Severe Acute Asthma in the Emergency Department: CTS Symposium.

1. 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

2. 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.

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

4. 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.

5. 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.

6. Asthma – how it should be treated…

7. Asthma – how it is treated…

8. 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 > COPD > LRI >>> URI reliability.

9. 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 A person visits an Alberta ED every 16 minutes with asthma Rowe BH, et al. Chest. 2009

10. Age specific ED visit rates/1000

11. 2.6 times higher rates In 2004/5, Welfare group (<65yr) 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)

12. 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.

13. Severity assessment (CAEP/CTS)

14. ED (simple) Approach

15. 90% of visits resulted in discharges from EDs in 2004/2005 Rowe BH, et al. Chest. 2009

16. Translational model Westfall, J. M. et al. JAMA 2007;297:403-406

17. Finding the evidence 2011 Especially productive EM group: Cochrane Airways Group.

18. 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. Hodder R, et al. Can Med Assoc J. 2010

19. 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

20. 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 don’t seem to be more efficacious). • Outcomes sub-grouped into peds and adults.

21. Nebulizers vs MDI + Spacers? Cates CA, et al. CL 2010. Outcome: admissions.

22. Nebulizers vs MDI + Spacers? Cates CA, et al. CL 2010. Outcome: LOS in ED.

23. Nebulizers vs MDI + Spacers? Cates CA, CL 2010. Outcome: Rise in pulse rate (% baseline).

24. 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; 14:1106–1113.

25. 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.

26. 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

27. Anticholinergics (ipratropium bromide) • During the ED stay • P: 2189 patients, > 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.

28. IB + SABA in the ED

29. CTS-CAEP Asthma Guideline • Inhaled SABA: • Recommends salbutamol. • Inhaled SAAC: • Recommends IB to reduce admission. • Systemic corticosteroids: • Recommends SCS to reduceadmission. • Adjunctive care: • IV MgSO4, ICS, IM epinephrine, NIV? Hodder R, et al. Can Med Assoc J. 2010

30. During the ED stay Mainstay of ED asthma treatment. CAEP AIR study: 96% SABA (3); 85% SAAC (3); 78% of ED patients received SCS. What’s the evidence? Systemic Corticosteroids Rowe BH, et al. Acad Emerg Med 2008; 15:709–717

31. 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. Rowe BH, et al. Cochrane Library, Version 1. 2007

32. SCS - admissions Rowe BH, et al. Cochrane Library, Version 1. 2007

33. 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

34. In-ED use of MgSO4 (admissions) Rowe BH, et al. Cochrane Library, Version 1. 2007

35. In-ED use of ICS (admissions)

36. Treatment after discharge Preventing relapses

37. Alberta data - Relapse to ED ~6.4% individuals had a repeat ED visit at 7 days.

38. 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).

39. 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.

40. 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

41. 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

42. 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).

43. Systemic CS: preventing relapses

44. 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).

45. 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

46. 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 Rowe BH, et al. JAMA 1999

47. Relapse Rowe BH, et al. JAMA 1999

48. 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.

49. ICS + CS vs CS Evidence Edmonds ML, et al. Cochrane Library 2007

50. 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