Physiotherapy management of acute exacerbations of chronic obstructive pulmonary disease

Pain and Dyspnea During Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Documentation Audit 2019-2020

Background/Objectives: Patient-reported outcome measures (PROMs) assess the severity and impact of both pain and dyspnea in those with acute exacerbations of chronic obstructive pulmonary disease (COPD), but their frequency of use in clinical practice is unknown. This study aimed to determine the point prevalence of pain and dyspnea assessment in patients hospitalized with an acute exacerbation of COPD and the measurement tools applied for this purpose in clinical practice. Methods: Clinical notes and observation charts of patients admitted with acute exacerbations of COPD to a metropolitan hospital in 2019 and 2020 were retrospectively audited to identify the point prevalence of pain and dyspnea assessment, the PROMs applied, and their associated focal periods. Results: Pain and dyspnea were assessed using a PROM in 99% and 8% of cases of acute exacerbation of COPD, respectively. All PROMs used measured symptom intensity. Focal periods were rarely reported in the assessment of pain; in the dyspnea assessment, timeframes predominantly reflected the impact of exertion. Conclusions: At this single health service site, in people hospitalized with an acute exacerbation of COPD, pain was more frequently assessed using a PROM than dyspnea. Understanding factors influencing clinicians' choice of assessment tools may inform future recommendations for the assessment of these symptoms in people hospitalized with exacerbations of COPD.

Clinical application of intrapulmonary percussive ventilation: A scoping review

Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.

Validity and clinical applicability of the 60-secondecond sit-to-stand test in people with acute exacerbations of COPD

BACKGROUND

The 60-second sit-to-stand test (60STS) is a simple and increasingly popular test of physical function, however evidence to support its appropriateness for assessing people with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is lacking.

AIMS

To evaluate the concurrent, convergent, predictive and discriminant validity, and responsiveness of the 60STS against the six-minute walk test (6MWT) in people hospitalised due to AECOPD.

METHODS

Prospective cohort study involving 54 inpatients with AECOPD (53% males, mean age 69.0 years, FEV1 46.5% predicted). 60STS was performed 30 min after a six-minute walk test (6MWT) upon discharge, with follow-up testing repeated one-month later (n = 39). Outcome measures included 60STS repetitions (60STSr), six-minute walk distance (6MWD), heart rate, oxyhaemoglobin saturation (SpO2), perceived dyspnoea (Borg scale), and rate of perceived exertion (RPE). Concurrent validity was assessed via correlation, convergent validity via Bland-Altman plots, predictive validity via multivariate linear regression (adjusted for confounders), discriminant validity via unpaired t tests and responsiveness via Chi (Jenkins, 2007) [2] tests.

RESULTS

Discharge 60STSr and 6MWD were strongly correlated (r = 0.61). Bland-Altman plots for nadir SpO2, peak HR, Borg and RPE scores showed acceptable agreement in terms of mean differences, but wide limits of agreement. Poor 60STSr performers were older, had weaker quadriceps, and had lower 6MWD than high performers (p < 0.05 for all). 60STSr was not retained as a significant predictor of 6MWD in multivariate regression analyses. 80% of 60STSr improvers also improved >30m on 6MWT at follow-up.

CONCLUSION

The 60STS demonstrates satisfactory validity and responsiveness as a measure of exercise performance in people with AECOPD.

Home-based pulmonary rehabilitation early after hospitalisation in COPD (early HomeBase): protocol for a randomised controlled trial

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care.

METHODS

A multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9-10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up.

ETHICS AND DISSEMINATION

Human Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications.

TRIAL REGISTRATION NUMBER

ACTRN12619001122145.

Telerehabilitation for chronic respiratory disease

BACKGROUND

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

OBJECTIVES

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

MAIN RESULTS

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

AUTHORS' CONCLUSIONS

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections

INTRODUCTION

Physiotherapy may play a role in the recovery of signs, symptoms and function of patients with lower respiratory tract infections (LRTI) but its effectiveness is still controversial.

OBJECTIVES

To assess the effects of respiratory physiotherapy compared with standard pharmacological care on symptoms and function in outpatients with LRTI.

DESIGN

Single-blind, randomised controlled trial.

SETTING

Outpatients were recruited from the casualties of a central hospital.

PARTICIPANTS

Outpatients with LRTI were recruited and randomly allocated to the control (pharmacological) or experimental (pharmacological and respiratory physiotherapy) group.

INTERVENTION

The intervention consisted of conventional pharmacological treatment and conventional pharmacological treatment plus respiratory physiotherapy. Respiratory physiotherapy included breathing and airway clearance techniques, exercise training and education during 3-weeks, 3 times per week.

MAIN OUTCOME MEASURE

Primary outcome measures - occupation rate of wheezes Wh%; Secondary outcome measures - number of crackles, peripheral oxygen saturation (SpO2) modified Borg scale (mBorg), modified Medical Research Council scale (mMRC), 6-min walk test (6MWT), forced expiratory volume in 1 s and forced vital capacity, and volume and density of the lung and bronchial tree volume.

RESULTS

Ninety-seven patients (53 controls and 44 experimental) completed the intervention. After the intervention, both groups improved significantly in all variables (0.0001 < p < 0.04; 0.001<ƞ²<0.092), with the exception of the mBorg. The magnitude of improvement of the experimental group exceeded the control group in the number of crackles, SpO2 levels, mMRC and 6MWT (0.002 < p < 0.032; 0.002<ƞ²<0.092).

CONCLUSION

Adding respiratory physiotherapy to the pharmacological treatment of outpatients with LRTI results in greater recovery of symptoms and function parameters.

TRIAL REGISTRATION

NCT02053870.

A novel counterbalanced implementation study design: methodological description and application to implementation research

Background

Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy.

Methods

In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition.

Results

An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts.

Conclusion

A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0896-0) contains supplementary material, which is available to authorized users.

Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD?

Background

The 6-minute pegboard and ring test (6-PBRT) is a useful test for assessing the functional capacity of upper limbs in patients with stable COPD. Although 6-PBRT has been validated in stable patients, the possibility of a high floor effect could compromise the validity of the test in the hospital setting. The aim of this study was to verify the convergent validity of 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD).

Methods

A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD and healthy elderly participants, voluntarily recruited from the community, were considered for inclusion. All participants underwent a 6-PBRT. Isokinetic evaluation to measure the strength and endurance of elbow flexors and extensors, handgrip strength (HGS), spirometry testing, the modified Pulmonary Functional Status Dyspnea Questionnaire (PFSDQ-M), the COPD assessment test (CAT), and symptoms of dyspnea and fatigue were all measured as comparisons for convergent validity. Good convergent validity was considered if >75% of these hypotheses could be confirmed (correlation coefficient>0.50).

Results

A total of 17 patients with AECOPD (70.9±5.1 years and forced expiratory volume in 1 second [FEV₁] of 41.8%±17.9% of predicted) and 11 healthy elderly subjects were included. The HGS showed a significant strong correlation with 6-PBRT performance (r=0.70; p=0.002). The performance in 6-PBRT presented a significant moderate correlation with elbow flexor torque peak (r=0.52; p=0.03) and elbow extensor torque peak (r=0.61; p=0.01). The total muscular work of the 15 isokinetic contractions of the elbow flexor and extensor muscles showed a significant moderate correlation with the performance in 6-PBRT (r=0.59; p=0.01 and r=0.57; p=0.02, respectively). Concerning the endurance of elbow flexors and extensors, there was a significant moderate correlation with 6-PBRT performance (r=−0.50; p=0.04 and r=−0.51; p=0.03, respectively). In relation to the upper-extremity physical activities of daily living (ADLs) assessed by means of PFSDQ-M, there was a significant moderate correlation of 6-PBRT with three domains: influence of dyspnea on ADLs (r=−0.66; p<0.001), influence of fatigue on ADLs (r=−0.60; p=0.01), and change in ADLs in relation to the period before the disease onset (r=−0.51; p=0.03). The CAT was also correlated with 6-PBRT (r=−0.51; p=0.03). Finally, the performance in 6-PBRT showed a significant moderate correlation with the increase in dyspnea (r=−0.63; p=0.01) and a strong correlation with the increase in fatigue of upper limbs (r=−0.76; p<0.001) in patients with AECOPD. Convergent validity was considered adequate, since 81% from 16 predefined hypotheses were confirmed. There was no correlation between 6-PBRT and patients’ height. The performance in 6-PBRT was worse in patients with AECOPD compared to healthy elderly individuals (248.7±63.0 vs 361.6±49.9 number of moved rings; p<0.001).

Conclusion

The 6-PBRT is valid for the evaluation of functional capacity of upper limbs in hospitalized patients with AECOPD.

Outcome Measures Used in Pulmonary Rehabilitation in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review

BACKGROUND

Conflicting results about the effects of community-based pulmonary rehabilitation in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exist, possibly because the variety of outcome measures used and the lack of appropriate measurement properties hinder the development of pulmonary rehabilitation guidelines.

PURPOSE

The purpose of this study was to identify and review the measurement properties of patient-reported outcome measures (PROMs) and clinical outcome measures of AECOPD that are used in pulmonary rehabilitation and that can be easily applied in a community setting.

DATA SOURCES

PubMed, Web of Science, Scopus, and CINAHL were searched up to July 1, 2016.

STUDY SELECTION

Phase 1 identified outcome measures used in pulmonary rehabilitation for AECOPD. Phase 2 reviewed the measurement properties of the identified outcome measures.

DATA EXTRACTION

One reviewer extracted the data and 2 reviewers independently assessed the methodological quality of the studies and the measurement properties of the outcome measures by using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations.

DATA SYNTHESIS

Twenty-three PROMs and 18 clinical outcome measures were found. The outcome measures most used were the St George Respiratory Questionnaire (n = 15/37 studies) and the 6-minute walk test (n = 21/37 studies). Thirty-two studies described the measurement properties of 22 PROMs and 7 clinical outcome measures. The methodological quality of the studies was mostly poor, and the measurement properties were mostly indeterminate. The outcome measure exhibiting more robust properties was the COPD Assessment Test.

LIMITATIONS

A Number of studies were not found with the validated search strategy used and were included a posteriori; the fact that 3 studies presented combined results- for patients who were stable and patients with exacerbation-affected the conclusions that can be drawn.

CONCLUSIONS

A Large variety of outcome measures have been used; however, studies on their measurement properties are needed to enhance the understanding of community pulmonary rehabilitation for AECOPD.

Advances in cardiorespiratory physiotherapy and their clinical impact

INTRODUCTION

Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.

Use of biologics to treat acute exacerbations and manage disease in asthma, COPD and IPF

A common feature of chronic respiratory disease is the progressive decline in lung function. The decline can be indolent, or it can be accelerated by acute exacerbations, whereby the patient experiences a pronounced worsening of disease symptoms. Moreover, acute exacerbations may also be a marker of insufficient disease management. The underlying cause of an acute exacerbation can be due to insults such as pathogens or environmental pollutants, or the cause can be unknown. For each acute exacerbation, the patient may require medical intervention such as rescue medication, or in more severe cases, hospitalization and ventilation and have an increased risk of death. Biologics, such as monoclonal antibodies, are being developed for chronic respiratory diseases including asthma, COPD and IPF. This therapeutic approach is particularly well suited for chronic use based on the route and frequency of delivery and importantly, the potential for disease modification. In recent clinical trials, the frequency of acute exacerbation has often been included as an endpoint, to help determine whether the investigational agent is impacting disease. Therefore the significance of acute exacerbations in driving disease, and their potential as a marker of disease activity and progression, has recently received much attention. There is also now a need to standardize the definition of an acute exacerbation in specific disease settings, particularly as this endpoint is increasingly used in clinical trials to also assess therapeutic efficacy. Moreover, specifically targeting exacerbations may offer a new therapeutic approach for several chronic respiratory diseases.

Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial

QUESTION

Among people who are hospitalised for community-acquired pneumonia, does an inpatient exercise-based rehabilitation program improve functional outcomes, symptoms, quality of life and length of hospital stay more than a respiratory physiotherapy regimen?

DESIGN

Randomised trial with concealed allocation, intention-to-treat analysis and blinding of some outcomes.

PARTICIPANTS

Forty-nine adults hospitalised for community-acquired pneumonia.

INTERVENTION

The experimental group (n=32) underwent a physical training program that included warm-up, stretching, peripheral muscle strength training and walking at a controlled speed for 15 minutes. The control group (n=17) underwent a respiratory physiotherapy regimen that included percussion, vibrocompression, respiratory exercises and free walking. The intervention regimens lasted 8 days.

OUTCOME MEASURES

The primary outcome was the Glittre Activities of Daily Living test, which assesses the time taken to complete a series of functional tasks (eg, rising from a chair, walking, stairs, lifting and bending). Secondary outcomes were distance walked in the incremental shuttle walk test, peripheral muscle strength, quality of life, dyspnoea, lung function, C-reactive protein and length of hospital stay. Measures were taken 1 day before and 1 day after the intervention period.

RESULTS

There was greater improvement in the experimental group than in the control group on the Glittre Activities of Daily Living test (mean between-group difference 39 seconds, 95% CI 20 to 59) and the incremental shuttle walk test (mean between-group difference 130 m, 95% CI 77 to 182). There were also significantly greater improvements in quality of life, dyspnoea and peripheral muscle strength in the experimental group than in the control group. There were no between-group differences in lung function, C-reactive protein or length of hospital stay.

CONCLUSION

The improvement in functional outcomes after an inpatient rehabilitation program was greater than the improvement after standard respiratory physiotherapy. The exercise training program led to greater benefits in functional capacity, peripheral muscle strength, dyspnoea and quality of life.

REGISTRATION

ClinicalTrials.gov, NCT02103400.

Effects of a respiratory physiotherapy session in patients with LRTI: a pre/post-test study

INTRODUCTION

The role of respiratory physiotherapy (RP) in lower respiratory tract infections (LRTI) has been questioned. However, studies have focused on hospitalised patients, and the presence/absence of an underlying disease has been neglected.

OBJECTIVES

To assess the effects of a RP session in community patients with LRTI and to explore the differences between patients with pneumonia (restrictive disease - AR) and those with exacerbations of an obstructive disease (AO).

METHODS

A pre/post-test study was conducted. A RP session was applied to patients with LRTI and crackles, wheezes, dyspnoea, perception of sputum and oxygen saturation were collected pre/post session. Comparisons were performed using paired t-tests or Wilcoxon tests.

RESULTS

Thirty patients (14 males, 55.23 ± 17.78 years) with pneumonia (AR, n = 12), exacerbations of chronic obstructive pulmonary disease, acute bronchitis and asthma (AO, n = 18) were enrolled. After treatment, the total sample presented lower wheeze rates at trachea (P = 0.02; r = -0.54) and less sputum (P = 0.01; r = -0.47). AR patients presented a decrease in the number of crackles (P < 0.05; 0.30 < d_z  < 0.26) and number and rate of wheezes at chest locations (P < 0.05; -0.56 < r < -0.48). AO patients showed an increase in the number of crackles (P < 0.05; 0.20 <d_z <0.31), wheeze frequency (P = 0.03; r = -0.27) and dyspnoea (P = 0.04; r = -0.55); and a decrease in the number of wheezes at trachea (P = 0.02; r = -0.54).

CONCLUSIONS

RP seems effective in reducing wheezes and perception of sputum in patients with LRTI. However, when considering AR and AO diseases separately, further changes in respiratory sounds and dyspnoea emerged. This highlights the importance of considering subgroups of patients with LRTI to develop RP evidence-base practice.

Gaps in the inpatient management of chronic obstructive pulmonary disease exacerbation and impact of an evidence-based order set

BACKGROUND

Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions.

OBJECTIVE

To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD.

METHODS

The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario.

RESULTS

A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5 ± 7.7 days before order sets to 4.1 ± 5.0 days with order sets (P=0.017).

CONCLUSIONS

Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.