Asthma: how to prevent readmission and death

Simon QuantrillConsultant chest physicianWhipps Cross Chest Clinic

BMJ 1967:

Asthma: the challenges

Death

Readmissions/admissions

Concordance, action plans, PEF

Underestimation of severity

Underdiagnosis

BTS standards

Financial

penalties

Litigation

Asthma: admissions to Whipps Cross

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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

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.

Things we need to do for asthmatics

1. Get better at diagnosis

Asthma is underdiagnosed

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

Childhood asthma is markedly underdiagnosed

Speight ANP. BMJ 1983;286:1253-6

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

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

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)

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

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

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”

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

Things we need to do for asthmatics

1. Get better at diagnosis2. Get better at severity assessment, and:3. Treat accordingly by stepping therapy up

and down

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

Asthma Insights and Reality in Europe (AIRE) study

• Questionnaire study n=2803 asthmatics• In the past 12 months, due to asthma:• 25% reported unscheduled urgent care visit• 10% ≥1 A&E visit• 7% overnight hospitalisation • But:• 50% of those with severe persistent symptoms also

considered their asthma to be well-controlled• 63% had used SABAs and only 23% had used ICS in

the last 4 weeks

Rabe KF, Eur Respir J 2000; 16: 802-7

Some asthmatics are poor perceivers of breathlessness

Poor perception Good perception

Presented to GP 1 (6%) 15 (94%)

Did not present to GP 8 (26%) 23 (74%)

Van Schayck C. Thorax 2000;55:562-5Histamine challenge test with Borg scores

9/47 were poor perceivers in this test

Poor perceivers are at higher risk of death and near-fatal asthma

Poor perceivers(n=29)

Normal perceivers(n=67)

High perceivers(n=17)

ED visits 32 8 14

Hosp admission 22 4 3

Near-fatal asthma 13 2 1

Death 6 1 0

Magadle R. Chest 2002;121:329-3n=113, stable asthmatic out-patients, breathing against increasing levels of resistance, + Borg score

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”.

Asthma steps management

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

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

Assessing asthma control: the Asthma Control Test

Better care is associated with fewer readmissions

Slack R. Quality in Health Care 1997;6:194-8.

Things we need to do for asthmatics

1. Get better at diagnosis2. Get better at severity assessment, and:3. Treat accordingly by stepping therapy up and

down4. Do serial peak flows especially when chesty

Patients discharged with PEF variability >25% are more likely to relapse

Low variability High variability0

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Readmitted within 8 weeks

Udwadia ZF. J R Coll Phys Lon 1990;24:112-4.

Things we need to do for asthmatics

1. Get better at diagnosis2. Get better at severity assessment, and:3. Treat accordingly by stepping therapy up and

down4. Do serial peak flows especially when chesty5. Educate inc inhaler technique, and:6. Discuss action plan, and:7. Rescue pack of prednisolone

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

PEF-based action plans reduce readmissions

Osman LM. Thorax 2002;57:869-74

PEF-based action plans reduce admissions

Cowie RL. Chest 1997;112:1534-8n=150, prior A&E visit, 6 month study

Things we need to do for asthmatics

1. Get better at diagnosis2. Get better at severity assessment, and:3. Treat accordingly by stepping therapy up and down4. Do serial peak flows especially when chesty5. Educate inc inhaler technique, and:6. Discuss action plan, and:7. Rescue pack of prednisolone, PEF meter and diary8. Advise see GP/asthma nurse next working day, and:9. Book OPA with Specialist Nurse within 4 weeks (or

consultant)

Follow-up within 30 days by a GP or respiratory physician is associated with fewer readmissions

Sin DD. Am J Med 2002;112:120-5.

N=25,256 COPD + asthma85% GP, 15% Resp physicianIn asthma:25% readmissions

Prevention of admission, readmission and death due to asthma: what to do when you review patients next working day

Therapy stepped up, eg beclo 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