The 2016 Melbourne thunderstorm asthma epidemic: Risk factors for severe attacks requiring hospital admission

BACKGROUND

The world's most catastrophic and deadly thunderstorm asthma epidemic struck Melbourne, Australia, on November 21, 2016.

OBJECTIVE

Among thunderstorm-affected patients presenting to emergency rooms (ERs), we investigated risk factors predicting severe attacks requiring admission to hospital.

METHODS

Thunderstorm-affected patients were identified from ER records at the eight major Melbourne health services and interviewed by telephone. Risk factors for hospital admission were analyzed.

RESULTS

We interviewed 1435/2248 (64%) of thunderstorm-affected patients, of whom 164 (11.4%) required hospital admission. Overall, rhinitis was present in 87%, and current asthma was present in 28%. Odds for hospital admission were higher with increasing age (odds ratio 1.010, 95% CI 1.002, 1.019) and among individuals with current asthma (adjusted odds ratio [aOR] 1.87, 95% CI 1.26, 2.78). Prior hospitalization for asthma in the previous 12 months further increased the odds for hospital admission (aOR 3.16, 95% CI 1.63, 6.12). Among patients of Asian ethnicity, the odds for hospital admission were lower than for non-Asian patients (aOR 0.59, 95% CI 0.38, 0.94), but higher if born in Australia (OR = 5.42, 95% CI 1.56, 18.83).

CONCLUSIONS

In epidemic thunderstorm asthma patients who presented to the ER, higher odds for hospital admission among patients with known asthma were further amplified by recent asthma admission, highlighting the vulnerability conferred by suboptimal disease control. Odds for hospital admission were lower in Asian patients born overseas, but higher in Asian patients born locally, than in non-Asian patients; these observations suggest susceptibility to severe thunderstorm asthma may be enhanced by gene-environment interactions.

Attitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists

Background

Chronic obstructive pulmonary disease (COPD) guidelines recommend early access to palliative care together with optimal, disease-directed therapy for people with advanced disease, however, this occurs infrequently. This study explored the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD.

Methods

An online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom.

Results

Five hundred seventy-seven (33.1%) responses were received, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Most respiratory doctors (140, 80.9%) were very or quite comfortable providing a palliative approach themselves to people with COPD. 113 (63.8%) respiratory doctors recommended referring people with advanced COPD to specialist palliative care, mainly for access to: psychosocial and spiritual care (105, 59.3%), carer support (104, 58.5%), and end-of-life care (94, 53.1%). 432 (98.2%) participants recommended initiating ACP discussions. Palliative medicine doctors were more likely to recommend discussing: what palliative care is (p < 0.0001), what death and dying might be like (p < 0.0001) and prognosis (p = 0.004). Themes highlighted in open responses included: inadequate, fragmented models of care, with limited collaboration or support from palliative care services.

Conclusions

While both specialties recognised the significant palliative care and ACP needs of people with advanced COPD, in reality few patients access these elements of care. Formal collaboration and bi-directional support between respiratory and palliative medicine, are required to address these unmet needs.

Parasternal intercostal muscle ultrasound in chronic obstructive pulmonary disease correlates with spirometric severity

In chronic obstructive pulmonary disease (COPD), loss of computed tomography (CT)-measured intercostal mass correlates with spirometric severity. Intercostal muscle ultrasound offers a repeatable and radiation-free alternative, however requires validation. We aimed to determine the reliability of parasternal intercostal muscle ultrasound, and the concurrent validity of parasternal ultrasound with clinicometric parameters. Twenty stable COPD patients underwent ultrasound measurement of thickness and echogenicity of 2^nd and 3^rd parasternal intercostal muscles, dominant pectoralis major and quadriceps, and diaphragm thickness; spirometry; and chest CT. Intra-rater intraclass correlation (ICC) for ultrasound intercostal thickness was 0.87-0.97 depending on site, with echogenicity ICC 0.63-0.91. Inter-rater ICC was fair to excellent. Ultrasound intercostal thickness moderately correlated with FEV₁% predicted (r = 0.33) and quadriceps thickness (r = 0.31). Echogenicity correlated negatively with FEV₁% predicted (r = -0.32). CT-measured lateral intercostal mass correlate negatively with parasternal ultrasound intercostal thickness. These data confirm ultrasound of parasternal intercostal musculature is reproducible. Lower intercostal muscle quantity and quality reflects greater COPD spirometric severity. This novel tool may have biomarker potential for both the systemic effects of COPD on muscle as well as local disruption of respiratory mechanics. The negative correlation between CT and ultrasound measurements may reflect complex site-dependent interactions between respiratory muscles and the chest wall.

Low rates of eligibility for lung cancer screening in patients undergoing computed tomography coronary angiography

Incidental findings, including pulmonary nodules, on computed tomography coronary angiography (CTCA) are common. Previous authors have suggested CTCA could allow opportunistic screening for lung cancer, though the lung cancer risk profile of this patient group has not previously been established. Smoking histories of 229 patients undergoing CTCA at two tertiary hospitals were reviewed and only 25% were current or former smokers aged 55-80 years old. Less than half of this group were eligible for screening based on the PLCO_m2012 risk model. We conclude that routine screening in the form of full thoracic field imaging, of individuals undergoing CTCA is not appropriate as it would likely result in net harm.

Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists

This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.

Early decision-making in acute pulmonary embolism: a retrospective clinical audit

BACKGROUND

There is increasing evidence supporting early discharge of patients with acute pulmonary embolism (aPE) deemed 'low prognostic risk' as a safe and viable alternative to admission if identified correctly by guideline algorithms.

AIM

To determine if risk stratification guidelines were followed accurately in an Australian tertiary hospital.

METHODS

Patients admitted to the emergency department with a diagnosis of PE were included from December 2012 to December 2017. The 272 patients were retrospectively assessed for prognostic risk prior to and after release of the 2014 European Society of Cardiology (ESC) guidelines. This included the simplified Pulmonary Embolism Severity Index (sPESI), and evidence of right heart dysfunction. Thereafter, patients were dichotomised into low (i.e. sPESI = 0) and non-low (i.e. sPESI ≥1 with or without the evidence of right heart dysfunction) prognostic risk groups.

RESULTS

Prior to ESC guideline release, 52 (65%) of the 80 patients diagnosed with PE were non-low risk and 12 (23%) of these were discharged home; 11 (91.7%) of the 12 discharges had unrecognised sPESI medical history components. After ESC guideline release, 122 (63.5%) of the 192 patients were non-low risk and 20 (16.4%) of these were discharged home; 18 (90%) of the 20 discharges had unrecognised sPESI medical history components.

CONCLUSION

We found that the sPESI score is not adequately applied in determining prognostic risk for acute PE. In cases of non-low-risk discharge, both prior to and after ESC guideline release, the medical history components of the sPESI score are under-recognised as a marker of increased prognostic risk.

Diagnostic chest ultrasound for acute respiratory failure

Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.

The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on health services, and patient risk factors

BACKGROUND

A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies.

METHODS

Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions.

FINDINGS

Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m³). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p<0·0001) and south-east Asian birth (8% vs 1%, p<0·0001) compared with previous 3 years. Questionnaire data from 1435 (64%) of 2248 emergency department presentations showed a mean age of 32·0 years (SD 18·6), 56% of whom were male. Only 28% had current doctor-diagnosed asthma. 39% of the presentations were of Asian or Indian ethnicity (25% of the Melbourne population were of this ethnicity according to the 2016 census, relative risk [RR] 1·93, 95% CI 1·74-2·15, p <0·0001). Of ten individuals who died, six were Asian or Indian (RR 4·54, 95% CI 1·28-16·09; p=0·01). 35 individuals were admitted to an intensive care unit, all had asthma, 12 took inhaled preventers, and five died.

INTERPRETATION

Convergent environmental factors triggered a thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity on Nov 21, 2016, creating a new benchmark for emergency and health service escalation. Asian or Indian ethnicity and current doctor-diagnosed asthma portended life-threatening exacerbations such as those requiring admission to an ICU. Overall, the findings provide important public health lessons applicable to future event forecasting, health care response coordination, protection of at-risk populations, and medical management of epidemic thunderstorm asthma.

FUNDING

None.

Junior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease

BACKGROUND

Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off-licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD.

AIMS

To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD.

METHODS

All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined.

RESULTS

Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients.

CONCLUSION

This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.

Individualized breathlessness interventions may improve outcomes in patients with advanced COPD

BACKGROUND AND OBJECTIVE

Many patients with advanced COPD experience refractory breathlessness and individualized breathlessness interventions may improve management of this complex symptom. The aims of this study were to develop, implement and assess the efficacy of a breathlessness intervention for patients with COPD and refractory breathlessness and to evaluate patient acceptability.

METHODS

An individualized breathlessness plan, information leaflets, breathlessness education and a hand-held fan were offered to consecutive patients with severe COPD and refractory breathlessness attending a tertiary integrated respiratory and palliative care service. Validated dyspnoea, quality of life and anxiety/depression questionnaires were administered at baseline and after 6 weeks, with change in dyspnoea scores being the primary outcome measure. A subset of patients participated in a structured telephone interview to qualitatively assess the intervention.

RESULTS

Twenty-six patients with severe COPD (mean forced expiratory volume in 1 s (FEV₁ ) 38%) were included, with a mean age of 74 years. Mean modified Medical Research Council Breathlessness Scale score was 3.5. Anxiety and depression were common, being present in 38% and 35% of participants. At 6 weeks, there was a clinically significant improvement in breathlessness severity as measured by the Numerical Rating Scale. The subset of patients with anxiety/depression also saw significant improvement in all domains of the Self-Administered Standardized Chronic Respiratory Questionnaire (CRQ-SAS). Patients reported that the intervention was highly useful and acceptable.

CONCLUSION

This feasibility study of individualized breathlessness interventions in patients with severe COPD and refractory breathlessness is the first to demonstrate a clinically significant reduction in dyspnoea scores, with high levels of patient acceptability.

Integrated respiratory and palliative care may improve outcomes in advanced lung disease

The unaddressed palliative care needs of patients with advanced, nonmalignant, lung disease highlight the urgent requirement for new models of care. This study describes a new integrated respiratory and palliative care service and examines outcomes from this service. The Advanced Lung Disease Service (ALDS) is a long-term, multidisciplinary, integrated service. In this single-group cohort study, demographic and prospective outcome data were collected over 4 years, with retrospective evaluation of unscheduled healthcare usage. Of 171 patients included, 97 (56.7%) were male with mean age 75.9 years and 142 (83.0%) had chronic obstructive pulmonary disease. ALDS patients had severely reduced pulmonary function (median (interquartile range (IQR)) forced expiratory volume in 1 s 0.8 (0.6-1.1) L and diffusing capacity of the lung for carbon monoxide 37.5 (29.0-48.0) % pred) and severe breathlessness. All patients received nonpharmacological breathlessness management education and 74 (43.3%) were prescribed morphine for breathlessness (median dose 9 mg·day-1). There was a 52.4% reduction in the mean number of emergency department respiratory presentations in the year after ALDS care commenced (p=0.007). 145 patients (84.8%) discussed and/or completed an advance care plan. 61 patients died, of whom only 15 (24.6%) died in an acute hospital bed. While this was a single-group cohort study, integrated respiratory and palliative care was associated with improved end-of-life care and reduced unscheduled healthcare usage.

Venous thromboembolism management practices and knowledge of guidelines: a survey of Australian haematologists and respiratory physicians

BACKGROUND

Current international clinical practice guidelines do not adequately address all clinical scenarios in the management of venous thromboembolism (VTE), and no comprehensive Australian guidelines exist.

AIMS

To identify areas of uncertainty in VTE management and whether self-reported practice is consistent with guidelines.

METHODS

We conducted an Australian cross-sectional online survey consisting of 53 questions to investigate doctors' VTE management practices. The survey was distributed to consultant and trainee/registrar haematologists and respiratory physicians with the aid of participating medical societies.

RESULTS

A total of 71 haematologists and 110 respiratory physicians responded to the survey. The majority of survey respondents were 31-50-years old and worked in teaching hospitals and in the acute care setting. Under-treatment was reported for high-risk pulmonary embolism (PE) and duration of anticoagulation for first-episode unprovoked PE (32 and 83% respectively). Over-treatment was reported in areas of thrombolysis for intermediate-risk PE (16%) and duration of anticoagulation for first-episode provoked PE (41%). Uncertainty and variations in doctors' management approaches were also found.

CONCLUSION

This survey demonstrated significant over-treatment, under-treatment and variability in the practice of VTE management. The findings highlight the need for the development and implementation of national guidelines for the management of VTE in Australia.

A hospital and home-based exercise program to address functional decline in people following allogeneic stem cell transplantation

PURPOSE

The aims of this study are to investigate the feasibility of an exercise program commencing 60 days following allogeneic stem cell transplantation (alloSCT), to investigate changes in physical function and health-related quality of life (HRQoL) in patients from pre- to post-alloSCT and to explore changes in patient outcomes before and after the program.

METHODS

This study is a single site, prospective case series including 43 adults undergoing alloSCT. The intervention was an 8-week outpatient and home-based exercise and education program. Outcomes included feasibility (consent, attendance, compliance and completion rates), functional exercise capacity (incremental shuttle walk test), muscle strength (hand-held dynamometry), self-efficacy for physical activity (Physical Activity Assessment Inventory) and HRQoL (Functional Assessment of Cancer Therapy-Bone Marrow Transplant). Outcomes were measured pre-alloSCT, 60 days post-alloSCT (pre-intervention) and 100 days post-alloSCT (post-intervention).

RESULTS

The consent rate was 93%. From baseline to 60 days post-alloSCT, there was significant decline in functional exercise capacity (mean difference 224 m, 95% CI 153-295, p < 0.0005), self-efficacy for physical activity (294 points, 95% CI 136-452, p = 0.001) and HRQoL (15 points, 95% CI 8-21, p < 0.0005). Ten participants did not commence the exercise program due to death (n = 5), illness (n = 1) or cancellation of alloSCT (n = 4). The intervention was feasible in those not affected by major medical complications or death. No adverse events occurred. From pre- to post-intervention, there was significant improvement in functional exercise capacity (p = 0.001) and HRQoL (p = 0.001).

CONCLUSIONS

AlloSCT results in significant decline in functional exercise capacity, self-efficacy for physical activity and HRQoL, which may be improved through an exercise program. This pilot demonstrated safety, feasibility and high patient interest. Further randomised research is required.

Influenza epidemiology in patients admitted to sentinel Australian hospitals in 2016: the Influenza Complications Alert Network (FluCAN)

During the period 1 April to 30 October 2016 (the 2016 influenza season), 1,952 patients were admitted with confirmed influenza to one of 17 FluCAN sentinel hospitals. Of these, 46% were elderly (e65 years), 18% were children (<16 years), 5% were Aboriginal and Torres Strait Islander peoples, 3% were pregnant and 76% had chronic co-morbidities.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial

Background

Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC.

Methods

This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference.

Discussion

There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting.

Trial registration

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614001268639: (4/12/14).

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3651-4) contains supplementary material, which is available to authorized users.

A prospective cohort study of thoracic ultrasound in acute respiratory failure: the C3PO protocol

OBJECTIVES

This study was performed to assess the clinical utility of a standardised thoracic ultrasound examination when added to standard care in patients with acute respiratory failure admitted to an intermediate care unit. This study aimed to assess the impact on clinical diagnosis, clinician confidence and management. Ultrasound has been shown to have utility in patients admitted to intensive care and emergency; however, utility in a ward setting is unknown.

DESIGN

Prospective cohort study.

SETTING

Tertiary hospital in Melbourne, Australia.

PARTICIPANTS

50 patients with acute respiratory failure requiring admission to an intermediate care unit.

MAIN OUTCOME MEASURES

(1) Change in clinical diagnosis or additional clinical diagnosis following thoracic ultrasound. (2) Change in diagnostic confidence following thoracic ultrasound. (3) Change to management following thoracic ultrasound.

RESULTS

In 34% of patients, ultrasound detected unexpected findings that changed or added to the clinical diagnosis. Diagnostic confidence was increased in 44%, and the treating clinician altered the management plan in 30% as a result of the ultrasound. Ultrasound was particularly useful in clarifying the diagnosis in patients with multiple initial diagnoses, reducing to a single diagnosis in 69%.

CONCLUSIONS

Thoracic ultrasound has clinical utility in non-intubated adults with acute respiratory failure managed outside intensive care settings. It changed aetiological diagnosis, increases diagnostic confidence and altered clinical management in one out of three patients scanned. Our results suggest extended utility of thoracic ultrasound in acute respiratory failure to a broader context outside the intensive care unit population.