Asthma: how to prevent readmission and death

1. BMJ 1967: Asthma: how to prevent readmission and death Simon Quantrill Consultant chest physician Whipps Cross Chest Clinic

3. Asthma: the challenges BTS standards Litigation Financial penalties

4. Asthma: admissions to Whipps Cross

5. Prevention of exacerbation/admission/death – case history • 53 year old woman, asthmatic, never smoker • Joined GP practice in 1994, taking salb + beclo previously • Resp symptoms August 1997 reviewed 4 times in 3 weeks, wheeze noted on examination • October 1997 salbutamol PRN • 2001 and 2002 cough – no treatment • Dec 2005 chesty cough 8 weeks. 2 courses antibiotics. Feb 2006 wheeze – salbutamol restarted: diagnosis “viral-induced wheeze”. • Next review Dec 2006 “asthma resolved suspect nocturnal wheeze only”. • April 2008 exacerbation asthma – inhaled steroid added. • May 2008 exacerbation asthma. • October 2008 prescription for salbutamol 2p tds • January 2009 died of acute asthma

6. Who dies of asthma and where? • 1300 deaths annually in UK • Median age >50 years old • Median age of onset asthma 30 years • Obese 30% • Psychosocial factors 50% • 80% ever admitted to hospital with asthma • 18% previously ventilated • 64% severe, 29% moderate, 7% mild asthma • 50% never attended hospital respiratory clinic • 90% died in community (inc 20% in A&E) • 80% may be preventable (mixture of patient and healthcare professional factors) Sturdy PM. Thorax 2005;60:909-15, Burr ML. Thorax 1999;54:985-9, Rea HH. Thorax 1986;41:833-9.

7. Things we need to do for asthmatics • Get better at diagnosis

8. Asthma is underdiagnosed n=86/1155 (7%) with FEV1 + symptoms Van Schayck C. Thorax 2000;55:562-5

9. Childhood asthma is markedly underdiagnosed Speight ANP. BMJ 1983;286:1253-6

10. Why is asthma underdiagnosed? • To avoid parental anxiety • Stigma attached to “asthma” word • Because of the belief that “wheezy bronchitis” etc is a separate entity • Because infective exacerbations are labelled as “chest infections” • Because people don’t always complain to their doctor of chest symptoms • Because doctors don’t always take careful histories • To avoid a shed load of work eg detailed history, PEF recordings, lung function, time-consuming patient education • To avoid a difficult conversation with people who don’t want to have asthma • Because making a new diagnosis of asthma seems a big thing and the implications are big, eg need for long-term inhaled steroids • Because lack of continuity of care in hospital means it will be someone else’s problem the next day

11. Improving asthma diagnosis: history • Intermittent breathlessness, wheeze, cough • Diurnal variation, esp worse at night or early am • Reduction in exercise tolerance, ability to comfortably accomplish tasks • Recurrent “chest infections” • Association with hayfever, eczema • Family history • Smoking

12. Asthma diagnosis: examination • Wheeze nearly always present at some point, but not always at first • Wheeze nearly always = asthma (or other obstructive airways disease, eg COPD, bronchiectasis)

13. Asthma diagnosis: tests of airflow obstruction • Peak flow monitoring -over at least 2 weeks -even better if during a “chest infection” • Spirometry -will need at least two done some time apart -even better if during a “chest infection” or otherwise symptomatic -normal does not exclude asthma -beware of interpretation of FEV1/FVC ratio with raised BMI

14. Asthma is underdiagnosed: case history • 64 yr female • Breast cancer + lung mets • Mild LLL pneumonia • Crackles wheeze • Oral steroids + nebs • Seretide 500 1p bd • PEF recordings

15. Peak flows are crucial to the diagnosis • 75 yr old man, retired engineer, stopped smoking 15 years ago • “Unwell for 5/52, coughing ++, white sputum, SOB on exertion” • No improvement with amoxycillin • “no past h/o COPD” • O/e crackles on admission • Wheezes and crackles thereafter • Treatment: antibiotics, nebulised salbutamol, prednisolone • Discharged after 6 days to finish course of antibiotics and chest clinic follow-up • Diagnoses on discharge summary: “COUGH, BILATERAL BRONCHITIS, POSSIBLE COPD”

16. Asthma is underdiagnosed: case history • 28 yr female, 23 weeks pregnant, admitted Nov 2011, cough, sputum, dyspnoea • Wheeze noted on auscultation, 2 doses prednisolone and 5 nebs salbutamol given • (Why did this patient not have PEFs recorded despite having bronchodilators and steroids) • Diagnosis at discharge: “LRTI”, given co-amoxiclav • Readmitted Jan 2012: 30/40, wheezy, PEF 175 • Oral steroids + nebs • Discharged on Symbicort • Update May 2012: Symbicort SMART regime, FEV1 86% • Sep 2012: Asthma Control Test 25/25

17. Things we need to do for asthmatics • Get better at diagnosis • Get better at severity assessment, and: • Treat accordingly by stepping therapy up and down

18. Asthma severity is underestimated and asthma is therefore undertreated POMS: • 71% not-well controlled, 19% badly uncontrolled • 80% satisfied with control and 76% thought well-controlled Disconnect between asthma control and perception of symptoms

20. Some asthmatics are poor perceivers of breathlessness 9/47 were poor perceivers in this test Histamine challenge test with Borg scores Van Schayck C. Thorax 2000;55:562-5

21. Poor perceivers are at higher risk of death and near-fatal asthma n=113, stable asthmatic out-patients, breathing against increasing levels of resistance, + Borg score Magadle R. Chest 2002;121:329-3

22. Prevention of exacerbation/admission/death – case history • 7 yr old, known asthma, seen in A+E triage ?asthma attack, prednisolone given, 3/7 cough worse at night, SOB, using salbutamol with improvement. Imp: URTI. • Became worse and saw GP, given salbutamol and prednisolone 5/7 • 2/52 later, in A+E, wheeze, cough, SOB. “On steroid + salbutamol inhaler”. Wheeze noted. Imp: Unstable asthma. 10 puffs salbutamol + ipratropium given, + prednisolone. Home with “atrovent 2 puffs bd + salbutamol, GP to review asthma medication control”. • 2/52 later, in A+E, cough, SOB, on “Atrovent (not used as expired), Seretide BD, (triage - Becotide)”. Wheeze + subcostal recession noted. Imp: resp tract infection exacerbating asthma ?poorly controlled (no steroid inhaler ?as a result of changing meds). Prednisolone and salb nebs given. “Advised to use atrovent inhaler + go home with prednisolone. Leaflet on asthma given. Advised to see GP asap for an asthma review, advice given on how to take inhalers.” • 2/52 later collapsed at home after severe asthma attack, unresponsive to salbutamol. Asystolic cardiac arrest, pronounced dead in A+E. Medication: Ventolin PRN, Seretide (“green inhaler”) BD, Previously been on Becotide”.

23. Asthma steps management Notes: Step down if possible every 3-6 months Step boundaries are blurred Consider also exacerbations and lung function

24. Assessing asthma control: RCP 3 questions In the last month: • Have you had difficulty sleeping because of your asthma? • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? • Has your asthma interfered with your usual activities (eg housework, work, school etc) “No” to all = well-controlled asthma

25. Assessing asthma control: the Asthma Control Test

26. Better care is associated with fewer readmissions Slack R. Quality in Health Care 1997;6:194-8.

27. Things we need to do for asthmatics • Get better at diagnosis • Get better at severity assessment, and: • Treat accordingly by stepping therapy up and down • Do serial peak flows especially when chesty

28. Patients discharged with PEF variability >25% are more likely to relapse Udwadia ZF. J R Coll Phys Lon 1990;24:112-4.

29. Things we need to do for asthmatics • Get better at diagnosis • Get better at severity assessment, and: • Treat accordingly by stepping therapy up and down • Do serial peak flows especially when chesty • Educate inc inhaler technique, and: • Discuss action plan, and: • Rescue pack of prednisolone

30. Specialist nurse patient education reduces readmissions • Two hospital specialist nurses in East London • Patients reviewed in clinic within GP practice after discharge • Inhaler technique • PEF-based action plan (self-management plan) • Supply of rescue OCS Griffiths C et al. BMJ 2004;328:144

31. PEF-based action plans reduce readmissions Osman LM. Thorax 2002;57:869-74

32. PEF-based action plans reduce admissions Cowie RL. Chest 1997;112:1534-8 n=150, prior A&E visit, 6 month study

33. Things we need to do for asthmatics • Get better at diagnosis • Get better at severity assessment, and: • Treat accordingly by stepping therapy up and down • Do serial peak flows especially when chesty • Educate inc inhaler technique, and: • Discuss action plan, and: • Rescue pack of prednisolone, PEF meter and diary • Advise see GP/asthma nurse next working day, and: • Book OPA with Specialist Nurse within 4 weeks (or consultant)

34. Follow-up within 30 days by a GP or respiratory physician is associated with fewer readmissions N=25,256 COPD + asthma 85% GP, 15% Resp physician In asthma: 25% readmissions Sin DD. Am J Med 2002;112:120-5.

35. Prevention of admission, readmission and death due to asthma: what to do when you review patients next working day • Therapy stepped up, egbeclo Symbicort, or montelukast added • Appropriate length oral steroids given, usually 10-14 days • Rescue pack oral steroids given • Inhaler technique checked, recorded and satisfactory • Asthma education/compliance addressed • Action plan given and understood • PEF meter given and diary carding twice a day • OPA booked for within 4 weeks with Specialist Airways Nurse/Chest Consultant