What s New in Acute COPD? Dr Nick Scriven Consultant AIM President SAM

Covering: Basic Definition New assessment criteria Some newer treatments BiPAP

Not Covering:

Definitions: Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections. The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events

Prevalence: Estimated 384 million COPD cases in 2010. Estimated global prevalence of 11.7% (95% CI 8.4% 15.0%). Three million deaths annually. With increasing prevalence of smoking in developing countries, and aging populations in high-income countries, the prevalence of COPD is expected to rise over the next 30 years. By 2030 predicted 4.5 million COPD related deaths annually.

A new way of categorising patients:

A new way of categorising patients: Example Consider two patients: Both patients with FEV 1 < 30% of predicted Both with CAT scores of 18 But, one with 0 exacerbations in the past year and the other with 3 exacerbations in the past year. Both would have been labelled GOLD D in the prior classification scheme. With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D. The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.

Chronic treatment update:

Some Key points:

Roflumilast Gold 2017

Roflumilast 2 main papers REACT and RE2SPOND NICE 2017: Roflumilast, as an add-on to bronchodilator therapy, is recommended as an option for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis, only if: the disease is severe, defined as a forced expiratory volume in 1 second (FEV 1 ) after a bronchodilator of less than 50% of predicted normal, and the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid. Treatment with roflumilast should be started by a specialist in respiratory medicine.

Macrolides CHEST/CTS 2015 Acute Exacerbation of COPD Guidelines recommend macrolide prophylaxis for patients with moderate to severe COPD, who have a history of one or more moderate or severe COPD exacerbations in the previous year despite optimal maintenance inhaler therapy to prevent acute exacerbations of COPD. GOLD Guidelines 2015 that although recent trials of daily azithromycin showed efficacy on exacerbation rates, they did not recommend treatment due to an unfavourable balance between benefits and side effects. NICE 2016 has not issued any recommendations on the use of azithromycin in COPD for its immunomodulatory and lung remodelling properties

Macrolides BTS

Macrolides Gold 2017

Basic Exacerbation management An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. Short-acting inhaled beta 2 -agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation. Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge. Systemic corticosteroids can improve lung function (FEV 1 ), oxygenation and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days. Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-7 days. Methylxanthines are not recommended due to increased side effect profiles. Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival. Following an exacerbation, appropriate measures for exacerbation prevention should be initiated.

Mortality of Exacerbations Connolly et al (2006) 90 day mortality associated to a hospitalised COPD exacerbation at 15.3% Hartl et al (2013) 90 day mortality associated to a hospitalised COPD exacerbation at 10.8% Roberts et al (2001) 90 day mortality associated to a hospitalised COPD exacerbation at 13.7% Wildman et al (2008) 180 day mortality associated to a hospitalised COPD exacerbation at 37.9% Soler-Cataluna, (2005) post hospitalisation mortality hazard ratio of 2.235

Exacerbation Classification Classification of hospitalized patients No respiratory failure Acute respiratory failure non-life-threatening Acute respiratory failure life-threatening NOW Use the DeCaf score

DECAF The Dyspnoea, Eosinopenia, Consolidation, Acidaemia, and Atrial Fibrillation (DECAF) score was derived in a large cohort of consecutive patients hospitalised with AECOPD simple to apply at the bedside and predicts in hospital mortality using indices routinely available on admission The score comprises five predictors, the strongest of which is stable state dyspnoea, as measured by the extended Medical Research Council Dyspnoea score

DECAF Variable Score Dyspnoea emrcd 5a 1 emrcd 5b 2 Eosinopenia (<0.05 10 9 /l) 1 Consolidation 1 Acidaemia (ph <7.3) 1 Atrial fibrillation 1 Total DECAF Score 6

Receiver operator characteristic curve showing discrimination of Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) Score for inhospital mortality in the total population. Copyright BMJ Publishing Grou Ltd & British Thoracic Society. All rights reserved. John Steer et al. Thorax 2012;67:970-976

BiPAP Yoniv 2000 to date NCEPOD 2017 Journal of Intensive Care 2018 BTS Standards of care April 2018

Yoniv and on. The Yoniv study published in 2000 showed that NIV could safely be delivered on general respiratory wards, albeit with carefully selected patients and under the care of enthusiasts in this technique. This encouraged other clinicians to set up ward-based NIV services, and over the next 15 years, such services and the demand for them grew explosively. By 2014, the vast majority of hospitals admitting patients with acute exacerbations of COPD had the ability to provide NIV outside of the critical care unit, most often on respiratory wards and/or medical assessment units.

NCEPOD 2017 Bottom line for BiPAP Its done a lot BUT we re not as good as we think we are!

Initial management EWS not used in 159/338 (47%) EWS of 6 or more in 56.4% EWS 9 or more in 17.3% 27

Initial Management

Who and Where?

Respiratory ward: 214/425 (50.4%) Critical care: 136/425 (32%) AMU: 120/425 (28.2%) 31

Results

Mortality: summary 33

NCEPOD RECOMMENDATIONS 2017 All hospitals should have a clinical lead for their acute NIV service Treatment with acute NIV must be started within a maximum of one hour of the blood gas measurement that identified the need for it, regardless of the patient s location All hospitals where acute NIV is provided must have an operational policy All patients treated with acute NIV must have a treatment escalation plan in place prior to starting treatment. All patients treated with acute NIV must be discussed with a specialist competent in the management of acute NIV at the time treatment is started or at the earliest opportunity afterwards. Consultant specialist review to plan ongoing treatment should take place within a maximum of 14 hours

NCEPOD, in their recommendations, suggest acute NIV is only done in areas equipped with oximetry and continuous electrocardiogram (ECG) monitoring and staffed, at a minimum, with a nurse:patient ratio of 1:2. This is effectively specifying that acute NIV is only done in an HDU or higher level environment. This is very much in keeping with the concept of ventilation as a complex specialist intervention, also promoted in the British Thoracic Society (BTS) guidelines. Given the numbers receiving ward-based NIV, this is not going to be possible to implement immediately in many hospitals.

The challenge is to offer rapid and reliable NIV to acute type 2 respiratory patients, 24/7, delivered by staff able to spot suitable patients and the confidence to adjust ventilator settings to get the most out of the machines. The full range of intensive care therapies needs to be accessible to those who would benefit from them, but NIV will be the definitive organ support for the majority and perhaps the majority need protecting from the excesses of critical care. Ultimately, hospitals will need to come up with local solutions that fit their situations and facilities. These will come (and in many places, have come) from conversations between critical care, acute and emergency medicine and the respiratory wards.

BTS Standards of care (published 5/4/18 BMJ) 1: Acute non-invasive ventilation (NIV) should be offered to all patients who meet evidence-based criteria. Hospitals must ensure there is adequate capacity to provide NIV to all eligible patients. 2: All staff who prescribe, initiate or make changes to acute NIV treatment should have evidence of training and maintenance of competencies appropriate for their role. 3: Acute NIV should only be carried out in specified clinical areas designated for the delivery of acute NIV. 4: Patients who meet evidence-based criteria for acute NIV should start NIV within 60 min of the blood gas result associated with the clinical decision to provide NIV and within 120 min of hospital arrival for patients who present acutely. 5: All patients should have a documented escalation plan before starting treatment with acute NIV. Clinical progress should be reviewed by a healthcare professional with appropriate training and competence within 4 hours and by a consultant with training and competence in acute NIV within 14 hours of starting acute NIV. 6: All patients treated with acute NIV should have blood gas analysis performed within 2 hours of starting acute NIV; failure of these blood gas measurements to improve should trigger specialist healthcare professional review within 30 min.

Summary Whats new ->Not a lot! What can we learn -> Quite a bit DECAF/BIPAP Watch this space for chronic disease management

Join The Society for Acute Medicine in 2018 for SAMsterDAM 3-4 May & SAMBOURNEmouth 20-21 September Great Speakers: Great programme (12 CPD points) including: Organising Healthcare, Heart Failure, Psychiatry on the AMU, AKI, Diabetes, Urban Disaster Planning, Elderly Care, Toxicology, Rarities in Acute Care, The Acute Consult et al, Posters & Cases Register: www.samdam2018.org Programme packed with National & International Speakers including: Prof Julian Bion Prof Tim Briggs Prof Peter Trainer Dr Lawrence Wellikson, Society of Hospital Medicine USA etc Registration & abstract submission > May www.acutemedicine.org.uk