1. Emergencies in primary care Asthma/Exacerbation of COPD Dr Adetoun Dipeolu Dr Nekhul Thomson VTS teaching session 23/09/09

2. Case scenario Acute severe asthma

3. A 25-year-old asthmatic lady has a bad cough. She has had symptoms for about two weeks but to your annoyance she contacts you (by phone) just at the start of a full afternoon surgery. She insists it is urgent and as her history unfolds you discover that her cough is worse at night, that she is severely breathless at night and even more so when walking her dog up the local hills. She is struggling to complete sentences as she speaks on the phone and you can tell she is wheezing badly. You know you have to see her.

4. You check her medication hx and she is on salbutamol inhaler, long acting salmeterol inhaler plus a steroid inhaler Her records show she has not used any inhaled steroid or salmeterol for three months. She defaulted from the asthma clinic two months ago as "everything was fine then".

5. She arrives at the surgery and you note that she looks quite unwell, not able to speak in full sentences and you could hear an audible wheeze She manages to inform you she has been using her inhalers and has no clue as to what may have triggered off her symptoms Without wasting much time on hx you go on to examination which shows pulse 120, respiratory rate 25, sats 95%, PEFR 200 (50% predictive) and wheeze throughout her chest. Her temperature is 37.4°C and BP is 120/80.

6. At this point, you have made a diagnosis of acute severe asthma This patient has never had previous admissions for asthma nor has she previously been on steroids You are confident of your asthma management skills and you know that you have very good patient support structures within your practice. You decided to use large dose of steroids 40mg prednisolone orally along with nebulised bronchodilators which is readily available in your practice ( you are still working within BTS guidelines for management of severe acute asthma)

7. Your plan is to stabilise her and if she has good response to arrange follow-up the next morning but safety netting overnight. Then book her an urgent appt with your asthma nurse You wait a few minutes, hoping for some measure of improvement You keep chatting with her but then noticed she has gone quiet and blue She is now making feeble respiratory effort. You recheck her pulse now 56, her sats had fallen to 92%. She is just about managing PEFR of 150 Rpt auscultation, her chest is now near silent You recognise that this has become life threatening and you ring the ambulance

8. BTS guidelines The BTS guideline (2008 [pdf]) supports admission in this context. However, they would also support a trial of corticosteroids in the community.pdf If the patient has had previous admissions for asthma or has previously been on steroids, the indication for admission is stronger still. If you are unsure of your asthma management skills or there are poor patient support structures, admission would be the safest option here.

9. However, the BTS guideline does allow some latitude. If you are confident of your asthma management skills it would be reasonable to start pt on prednisolone 40 mg per day along with inhaled bronchodilators, possibly nebulised or via a large volume spacer. You would need to administer bronchodilators by nebuliser and document a good response to this measure.

10. The guideline points out that most acute severe asthma attacks build up over a period of several hours. Early and effective intervention has the potential to head off some hospital admissions. The guideline recommends admission if any of the features of acute severe asthma persist despite nebulised therapy. Features of acute severe asthma in adults are: pulse greater than 110 bpm unable to finish sentences respiratory rate over 25 breaths per minute peak flow below 50% predicted

11. The new guideline distinguishes between acute severe asthma and life-threatening asthma. Life-threatening asthma has the following features: PEFR less than 33% predicted O2 saturation below 92% Arterial partial pressure O2 <8 kPa normal arterial partial pressure CO2 silent chest cyanosis feeble respiratory effort bradycardia dysrythmia hypotension exhaustion confusion coma If any of these features are present, immediate hospital admission is mandatory.

12. COPD exacerbation Guidelines to management in primary care Nice Guidelines 2004

13. Definition An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication

14. Patients with COPD face a life complicated by symptoms, exacerbations and potentially hospital admissions and death from their disease or its complications. COPD is characterised by reduced lung function. These patients become socially isolated, lose their independence, become depressed and lose contact with family and friends, often being replaced by contact with the healthcare services.

15. Assessment of need for hospital treatment FactorTreat at home Treat in hospital Able to cope at homeyesno Breathlessnessmildsevere General conditiongoodPoor/ deteriorating Level of activitygoodPoor/Confined to bed cyanosisnoyes

16. FactorTreat at home Treat in hospital Worsening peripheral oedema noyes Level of consciousnessnormalimpaired Already receiving LTOTnoyes Social circumstancesgoodLiving alone /not coping Acute confusionnoyes Rapid rate of onsetnoyes Sats <90%noyes

17. FactorTreat at home Treat in hospital Significant comorbidity (particularly cardiac disease and insulin- dependent diabetes) noyes Changes on the chest radiograph nopresent Arterial pH level≥ 7.35< 7.35 Arterial PaO2≥ 7 kPa< 7 kPa

18. Investigation of an exacerbation The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations However, in certain situations, investigations may assist in ensuring appropriate treatment is given. Different investigation strategies are required for patients managed in hospital (who will tend to have more severe exacerbations) and those managed in the community.

19. In patients with an exacerbation managed in primary care: sending sputum samples for culture is not recommended in routine practice pulse oximetry is of value if there are clinical features of a severe exacerbation

20. Pharmacological management Increased breathlessness is a common feature of an exacerbation of COPD. This is usually managed by taking increased doses of short acting bronchodilators and these drugs may be given using different delivery systems.

21. Delivery systems for inhaled therapy during exacerbations Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD. The choice of delivery system should reflect the dose of drug required, the ability of the patient to use the device and the resources available to supervise the administration of the therapy.

22. Systemic corticosteroids In the absence of significant contraindications, oral corticosteroids should be considered in patients managed in the community who have an exacerbation with a significant increase in breathlessness which interferes with daily activities. Patients requiring corticosteroid therapy should be encouraged to present early to get maximum benefits Prednisolone 30 mg orally should be prescribed for 7 to 14 days

23. It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy. For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the British National Formulary section 6.3.2. Osteoporosis prophylaxis should be considered in patients requiring frequent courses of oral corticosteroids. Patients should be made aware of the optimum duration of treatment and the adverse effects of prolonged therapy. Patients, particularly those discharged from hospital, should be given clear instructions about why, when and how to stop their corticosteroid treatment.

24. Antibiotics Antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum. Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia. Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline. When initiating empirical antibiotic treatment, prescribers should always take account of any guidance issued by their local microbiologists. When sputum has been sent for culture, the appropriateness of antibiotic treatment should be checked against laboratory culture and sensitivities when they become available.

25. During the transfer to hospital the following points should be considered. It is not desirable to exceed an oxygen saturation of 93%. Oxygen therapy should be commenced at approximately 40% and titrated upwards if saturation falls below 90% and downwards if the patient becomes drowsy or if the saturation exceeds 93–94%. Patients with known type II respiratory failure need special care, especially if they require a long ambulance journey or if they are given oxygen at home for a prolonged period before the ambulance arrives. The aim of supplemental oxygen therapy in exacerbations of COPD is to maintain adequate levels of oxygenation (SaO2 greater than 90%), without precipitating respiratory acidosis or worsening hypercapnia. Patients with pH less than 7.35 should be considered for ventilatory support.

26. Thank you