Low-dose azithromycin prophylaxis is associated with improved outcomes in people suffering frequent exacerbations of chronic obstructive pulmonary disease (COPD), but the use of macrolides in patients with cardiovascular disease has been debated. To investigate the risk of adverse events after COPD exacerbations in patients with atrial fibrillation (AF) treated with azithromycin prophylaxis. Retrospective cohort study within the TriNetX Platform, including AF patients with COPD exacerbations. Risks of primary and secondary outcomes were recorded up to 30 days post-COPD exacerbations and compared between azithromycin users and azithromycin non-users. The primary outcomes were the risks for a composite of (1) cardiovascular (all-cause death, heart failure, ventricular arrhythmias, ischemic stroke, myocardial infarction, and cardiac arrest), and (2) hemorrhagic events (intracranial hemorrhage (ICH), and gastro-intestinal bleeding). Cox-regression analyses compared outcomes between groups after propensity score matching (PSM). After PSM, azithromycin users (n = 2434, 71 ± 10 years, 49% females) were associated with a lower 30-day risk of post-exacerbation cardiovascular (HR 0.67, 95% CI 0.61-0.73) and hemorrhagic composite outcome (HR 0.45, 95% CI 0.32-0.64) compared to azithromycin non-users (n = 2434, 72 ± 11 years, 51% females). The beneficial effect was consistent for each secondary outcomes, except ICH. On sensitivity analyses, the reduced risk of adverse events in azithromycin users was irrespective of smoking status, exacerbation severity, and type of oral anticoagulation. Azithromycin prophylaxis is associated with a lower risk of all-cause death, thrombotic and hemorrhagic events in AF patients with COPD. The possible role of azithromycin prophylaxis as part of the integrated care management of AF patients with COPD needs further study.
Respiratory virtual wards provide the opportunity to support COPD acute exacerbation management within the community,1 and can reduce the burden on secondary care admissions, where re-admission rates are approximately 20%.2 Appropriate patient selection is key for the successful implementation of virtual wards; however little is known about the characteristics of those readmitted to secondary care from virtual wards. We therefore investigated readmissions to secondary care following management of COPD exacerbation on the virtual ward.
Methods
A retrospective review of consecutive patients managed in our virtual ward for COPD exacerbation from June 2022 to May 2023 was undertaken using our local electronic healthcare record system. Clinical characteristics, outcomes and readmissions rates at 30 days from index admission were recorded. Groups were compared by 30-day readmission status to assess for characteristics associated with readmission.
Results
Overall, 217 patients diagnosed with AECOPD were supported in the virtual ward during the study time period. All patient demographics were; 67 (30.1%) male, mean age 71 years. 30-day readmission occurred in 28/217 (13%) of patients and was more likely to occur when the patient was female (82.1% vs 77.2% not readmitted), in current smokers (32.1% versus 24.3%), and resident in a postcode within the 1st decile (top 10%) for Multiple Deprivation (60.7% versus 50.3%).
Conclusion
30-day readmission within the ARI Virtual ward stands below the 20% reported in other studies for COPD exacerbations managed in secondary care. Further work is needed to determine the role of comorbidities, baseline physiological readings and level of care prior to virtual ward onboarding have as determinants of readmission risk.
References
NHS England, 2022. Acute respiratory infection virtual ward. Guidance note. Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD readmissions: addressing COPD in the era of value-based health care. Chest, 2016;150(4), pp.916–926.
Despite the introduction of Oxygen Alert Cards, guidelines and audits, oxygen therapy remains overused in NHS practice, and this may lead to iatrogenic mortality. This pilot study aimed to examine the use of Oxygen Alert Wristbands (OxyBand) designed to alert health professionals who are delivering oxygen to patients to ensure that the oxygen is administered and titrated safely to the appropriate target saturations. Patients at risk of hypercapnic acidosis were asked to wear OxyBands while presenting to paramedics and health professionals in hospitals. Inappropriate prescription of oxygen reduced significantly after the OxyBands were used. A questionnaire-based assessment showed that the clinicians involved had a good understanding of the risks of uncontrolled oxygen. Forty-two patients found the wrist band comfortable to wear, and only two did not. OxyBands may have the potential to improve patient safety over Oxygen Alert Cards.
The Knowsley Community Respiratory Service (KCRS) provides 24 hours per day, 7 days per week hospital at home support for patients with COPD. Current UK guidance1 recommends that patients with an arterial PaO2 of < 7kPa be managed in the hospital setting. Despite the current recommendation, many patients declined hospitalization during an exacerbation. We wished to explore the safety of patients being managed at home despite lower arterial oxygen levels.
Aims
To evaluate the outcome of patients with COPD exacerbations being managed at home with an arterial PaO2 of < 7.3Kpa. Group A: Pa02 6.7–6.99kpa, Group B: Pa02:7.0 – 7.3kpa.
Methods
Retrospective data were evaluated over a period of 10 months for 103 patients. Smokers (37), Male:42% Female:58%, Mean age: 73, Mean predicted FEV1%: 42.8%. Group A & B Mean NEWS2:3
Results
79 avoided admission (77%) & 24 admitted (23%). Number of patients kept at home but admitted within 30 days is 6 (7.6%). Group A (37) were safely managed at home, Group B (42). More intervention required such as repeat ABG for patients managed at home in group A. Overall 17 patients received 02 titration to prevent a hospital admission (Group A: 10, Group B:7).
Conclusion
The community respiratory team supports patients to be managed at home safely with a lower Pa02 to avoid unnecessary hospital admission and provide early supported discharge.
Reference
Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline December 2018.
PR is a pivotal treatment for managing chronic respiratory disease, despite this referrals into PR remain low, as highlighted from the national COPD audit programme. The NHS long term plan, for the first time highlighted respiratory is as a key area for improvement, encompassing improving access and uptake of PR. However little is known about the ability of local PR services to be able to provide this. A scoping exercise was undertaking in C&M to review current service provision. Clinical leads from all the PR services in C&M were contacted in 2019 and a face to face or telephone discussion was conducted. This was followed up with an email document detailing further information required about funding, staffing numbers, challenges to service and further developments. 10 services were contacted to be involved in the project. 8 services responded. PR provision across C&M is patchy, with good access in some areas and more limited access in others. Waiting times vary across the area from 2- 24 weeks, as do inbound referral numbers. Outcome measures vary widely across the area, as do length and type of programme and provision of post exacerbation PR. There was good engagement from PR services; however it highlights the significant variation in provision across a small area in the UK, and a postcode lottery patient's face in trying to access services. Staff running programmes were dedicated and keen to increases access and uptake, however many were faced with significant staffing problem and commissioning strictures. Quick wins are available such as rolling programmes and diversifying, but clearly investment in grass root services is required.
Patients with COPD often have poorer quality of life and reduced life expectancy when compared to the general population, especially towards the terminal phase of their illness. Patients can experience a higher symptom burden than those reported by patients with end stage lung cancer. The importance of palliative care (PC) in this group is well known, but frequently have poorer access to PC services. When to initiate PC in this group is challanging due to prognostic uncertainty. The GSF PIG is recommended for use with this patient group to predict 12 month mortality and belived to be accurate in 70% of cases, despite little evidence. To address the accuracy this study aims to evaluate this tool in predicting 12 month mortality in patients with a diagnosis of COPD. Method: Data collection was from a single service9 PC list, of patients deemed to be entering the last 12 months of life by triggering the GSF PIG. The length of time on th palliative register until death or Janruary 2017, when data analysis commenced, was reviewed. All data analysed was rotuinely collected by the service. Results: 448 patietns were included in the study, n=122 died with in 12 months, showing the GSF PIG to be accurate in 27% of cases. Subgroup ananlysis showed the importance of pulmonary rehabilitation to reduce mortality (p=0.001) with gait speed of <0/15 m/sec having the potenital to be an early prognostic indicator (p=0.008). Conclusion: These results suggest the GSF PIG is not an accurate 12 month mortality predictor, more research is needed re:gait speed as a prognostic indicator.
Background: The Knowsley Community Respiratory Service (KCRS) provides 24 hours per day, 7 days per week hospital at home support for patients with COPD. Current UK guidance1 recommends that patients with an arterial PaO2 of < 7kPa be managed in the hospital setting. Despite the current recommendation, many patients declined hospitalization during an exacerbation. We wished to explore the safety of patients being managed at home despite lower arterial oxygen levels. Aims: To evaluate the outcome of patients with COPD exacerbations being managed at home with an arterial PaO2 of < 7.3Kpa. Group A: Pa02 6.7-6.99kpa, Group B: Pa02:7.0 – 7.3kpa. Methods: Retrospective data were evaluated over a period of 10 months for 103 patients. Smokers (37), Male:42% Female:58%, Mean age: 73, Mean predicted FEV1%: 42.8%. Group A & B Mean NEWS2:3 Results: 79 avoided admission (77%) & 24 admitted (23%). Number of patients kept at home but admitted within 30 days is 6 (7.6%). Group A (37) were safely managed at home, Group B (42) . More intervention required such as repeat ABG for patients managed at home in group A. Overall 17 patients received 02 titration to prevent a hospital admission (Group A: 10, Group B:7). Conclusion: The community respiratory team supports patients to be managed at home safely with a lower Pa02 to avoid unnecessary hospital admission and provide early supported discharge. 1. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline December 2018
In times of financial restrictions and reform impediments, health services need to invest in resources that provide value for money and reduce hospital admissions. Improving disease management in the community is a primary target for those trying to reduce costs. The second most common cause of emergency admissions to hospital is chronic obstructive pulmonary disease and it has been suggested that more effective treatments and better management of the condition would likely result in an estimated 5% fewer admissions to hospital, saving around pound 15.5m each year. This article discusses how savings could be made by improving care provided in the community.
The National Review of Asthma Deaths published in 2015 suggested a high proportion (46%) of asthma deaths were preventable. Certain risk factors were highly associated with asthma mortality: inappropriate medication leading to abrupt asthma attacks, lack of engagement with medical services, lack of specialist input, history of previous emergency asthma admissions and discharge from hospital within 28 days following asthma exacerbations. Access to good quality specialist services needs to be improved to reverse this health inequality as recommended by BTS/SIGN. Aim: To review the impact of NRAD as part of a scoping process using national guidelines to assess current local standards of asthma care Methods: Emergency department (ED) care notes were reviewed retrospectively at a District General Hospital in the North West of England of patients with an admission code of 'asthma exacerbation' for a 2 week period Results: 21 patients attended ED during the study period. 60% were defined as having an acute severe asthma attack, 10% of whom received IV magnesium; 40% had a moderate acute asthma attack. 15% of patients had previously been admitted to the intensive care unit. All patients received nebulised therapy; 15% were not prescribed an ICS prior to ED attendance. Where indicated 02 therapy was appropriately administered in all patients. Asthma management plan was fully documented in only 35% of patients. 30% were discharged from ED with PEF<50% predicted. Only 25% of patients were referred to the community for follow up within 24hrs post discharge. Mean ED visits 3.5 Conclusion: Data suggests despite a hard-hitting widely publicised national review into asthma deaths, systems that might improve patients at risk are not in place 3yrs later
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