scan] [and an] angio[gram]. And the other thing I ve got on my list is a pneumothorax, but usually they have an x-ray, so you can pick that up by the time they come in the hospital. But those are the 2 things that certainly come to mind. So that s what really makes me kind of pushes me and makes me think of PE, besides the right heart strain and other findings. DR. JILL A. OHAR: Sure. Also with the congestive heart failure thing, I get asked all the time about physicians anxieties about beta-blockers and COPD. And there are so many papers out there now showing that beta-blockers in patients with COPD are not only beneficial, but [also that] patients who do have that component of heart failure who are treated with beta-blockers actually do markedly better than COPD patients who don t see a beta-blocker. So I think it s a really important thing to consider not only during the acute hospitalization, but [also] it s an opportunity to prevent an exacerbation. If there is an element of heart failure, let s optimally treat that now as an opportunity to keep this patient from coming back in. As you mentioned, the Jencks Centers for Medicare and Medicaid Services (CMS) data from the New England Journal [of Medicine] suggested that up to 70% come from other reasons. Are there any things you would do in their transition of care, specifically [in] this woman, to keep her out the third time? DR. SANJAY SETHI: Yes. In a way it s good that the CMS now has focused on COPD, that now we are applying these transitions-of-care models to COPD. Ideally, I think this should be a hospital-based program because that s where they stand the most to lose with readmissions, and they should be supporting it. And it should be applied to every COPD readmission. They get seen by a team, or at least by an individual from the team, which would affect the transition of care, and there are several elements to it. So when they go home, we examine the issues of their: A) Are they going to get their medications filled? Do they have the resources to get the medications filled? Their psychological and social support is that existing when they go home? Are they able to reach out to someone and get advice on a regular basis? And then, contact to be seen by a healthcare professional who is experienced in lung disease and COPD within a week or so is also quite important. DR. JILL A. OHAR: What would be your discharge prescriptions for this woman? 6

7 DR. SANJAY SETHI: So at this point, because she was on a LABA/ICS she was not on a LAMA, which also reduces exacerbations she was not taking her LABA/ICS properly. So at this point, I would be inclined to discharge her on a triple therapy and with a nebulizer for PRN use, provided she can take it properly, and then with a lot of education about being compliant with it. Now we do end up with scenarios where people are already on triple therapy, and then what do you do? DR. JILL A. OHAR: You anticipated my question! DR. SANJAY SETHI: I did, because I m sure we deal with the same situations. So in those patients, I think addition of either roflumilast or azithromycin on a chronic basis can help reduce clearly reduce the frequency of exacerbations. So those are the choices we have beyond the inhaled therapy. DR. JILL A. OHAR: What nonpharmacologic therapies would you order for her at discharge? DR. SANJAY SETHI: Well, clearly, I will make sure the immunizations are up to date, because otherwise you are going to get dinged for that. So that s a quality measure so you make sure the immunizations are up to date. Check her oxygen [and] smoking cessation. But I think the most favorite of yours is rehab[ilitation]. So would you start her on rehab right away or what would you do with that? DR. JILL A. OHAR: Yes, I would. I think that the reality of the situation is that in a low percentage of the time, she would be seen in 7 days. In reality, she would be seen more likely within 14 days. I know that there is a transitional care billing code for both, and so you get additional dollars for providing transitional care in the postdischarge period for up to 14 days. In that period of time, or at that visit, I would have her evaluated by our pulmonary rehab team for her ability to perform rehab. Pulmonary rehabilitation provides for you social support and actual didactics for smoking cessation, which is oh so critical in the postdischarge period. They also provide education about medications that we have been discussing. They provide education about nutrition, which is often a problem in the postdischarge period where people have lost weight in the hospital because they felt too ill to eat. I think the pulmonary rehabilitation in that discharge period provides more than just exercise. And social support. And we haven t really spent a lot of time talking about depression, which is one of the comorbidities that is oh so common among COPD patients and is so pervasive among the repeatedly admitted patients. 7

8 You ve talked about, does this person really have COPD? and the number of patients who come to you who really don t. They re smokers. So, when do you go ahead and get a follow-up spirogram? DR. SANJAY SETHI: If I have documented COPD in the past, well documented with proper pulmonary function, I really don t you know, unless it s going to change my management, repeating pulmonary function doesn t help me much. I do repeat it in case patients deteriorate slowly not an exacerbation, but the ones who keep on getting worse. Because then you start wondering: Is their lung function getting worse or [is it] something else that s precipitated it? In patients without a diagnosis, I find definitely doing a spirometry, and if you have a full pulmonary function test, [it] is very useful. And my time frame is usually 4 to 6 weeks. DR. JILL A. OHAR: I m a little more aggressive. I think, for number one, the vast majority of the patients I see have never had pulmonary function testing. And I think the guidelines kind of are sympathetic with my needs in that they say you need at least one to make a diagnosis. You need follow-up studies after an exacerbation, because up to 30% of patients will never come back to their baseline. So I think that s a really important study that we often don t get. So I think there is that potential for the loss of lung function over time that goes unrecognized, and I also find that the FEV1 is one of the clear and critical elements of prognosis. The FEV1 is the single best lab test that we have of everything to predict all-cause mortality. Clearly, what we haven t spoken about in this case is the significant minority of patients who exacerbate and will not live the next year. That s up to 25% of patients who come in for an exacerbation will be dead in a year. And trying to ferret out who those are And while FEV1 is not the be-all, end-all, it is an important predictor, along with [a] number of comorbidities that we ve talked about today. Also important is home oxygen; the need for that, whether patients have been ventilated and it s immaterial whether it s invasive or noninvasive. And clearly their age is another important factor. 8

9 What do you feel about diabetes and acute kidney injury or chronic kidney injury as a comorbidity that has the potential to bring this patient back in [the] postdischarge period? Do you do anything special about that? Do you look at a hemoglobin A1C (HbA1c)? Do you factor in your antibiotic choices when you re thinking about chronic kidney disease? DR. SANJAY SETHI: You know, hyperglycemia makes you more prone to infections, so if your diabetes is poorly controlled, the chances are you are going to get more infections, including infections of the lung. And again, you need to know the renal function to use your medications properly, to dose them properly. So those are clearly important issues and should be paid attention to, and they are comorbidities in COPD. I think what we both are talking about is emphasizing how to treat the patient, especially if you want to prevent readmission, rather than just treat the lungs. DR. JILL A. OHAR: I think this really highlights some of the challenges we all face and some of the approaches we can consider. I hope this has been helpful to the audience, and I want to thank the audience for joining us today. I also urge you to participate in the first Specialty House Call Case and other COPD activities available on mycme.com: the Medically Speaking roundtable webcast and the Current Medical Opinion with Q&A session. And thank you again. 9

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