Asthma and COPD Evidence-Based Disposition in the ED
- Aug 16th, 2021
- Timothy Wong
Authors: Timothy Wong, MD (EM Resident Physician, University of Kentucky) and Linda Katirji, MD (EM Attending Physician, University of Kentucky) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit); Summer Chavez, DO, MPH, MPM (EM Attending Physician, UT Houston)
A 64-year-old male with a history of COPD and CHF presents to the ED for shortness of breath for 1 week. During this time, he has also had productive cough, chills, and fatigue. He smokes two packs of cigarettes a day. His vitals are T 99.2 F, BP 138/92, HR 90, RR 24, SpO2 90% on room air. Physical exam is significant for diffuse bilateral wheezing with increased rales at the right lower lung field as well as bilateral pitting edema up to his ankles.
Among U.S. residents, over 25 million people are diagnosed with asthma and over 15 million are diagnosed with COPD (1, 2). Morbidity and mortality are significant higher in these patients than in the general population, especially in those with COPD. One outpatient study found that the mortality rate two years after COPD diagnosis was nearly 30% (3). The economic burden is also significant, with the 10-15% of patients who require hospitalization accounting for more than half of all COPD-related healthcare expenses (4), and total overall annual U.S. costs exceeding $40 billion (5). ED visits related to asthma or COPD encompass approximately 2% of annual U.S. ED encounters, amounting to nearly 2.5 million ED visits per year (6). Acute presentations can be wide-ranging in severity: from mild dyspnea to life-threatening respiratory failure. In addition to recognition, initial treatment, and acute stabilization of the disease process, ED physicians must ultimately determine the disposition of patients with acute asthma or COPD exacerbations. Disposition decisions should be individualized to the patient, taking into account clinical presentation, treatment response, the patient’s comorbidities, and socioeconomic factors such as the patient’s understanding of his or her illness, access to medications, and ability to obtain timely outpatient follow-up (7, 8).
Considerations for Hospitalization
Patients presenting to the ED with acute asthma or COPD exacerbation should be hospitalized if there is no clinical improvement after appropriate treatments (including supplemental oxygen, bronchodilators, corticosteroids, non-invasive ventilation), if they remain hypoxic (goal SpO2 ≥93-94% in asthma, ≥88% in COPD) and require above-baseline supplemental oxygen support, or if they have a new dysrhythmia (9-13). Hypoxia or hyperoxia, particularly in COPD exacerbation, is associated with greater mortality (up to two times greater in hyperoxia), need for assisted ventilation, and need for intubation (12, 14). Reassessment of these patients should be frequent after treatment initiation, keeping in mind that systemic corticosteroids can take up to 3 hours to begin to show benefits (15). Those with severe dyspnea, mental status decline such as confusion or lethargy, worsening hypoxemia (PaO2<40 mmHg) or significant acute hypercarbia associated with respiratory acidosis (pH<7.25) despite appropriate ED treatments, or hemodynamic instability requiring vasopressors, should be considered for admission to the ICU (9, 11). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) stratifies the severity of COPD exacerbations into three different classes: no respiratory failure, acute respiratory failure non-life-threatening, and acute respiratory failure life-threatening (11).
Predicting the need for mechanical ventilation (MV) can be challenging in acute asthma or COPD exacerbations. A recent study published by Nakwan and Prateepchaiboon examining 509 patients admitted to a tertiary care center for acute asthma exacerbation found that a history of at least 1-2 acute exacerbations within the past 12 months was a strong independent predictor of need for MV (16). In patients with acute COPD exacerbations admitted to the hospital or ICU, each of the independent factors of significant acidemia (pH<7.2), high APACHE II score (>23), and GCS<8 are independent predictors of need for MV (17, 18).
Certain comorbidities such as pneumonia, diabetes, arrhythmias, psychiatric disease, and substance abuse increase the risk for asthma-related death, but overall short-term mortality in patients with acute asthma exacerbation is rare (9). The same is not true for acute COPD exacerbations, whose patient population is often sicker (19). Concurrent pneumonia is an independent risk factor for hospital admission as well as for in-hospital mortality in patients admitted for COPD exacerbations (20, 21). Patients with focal opacity or evidence of pneumonia on CXR should be considered for admission. Patients with active and significant cardiac disease such as CHF, arrhythmia, or ischemic heart disease, should strongly be considered for admission to the hospital in the setting of acute episodes of obstructive lung disease. One-year mortality is significantly increased in these patients (22). In just one Italian multicenter prospective study of 288 patients hospitalized for acute COPD exacerbation, nearly 70% of in-hospital deaths were due to primary cardiac causes (13).
It is generally accepted that for patients with lower socioeconomic status (SES), with minimal to no home support, and/or with poor health literacy, closer attention is required when making a disposition decision. Lower SES and illicit drug use are both risk factors for asthma-related mortality (8). For patients with COPD, educational level less than high school and household income <$20,000 are associated with greater pulmonary function impairment (lower FEV1) and greater physical function limitations (poorer distance walked in six minutes) (23). Patients with greater socioeconomic obstacles encounter more severe disease and outcomes. They may benefit from social worker-provided resources in the ED, or brief hospital admission for medication education, arranging home health support, and establishing long-term specialist follow-up, all of which can be especially challenging to accomplish in a busy ED. Lastly, counseling and initiation of nicotine-replacement therapy are effective measures in promoting smoking cessation in patients in the ED, and smoking cessation reduces the progression of COPD, lowers the risk for acute exacerbations, and decreases all-cause mortality (5,24)
- Patients who have non-improving symptoms despite treatment, persistent abnormal vitals including SpO2 <88% (in COPD) or <93-94% (in asthma), or a new dysrhythmia should be admitted. Those with worsening hypoxia, respiratory acidosis, severe dyspnea requiring assisted ventilation, mental status changes, or hemodynamic instability requiring vasopressors should be admitted to the ICU.
- History of any asthma exacerbation within the last 1 year predicts need for MV in acute asthma exacerbation. GCS<8, acidemia (pH<7.2), and APACHE II score >23 predicts need for MV in AECOPD.
- Patients with concurrent pneumonia or cardiac disease should be considered for admission. Consider a patient’s understanding of their own illness and ability to access medications and follow-up prior to discharge even if he or she improves in the ED.
- Provide counseling on smoking cessation and offer nicotine-replacement therapy to patients in the ED with acute COPD to reduce the risk for future exacerbations and to reduce mortality.
Risk Assessment Tools
Numerous published scoring systems can aid in the disposition of patients presenting to the ED with acute asthma or COPD exacerbations. No single scoring system has achieved universal adoption nor should be used in isolation to determine disposition. . Listed below are just a few scoring systems in the literature.
Pediatric Respiratory Assessment Measure (PRAM) for Asthma Exacerbation Severity (25-28)
- Uses clinical exam findings and pulse oximetry, scores (mild 0-3, mod 4-7, severe 8-12) grade clinical severity
- PRAM 8 or greater at triage predicts ≥50% chance of needing admission
- PRAM score at 3 hours best predicts admission requirement
- Pros: well-validated, predicts admission; cons: one prospective study suggested PRAM score may be inferior to academic pediatric ED physician determination of severity, but may be more useful in community or rural EDs with clinicians less experienced with this patient population
Pediatric Asthma Severity Score (PASS) for Asthma Exacerbation Severity (29, 30)
- Uses only clinical exam findings, scores (0-3) grade clinical severity
- Scores correlate with hypoxia in ED, degree of airway obstruction, with needing admission
- Implemented in Children’s Hospital of Philadelphia ED Asthma Clinical Pathway, ICU recommended for PASS>3
- Pros: well-validated, built from large diverse population, simple to use; cons: only uses three exam findings (may miss other clinically-relevant criteria)
RAD (Respiratory rate, Accessory muscle use, Decreased breath sounds) (31)
- Uses only clinical exam findings, scores (0-3) grade clinical severity
- Similar in performance to PRAM or PASS when using responsiveness to change in FEV1 before and after treatment as primary outcome (derivation study)
- Pros: simple to use; cons: not as thoroughly studied as PRAM or PASS or PIS, only uses three exam findings (may miss other clinically-relevant criteria)
Pulmonary Index Score (PIS) (32)
- Uses clinical exam findings and pulse oximetry, scores (mild <7, mod 7-11, severe 12-15) grade clinical severity
- Score correlates well with changes in tests of pulmonary function, such as FEV1/FVC performed in the ED in derivation study
- Pros: well-validated, used in clinical trials; cons: may underestimate degree of severe asthma in older children with bradypnea due to respiratory rate being falsely reassuring
DECAF Score for Acute Exacerbation of COPD (33-36)
- Uses clinical, serological, and radiographic findings, scores (0-6) assess risk category for in-hospital mortality
- DECAF 0-1 (1-1.4% in-hospital mortality), 2 (5.4-8.4%), 3+ (21.4-34.7%)
- Performed better than APACHE-II, CAP, BAP-65, and CURB-65 in predicting in-hospital mortality in external validation study
- Exclusion: those on home oxygen or ventilation or those with expected survival <12 months
- Pros: well-validated, scoring criteria accessible in ED; cons: not widely implemented
National Early Warning Score 2 – COPD (NEWS2ALL COPD) (37, 38)
- Uses clinical (vitals and physical exam) findings, scores (low risk 0-4, mod/urgent 5-6, high/emergent 7-19) direct urgency of clinical response (triage) and level of care in acute illness – moderate or high scores prompt a clinical alert for an urgent or emergent assessment, respectively.
- Update in 2017 incorporates acute COPD-appropriate SpO2 scale (renamed NEWS2ALL COPD) to account for increased mortality for hyperoxia in COPD
- Retrospective trial in 6 UK EDs showed that application of NEWS2ALL COPD scoring system at trial can reduce frequency of clinical alerts at time of admission for those with acute exacerbation of COPD, with no difference in admission day mortality
- The NEW2 score is endorsed by the Royal College of Physicians and by the National Health Service and widely implemented throughout UK
- Pros: widely implemented/established in UK EDs, uses appropriate pulse oximetry parameter; cons: may be inferior to DECAF in predicting in-hospital mortality, not widely used in the U.S.
Case Follow Up
The patient is given a nebulized treatment of albuterol and ipratropium in the ED as well as oral prednisone. His chest x-ray shows a focal opacity in the RLL suggestive of a right sided pneumonia. He is given antibiotics in the ED for his suspected community-acquired pneumonia. His shortness of breath improves during his ED course and he is able to undergo an ambulation trial without difficulty. His vital signs remain stable. You calculate his DECAF score from the obtained labs and imaging and it is 1, low-risk for in-hospital mortality. He is able to be discharged from the emergency room with a course of antibiotics and steroids.
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