The "COPD emergency 2003" study: a description of the hospital management of exacerbations of COPD

CURRENT SITUATION: Despite its impact on public health and numerous recommendations COPD remains under-diagnosed and its care pathways are not well known. Exacerbations are common presentations of the illness and contribute greatly to its impact on the health of the individual and the community. Despite this the methods of their management in hospital have not been precisely described. The purpose of the prospective study "COPD emergency 2003" is to describe these different aspects of the management of COPD and to study their determining factors. MATERIALS AND METHODS: It is a prospective, multicentre observational study of all the exacerbations of COPD managed as emergencies in public and private hospitals during a two-month period. Enrolment takes place between October 2003 and January 2004. The analysis will begin when the last patient has been discharged from hospital. EXPECTED RESULTS: The data obtained will allow identification of those aspects of the management of COPD and its exacerbations that are heterogeneous or in conflict with the current guidelines as well as the patient care pathways. In the future this study should help target the approaches aimed at improving the outcomes of patients suffering from COPD.     

The epidemiology of Pseudomonas aeruginosa in oncology patients in a general hospital

Pseudomonas aeruginosa colonization and infection was studied over a 6-mo period in a 36-bed mixed general medical-oncology unit. We used selective media for serial surveillance cultures on 283 patients, the environment, and personnel. Twelve percent of patients were colonized on admission and 10% acquired P. aeruginosa. Using serotyping and multilocus enzyme electrophoresis, we identified 63 genetically distinctive strains; four prevalent strains accounted for 21% of isolates. Only 5 of 33 nosocomial acquisitions were due to horizontal transmission. Nine acquisitions were linked to environmental sources (e.g., sink surfaces), which often harbored antibiotic-resistant strains but posed a risk only to oncology patients. Although significant Pseudomonas infections occurred in only 11% of colonized patients, 63% of colonized severely neutropenic patients--predominantly those who had acquired the prevalent, often environmentally linked strains--developed infections. Thus, P. aeruginosa was a significant pathogen in oncology patients; typing by multilocus enzyme electrophoresis allowed the detection of important environmental sources.     

Risk factors for exacerbations and hospital admissions in asthma of early childhood

Hospital admissions and readmissions for asthma in early childhood remain causes for concern. The purpose of this study was to identify predisposing risk factors related to asthma exacerbations and precursors of hospital admissions in young children. Subjects were patients with doctor-diagnosed asthma from a clinical registration study, aged 0-4 years, and followed up for 2 years. Data from histories and laboratory tests for atopic status at initial presentation, and the patient's condition at visits over the 2-year follow-up period were evaluated. Exacerbation was defined as increases in cough and/or wheeze and/or breathlessness, increase in beta(2)-agonist use, and a clinical need for a short course of oral corticosteroids. Age groups 0-1 year and 2-4 years, based on age at initial presentation, were analyzed separately. In the age group 0-1 year, 71/113 (63%) patients had at least one exacerbation, and 20 experienced recurrent exacerbations (>/=3). Predisposing risk factors for exacerbation were damp housing (odds ratio (OR) 7.6 (2. 0-28.6)) and colds (OR 3.6 (1.4-9.6)), and for recurrent exacerbations sensitization to inhalant allergens (Phadiatop(R)) (OR 8.1 (1.6-40.5)) and damp housing (OR 3.8 (1.1-12.8)). Hospital admissions were significantly associated with number of exacerbations. In the age group 2-4 years, 58/144 (40%) patients had at least one exacerbation, and 21 experienced recurrent exacerbations (>/=2). Predisposing risk factors for exacerbation were mean age at initial presentation (OR 0.92 (0.88-0.97)) and level of total IgE (OR 2.3 (1.4-3.9)), whereas for recurrent exacerbations no predictor variables were found. Hospital admissions were significantly associated with damp housing. Results from this study may facilitate recognition of young asthmatic patients at risk of (recurrent) exacerbations, and help to identify those in whom early intervention with anti-inflammatory therapy may be necessary. We also emphasize the importance of preventive measures in decreasing damp housing.     

Direct medical costs of pediatric asthma exacerbations requiring hospital attendance in a middle-income country

Introduction and objectivesWith the aim of making informed decisions on resource allocation, there is a critical need for studies that provide accurate information on hospital costs for treating pediatric asthma exacerbations, mainly in middle-income countries (MICs). The aim of the present study was to evaluate the direct medical costs associated with pediatric asthma exacerbations requiring hospital attendance in Bogota, Colombia.Patients and methodsWe reviewed the available electronic medical records (EMRs) for all pediatric patients who were admitted to the Fundacion Hospital de La Misericordia with a discharge principal diagnosis pediatric asthma exacerbation over a 24-month period from January 2016 to December 2017. Direct medical costs of pediatric asthma exacerbations were retrospectively collected by dividing the patients into four groups: those admitted to the emergency department (ED) only; those admitted to the pediatric ward (PW); those admitted to the pediatric intermediate care unit (PIMC); and those admitted to the pediatric intensive care unit (PICU).ResultsA total of 252 patients with a median (IQR) age of 5.0 (3.0–7.0) years were analyzed, of whom 142 (56.3%) were males. Overall, the median (IQR) cost of patients treated in the ED, PW, PIMC, and PICU was US$38.8 (21.1–64.1) vs. US$260.5 (113.7–567.4) vs. 1212.4 (717.6–1609.6) vs. 2501.8 (1771.6–3405.0), respectively: this difference was statistically significant (p < 0.001).ConclusionsThe present study helps to further our understanding of the economic burden of pediatric asthma exacerbations requiring hospital attendance among pediatric patients in a MIC.     

Acute exacerbations of COPD

Acute exacerbations of COPD (AECOPD) are a common cause of morbidity and mortality. There is a need for a standardised definition of an exacerbation of COPD. The common aetiological factors are bacterial, viral infection and air pollutants. Exacerbations of COPD may adversely affect the natural history of COPD. Several strategies are available now to prevent or reduce exacerbations of COPD including immunisation against influenza and inhaled corticosteroids in patients with moderate/severe disease. The mainstay of treatment involves increasing bronchodilator therapy, systemic glucocorticoids which have now been shown to have a beneficial effect. The circumstances for the use of antibiotic therapy is now established in patients with increased breathlessness, increased sputum production and/or sputum purulence. In those with respiratory failure, noninvasive ventilation has been shown to reduce intubation rates, shorten lengths of hospitalisation, and improve mortality. Early or immediate supported discharge for selected patients has been shown to be effective in the management of patients with COPD.     

Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation

The principals of rehabilitation medicine are to prevent muscle atrophy and improve mobility. Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with muscle atrophy and yet many patients do not undergo pulmonary rehabilitation until they have been in stable health for some time. We investigated the outcome of a supervised home exercise programme initiated immediately after hospitalisation for an exacerbation of COPD. Thirty-one patients were randomised into an exercise group (n=16, FEV(1) 0.94+/-0.34 L) and a control group (n=15, FEV(1) 1.08+/-0.33 L). The exercise group received a twice-weekly supervised exercise programme, in their homes, for 6 weeks. Spirometry, exercise capacity, isometric muscle strength, dyspnea level, quality of life at baseline and 6 weeks as well as subsequent exacerbations were quantified. At 6 weeks, the exercise group, improved the shuttle walk test (198 m+/-95-304+/-136 m) and increased 3 min step test capacity (119+/-40-163+/-26s) (both P<0.001). Knee extensor muscle strength and quality of life scores also increased. Neither exercise capacity nor muscle strength altered in the control group. Follow-up at 3 months showed that three of the control group and none of the exercise group had experienced subsequent exacerbations (P=0.06). Early rehabilitation via a home from hospital programme improved exercise tolerance, muscle strength, dyspnea scores, quality of life in COPD patients and reduced the number of subsequent exacerbations.     

Variability in the organisation and management of hospital care for COPD exacerbations in the UK

Previous smaller UK audits have demonstrated wide variation in organisation, resources, and process of care for acute chronic obstructive pulmonary disease (COPD) admissions. Smallest units appeared to do less well. UK acute hospitals supplied information on (1) resources and organisation of care, (2) clinical data on process of care and outcomes for up to 40 consecutive COPD admissions. Comparisons were made against national recommendations. Eight thousand and thirteen admissions involved 7529 patients from 233 units (93% of UK acute Trusts). Twenty-six percent of units had at most one whole-time equivalent respiratory consultant while 12% had at least four. Thirty percent patients were admitted under a respiratory specialist and 48% discharged under their care whilst 28% had no specialist input at all. Variation in care provision was wide across all hospitals but patients in smaller hospitals had less access to specialist respiratory or admission wards, pulmonary rehabilitation programs, specialty triage or an early discharge scheme. Six percent of units did not have access to NIV and 18% to invasive ventilatory support. There remains wide variation in all aspects of acute hospital COPD care in the UK, with smaller hospitals offering fewest services. Those receiving specialist input are more likely to be offered interventions of proven effect. Management guidelines alone are insufficient to address inequalities of care and a clear statement of minimum national standards for resource provision and organisation of COPD care are required. This study provides a unique insight into the current state of care for patients admitted with COPD exacerbations in the UK.     

A pilot study of inspiratory capacity and resting dyspnea correlations in exacerbations of COPD and asthma

Measurement of inspiratory capacity (IC) as a marker of dynamic lung hyperinflation has been shown to correlate with dyspnea and exercise performance in stable COPD, and is therefore of potential utility in the management of this condition. We have examined whether similar relationships exist during acute exacerbations of COPD and asthma in order to determine whether there is a role for IC monitoring in acute management of these conditions. Eight patients with COPD and ten with asthma requiring hospital admission for acute exacerbations were studied with spirometry (including IC) at admission and at discharge and had concurrent self-perceived resting dyspnea ratings recorded. Over the admission there were significant improvements in resting dyspnea for the COPD group only, and improvements in spirometric indices in the asthma group only. No significant correlations were found between changes in dyspnea and changes in IC, in terms of acute responses to bronchodilator and in response to treatment over the hospital admission. These data suggest that dynamic hyperinflation during acute exacerbations of COPD and asthma is not as sensitive an indicator of resting dyspnea as in stable disease. A role for IC monitoring in the management of acute exacerbations of these diseases has not been identified.     

Recent asthma exacerbations: a key predictor of future exacerbations

OBJECTIVE: The objective of this analysis was to investigate whether patients with severe or difficult-to-treat asthma who experienced recent severe asthma exacerbations are at increased risk of future asthma exacerbations. METHODS: We conducted a 1.5-year prospective analysis of 2780 patients 12 > or =years of age from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study. Severe exacerbations were defined as either an asthma-related emergency department visit or night of hospitalization in the 3 months prior to study visit; a secondary analysis assessed prior steroid bursts as an independent predictor and outcome. Potential confounding was assessed by statistical adjustment for demographic and clinical factors, as well as asthma severity and asthma control. RESULTS: Compared with patients without a recent severe exacerbation, patients with a recent exacerbation were at increased risk of future exacerbation (odds ratio=6.33; 95% CI 4.57, 8.76), even after adjustment for demographics and clinical factors (odds ratio=3.77; 95% CI 2.62, 5.43), asthma severity (physician-assessed: odds ratio=5.62; 95% CI 4.03, 7.83), National Asthma Education and Prevention Program (odds ratio=5.07; 95% CI 3.62, 7.11), Global Initiative for Asthma (odds ratio=5.32; 95% CI 3.80, 7.47), and asthma control (odds ratio=3.90; 95% CI 2.77, 5.50). CONCLUSION: This analysis suggests that recent severe asthma exacerbations are a strong independent factor predicting future exacerbations and, as such, should be considered as part of the clinical assessment of patients with severe or difficult-to-treat asthma.