1
|
Lane ND, Gillespie SM, Steer J, Bourke SC. Uptake of Clinical Prognostic Tools in COPD Exacerbations Requiring Hospitalisation. COPD 2021; 18:406-410. [PMID: 34355632 DOI: 10.1080/15412555.2021.1959540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Clinical prognostic tools are used to objectively predict outcomes in many fields of medicine. Whilst over 400 have been developed for use in chronic obstructive pulmonary disease (COPD), only a minority have undergone full external validation and just one, the DECAF score, has undergone an implementation study supporting use in clinical practice. Little is known about how such tools are used in the UK. We distributed surveys at two time points, in 2017 and 2019, to hospitals included in the Royal College of Physicians of London national COPD secondary care audit program. The survey assessed the use of prognostic tools in routine care of hospitalized COPD patients. Hospital response rates were 71/196 in 2017 and 72/196 in 2019. The use of the DECAF and PEARL scores more than doubled in decisions about unsupported discharge (7%-15.3%), admission avoidance (8.1%-17%) and readmission avoidance (4.8%-13.1%); it more than tripled (8.8%-27.8%) in decisions around hospital-at-home or early supported discharge schemes. In other areas, routine use of clinical prognostic tools was uncommon. In palliative care decisions, the use of the Gold Standards Framework Prognostic Indicator Guidance fell (5.6%-1.4%). In 2017, 43.7% of hospitals used at least one clinical prognostic tool in routine COPD care, increasing to 52.1% in 2019. Such tools can help challenge prognostic pessimism and improve care. To integrate these further into routine clinical care, future research should explore current barriers to their use and focus on implementation studies.Supplemental data for this article is available online at https://dx.doi.org/10.1080/15412555.2021.1959540.
Collapse
Affiliation(s)
- Nicholas D Lane
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah M Gillespie
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John Steer
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C Bourke
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
2
|
Mathews KS, Goel NN, Vargas-Torres C, Olson AD, Zhou J, Powell CA, Mazumdar M, Stock GN, McDermott CM. A Cross-sectional Study of Hospital Performance on ICU Utilization Practices for Patients with Chronic Obstructive Pulmonary Disease. Lung 2020; 198:637-644. [PMID: 32495192 DOI: 10.1007/s00408-020-00364-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Intensive care unit (ICU) resources are a costly but effective commodity used in the management of critically ill patients with chronic obstructive pulmonary disease (COPD). ICU admission decisions are determined by patient diagnosis and severity of illness, but also may be affected by hospital differences in quality and performance. We investigate the variability in ICU utilization for patients with COPD and its association with hospital characteristics. METHODS Using a 3M administrative dataset spanning 2008-2013, we conducted a retrospective cohort study of adult patients discharged with COPD at hospitals in three state to determine variability in ICU utilization. Quality metrics were calculated for each hospital using observed-to-expected (O/E) ratios for overall mortality and length of stay. Logistic and multilevel multivariate regression models were constructed, estimating the association between hospital quality metrics on ICU utilization, after adjustment for available clinical factors and hospital characteristics. RESULTS In 434 hospitals with 570,517 COPD patient visits, overall ICU admission rate was 33.1% [range 0-89%; median (IQR) 24% (8, 54)]. The addition of patient, hospital, and quality characteristics decreased the overall variability attributable to individual hospital differences seen within our cohort from 40.9 to 33%. Odds of ICU utilization were increased for larger hospitals and those seeing lower pulmonary case volume. Hospitals with better overall O/E ratios for length of stay or mortality had lower ICU utilization. CONCLUSIONS Hospital characteristics, including quality metrics, are associated with variability in ICU utilization for COPD patients, with higher ICU utilization seen for lower performing hospitals.
Collapse
Affiliation(s)
- Kusum S Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neha N Goel
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA.
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley D Olson
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jing Zhou
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles A Powell
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory N Stock
- College of Business, University of Colorado at Colorado Springs, Colorado Springs, CO, USA
| | | |
Collapse
|
3
|
U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment. Crit Care Med 2020; 47:1522-1530. [PMID: 31385883 PMCID: PMC6798748 DOI: 10.1097/ccm.0000000000003903] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Supplemental Digital Content is available in the text. Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU.
Collapse
|
4
|
Viana RCTP, Pincelli MP, Pizzichini E, Silva AP, Manes J, Marconi TD, Steidle LJM. Chronic obstructive pulmonary disease exacerbation in the intensive care unit: clinical, functional and quality of life at discharge and 3 months of follow up. Rev Bras Ter Intensiva 2018; 29:47-54. [PMID: 28444072 PMCID: PMC5385985 DOI: 10.5935/0103-507x.20170008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/03/2017] [Indexed: 11/20/2022] Open
Abstract
Objective: The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure. Methods: This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up. Results: There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission. Conclusion: Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission.
Collapse
Affiliation(s)
- Renata Cristina Teixeira Pinto Viana
- Clínica Médica, Universidade do Vale do Itajaí - Itajaí (SC), Brasil.,Terapia Intensiva e Cuidados Paliativos, Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil
| | - Mariangela Pimentel Pincelli
- Departamento de Clínica Médica/Pneumologia, Hospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil.,Terapia Intensiva, Hospital Nereu Ramos - Florianópolis (SC), Brasil
| | - Emílio Pizzichini
- Departamento de Clínica Médica/Pneumologia, Hospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil
| | | | - Joice Manes
- Clínica Médica, Hospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil
| | | | - Leila John Marques Steidle
- Departamento de Clínica Médica/Pneumologia, Hospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil
| |
Collapse
|
5
|
Lindvig KP, Brøchner AC, Lassen AT, Mikkelsen S. Prehospital prognosis is difficult in patients with acute exacerbation of chronic obstructive pulmonary disease. Scand J Trauma Resusc Emerg Med 2017; 25:106. [PMID: 29096666 PMCID: PMC5667455 DOI: 10.1186/s13049-017-0451-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 10/24/2017] [Indexed: 12/02/2022] Open
Abstract
Background Patients with acute exacerbation of chronic obstructive pulmonary disease often require prehospital emergency treatment. This enables patients who are less ill to be treated on-site and to avoid hospital admission, while severely ill patients can receive immediate ventilatory support in the form of intubation. The emergency physician faces difficult treatment decisions, however, and prognostic tools that could assist in determining which patients would benefit from intubation and ventilator support would be helpful. The aim of the current study was to identify prehospital clinical variables associated with mortality from acute exacerbation of chronic obstructive pulmonary disease. As part of the study, we estimated the 30-day mortality for patients with this prehospital diagnosis. Methods A retrospective study was performed using data collected by the mobile emergency care unit in Odense, Denmark, combined with data from the patients’ medical records. Patients with the tentative diagnosis of acute exacerbation of chronic obstructive pulmonary disease between 1st July 2011 and 31st December 2013 were included in the study. Results Based on data from 530 patients, we found no statistically significant associations between prehospital clinical variables and mortality, apart from a minor association between older age and higher mortality. The overall 30-day mortality was 10%, while that for patients admitted to the intensive care unit was 30%. Conclusion No specific prehospital prognostic factors for mortality were identified. Prognostic assessment and the decision to withhold treatment for acute exacerbation of chronic obstructive pulmonary disease seem inadvisable in the prehospital setting.
Collapse
Affiliation(s)
- Katrine P Lindvig
- Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Junggreensvej 8, 1. tv, 5000, Odense C, Region of Funen, Denmark.
| | - Anne C Brøchner
- Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Junggreensvej 8, 1. tv, 5000, Odense C, Region of Funen, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Annmarie T Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Junggreensvej 8, 1. tv, 5000, Odense C, Region of Funen, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
[Management of inpatients with acute COPD exacerbation. When to indicate mechanical ventilation?]. Rev Mal Respir 2017; 34:439-449. [PMID: 28502366 DOI: 10.1016/j.rmr.2017.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
7
|
Sangwan V, Chaudhry D, Malik R. Dyspnea, Eosinopenia, Consolidation, Acidemia and Atrial Fibrillation Score and BAP-65 Score, Tools for Prediction of Mortality in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Comparative Pilot Study. Indian J Crit Care Med 2017; 21:671-677. [PMID: 29142379 PMCID: PMC5672673 DOI: 10.4103/ijccm.ijccm_148_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) being common and often fatal, prognostic tools in AECOPD are lacking. Materials and Methods A prospective, observational study was carried out in fifty patients of AECOPD admitted in A and E department. Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation (DECAF) score and elevated blood urea nitrogen, altered mental status, pulse >109, age >65 (BAP-65) score were calculated. Dyspnea was scored using extended Medical Research Council Dyspnoea score. Data were collected and analyzed using SPSS 17.0 software. Results Forty-one patients were discharged and 9 (18%) died during treatment. Patients who were discharged and patients who died during hospital stay were compared. There was no significant difference in terms of sociodemographic variables, presence of comorbidities, and other markers of disease severity. A significant difference was found in blood counts, blood urea, serum creatinine, acidotic respiratory failure, and atrial fibrillation. A higher value of DECAF score and BAP-65 score was found more commonly in patients who died. Sensitivity for prediction of mortality for DECAF score and BAP-65 score was 100% and specificity was 34.1% and 63.4%, respectively. Sensitivity for prediction of need for invasive ventilation for DECAF score and BAP-65 score was 80% and 100%, respectively, and specificity was 80% and 60%, respectively. Conclusion Both DECAF and BAP-65 scores were found to be good predictors of mortality and need for ventilation in this pilot study.
Collapse
Affiliation(s)
- Viral Sangwan
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India
| | - Roopa Malik
- Department of Obstetrics and Gynaecology, PGIMS, Rohtak, Haryana, India
| |
Collapse
|
8
|
Rivas-Ruiz F, Redondo M, González N, Vidal S, García S, Lafuente I, Bare M, Cano Aguirre MDP, Quintana-López JM. Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation. J Eval Clin Pract 2015; 21:848-54. [PMID: 26139468 DOI: 10.1111/jep.12390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To assess the adequacy of diagnostic effort in the emergency departments of Spanish hospitals with respect to episodes of exacerbation of chronic obstructive pulmonary disease (COPD). METHODS A descriptive cross-sectional study, conducted between 2007 and 2010 in 15 hospitals in Andalusia, Catalonia, Madrid and the Basque Country. The study population included cases of COPD exacerbation attended at the emergency departments of the participating hospitals. Diagnostic efforts were considered sufficient and appropriate when the emergency room conducted a clinical evaluation including electrocardiogram, chest X-ray, arterial blood gas analysis and spirometry. RESULTS 2852 episodes of COPD exacerbation attended in hospital emergency departments were assessed. 91.4% of the patients were male, with a mean age of 72.8 (SD 9.5) years, and 45.6% had had a previous emergency admission. The diagnostic effort was considered adequate in 60.1% of the episodes (95% CI: 58.3-61.9). The inter-hospital range of variation(25-75) was 1.67 and the coefficient of variation was 28.3%. In multivariate analysis, adjusting for hospital, date of admission and previous hospitalization, among the male patients, the OR for adequate diagnostic effort was 1.38 (95% CI: 1.04-1.84) CONCLUSION: With respect to diagnostic effort, inequities were observed in our assessment of episodes of COPD exacerbation attended in the emergency departments of Spanish public hospitals. In a high percentage of cases (40%), proper assessment was not conducted. Moreover, inter-individual and inter-hospital differences were observed.
Collapse
Affiliation(s)
- Francisco Rivas-Ruiz
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain.,Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Maximino Redondo
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain.,Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Nerea González
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Silvia Vidal
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain
| | - Susana García
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Iratxe Lafuente
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Marisa Bare
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain.,Corporaciò Parc Taulí, Unidad de Epidemiología Clínica, Barcelona, Spain
| | | | - José María Quintana-López
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | | |
Collapse
|
9
|
“Bigger Is Better?” What Drives Outcomes in Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease?*. Crit Care Med 2013; 41:2038-9. [DOI: 10.1097/ccm.0b013e31828fd700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
10
|
Kocks JWH, van den Berg JWK, Kerstjens HAM, Uil SM, Vonk JM, de Jong YP, Tsiligianni IG, van der Molen T. Day-to-day measurement of patient-reported outcomes in exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2013; 8:273-86. [PMID: 23766644 PMCID: PMC3678711 DOI: 10.2147/copd.s43992] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Exacerbations of chronic obstructive pulmonary disease (COPD) are a major burden to patients and to society. Little is known about the possible role of day-to-day patient-reported outcomes during an exacerbation. This study aims to describe the day-to-day course of patient-reported health status during exacerbations of COPD and to assess its value in predicting clinical outcomes. Methods Data from two randomized controlled COPD exacerbation trials (n = 210 and n = 45 patients) were used to describe both the feasibility of daily collection of and the day-to-day course of patient-reported outcomes during outpatient treatment or admission to hospital. In addition to clinical parameters, the BORG dyspnea score, the Clinical COPD Questionnaire (CCQ), and the St George’s Respiratory Questionnaire were used in Cox regression models to predict treatment failure, time to next exacerbation, and mortality in the hospital study. Results All patient-reported outcomes showed a distinct pattern of improvement. In the multivariate models, absence of improvement in CCQ symptom score and impaired lung function were independent predictors of treatment failure. Health status and gender predicted time to next exacerbation. Five-year mortality was predicted by age, forced expiratory flow in one second % predicted, smoking status, and CCQ score. In outpatient management of exacerbations, health status was found to be less impaired than in hospitalized patients, while the rate and pattern of recovery was remarkably similar. Conclusion Daily health status measurements were found to predict treatment failure, which could help decision-making for patients hospitalized due to an exacerbation of COPD.
Collapse
Affiliation(s)
- Jan Willem H Kocks
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Wakatsuki M, Sadler P. Invasive Mechanical Ventilation in Acute Exacerbation of COPD: Prognostic Indicators to Support Clinical Decision Making. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although non-invasive ventilation is the mainstay of management for patients with hypercapnic acute exacerbation of COPD, invasive mechanical ventilation (IMV) still has an important role to play. IMV can be used successfully to reduce mortality and still maintain quality of life in a subset of patients. Despite this, the evidence to support which patients will benefit from IMV is limited. This article reviews the literature available to guide clinician decision-making. Age is not a reliable independent predictor of survival for COPD patients receiving IMV, nor are levels of PaO2, PCO2, or use of long-term oxygen therapy. Body composition and nutritional status are independent predictors of survival and the presence of co-morbidities, such as cor pulmonale, cardiovascular disease and diabetes mellitus are negative prognostic indicators. Length of time in hospital prior to ICU admission also is an adverse prognostic factor. Although scoring systems exist, their ability to predict outcome for individual patients has limitations. Work needs to be done to improve end-of-life planning in COPD with the encouragement of discussion about advance directives when patients are reaching advanced stage of the disease.
Collapse
Affiliation(s)
- Mai Wakatsuki
- Specialist Registrar in Anaesthesia and Intensive Care Medicine, University Hospital Southampton NHS Foundation Trust
| | - Paul Sadler
- Consultant in Critical Care, Portsmouth Hospitals NHS Trust
| |
Collapse
|
12
|
Maltais F. Physiology to assist bedside prognostication in mechanically ventilated patients with chronic obstructive pulmonary disease. Respiration 2012; 84:14-6. [PMID: 22455984 DOI: 10.1159/000336833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
13
|
Messer B, Griffiths J, Baudouin SV. The prognostic variables predictive of mortality in patients with an exacerbation of COPD admitted to the ICU: an integrative review. QJM 2012; 105:115-26. [PMID: 22071965 DOI: 10.1093/qjmed/hcr210] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) frequently presents with an acute exacerbation (AECOPD). Debate exists as to whether these patients should be admitted to intensive care units (ICUs). An integrative review was performed to determine whether clinical variables available at the time of ICU admission are predictive of the intermediate-term mortality of patients with an AECOPD. METHODS An integrative review was structured to incorporate a five-stage review framework to facilitate data extraction, analysis and presentation. The quality of the studies contributing to the integrative review was assessed with a novel scoring system developed from previously published data and adapted to this setting. RESULTS The integrative review search strategy identified 28 studies assessing prognostic variables in this setting. Prognostic variables associated with intermediate-term mortality were low Glasgow Coma Scale (GCS) on admission to ICU, cardio-respiratory arrest prior to ICU admission, cardiac dysrhythmia prior to ICU admission, length of hospital stay prior to ICU admission and higher values of acute physiology scoring systems. Premorbid variables such as age, functional capacity, pulmonary function tests, prior hospital or ICU admissions, body mass index and long-term oxygen therapy were not found to be associated with intermediate-term mortality nor was the diagnosis attributed to the cause of the AECOPD. DISCUSSION Variables associated with intermediate-term mortality after AECOPD requiring ICU admission are those variables, which reflect underlying severity of acute illness. Premorbid and diagnostic data have not been shown to be predictive of outcome. A scoring system is proposed to assess studies of prognosis in AECOPD.
Collapse
Affiliation(s)
- B Messer
- Department of Anaesthetics, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK.
| | | | | |
Collapse
|
14
|
Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: A systematic review*. Crit Care Med 2011; 39:1174-89. [DOI: 10.1097/ccm.0b013e31820eacf2] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
15
|
Insights into chronic obstructive pulmonary disease patient attitudes on ventilatory support. Curr Opin Pulm Med 2011; 17:98-102. [DOI: 10.1097/mcp.0b013e32834318d3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
16
|
Ketchell I. Patients with cystic fibrosis should be intubated and ventilated. J R Soc Med 2010; 103 Suppl 1:S20-4. [PMID: 20573664 DOI: 10.1258/jrsm.2010.s11005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ian Ketchell
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Penlan Road, Penarth CF64 2XX, UK.
| |
Collapse
|
17
|
CHUNG LP, WINSHIP P, PHUNG S, LAKE F, WATERER G. Five-year outcome in COPD patients after their first episode of acute exacerbation treated with non-invasive ventilation. Respirology 2010; 15:1084-91. [DOI: 10.1111/j.1440-1843.2010.01795.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
18
|
Chakrabarti B, Sulaiman MI, Davies L, Calverley PMA, Warburton CJ, Angus RM. A study of patient attitudes in the United Kingdom toward ventilatory support in chronic obstructive pulmonary disease. J Palliat Med 2010; 12:1029-35. [PMID: 19663712 DOI: 10.1089/jpm.2009.0160] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Informed patient choice is central to modern clinical care but there is a paucity of data about how patients respond to information regarding complex therapies. This qualitative study aimed to understand the attitudes of patients with chronic obstructive pulmonary disease (COPD) toward acute ventilatory support and assess how aids to decision making regarding ventilation affect patients' views of therapy. METHODS A standardized five-stage interview process was used to explore attitudes toward noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) in 50 stable COPD patients. RESULTS Eighty-six percent found demonstration of NIV helpful in decision making compared to 24% with the photographic aid (p < 00.001). Although 96% were willing to receive NIV after a verbal description of the technique, only 76% consented when a photographic aid was shown. When NIV was demonstrated, willingness rose to 84%. While 60% were willing to receive IMV following a verbal description, this decreased to 58% following explanation of alternative treatments to IMV. Patients willing to receive IMV were younger (67 versus 76 years p = 0.016) and had a better functional status (NEADL index 20 versus 15 units p = 0.03). Only 34% had heard of advanced directives of care (ADCs), none had ever issued one but 48% expressed an interest in doing so following explanation of this process. CONCLUSION COPD patients would find both explanation and demonstration of NIV useful in an outpatient setting. Worsening functional status along with advanced age was associated with reduced willingness to receive invasive ventilatory support. Awareness of ADCs was found to be low although almost half of the patients expressed interest in the uptake of ADCs following explanation of the process.
Collapse
Affiliation(s)
- Biswajit Chakrabarti
- Clinical Sciences Centre, University of Liverpool, University Hospital Aintree, Liverpool, United Kingdom
| | | | | | | | | | | |
Collapse
|
19
|
Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D, Young D, Rowan K. Predicting mortality for patients with exacerbations of COPD and Asthma in the COPD and Asthma Outcome Study (CAOS). QJM 2009; 102:389-99. [PMID: 19369483 DOI: 10.1093/qjmed/hcp036] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Decisions about the intensity of treatment for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are influenced by predictions about survival and quality of life. Evidence suggests that these predictions are poorly calibrated and tend to be pessimistic. AIM The aim of this study was to develop an outcome prediction model for COPD patients to support treatment decisions. METHODS A prospective multi-centre cohort study in Intensive Care Units (ICU) and Respiratory High Dependency Units (RHDU) in the UK recruited patients aged 45 years and older admitted with an exacerbation of obstructive lung disease. Data were collected on patients' characteristics prior to ICU admission, and on their survival and quality of life after 180 days. An outcome prediction model was developed using multivariate logistic regression and bootstrapping. RESULTS Ninety-two ICUs (53% of those in the UK) and three RHDUs took part. A total of 832 patients were recruited. Cumulative 180-day mortality was 37.9%. Using data available at the time of admission to the units, a prognostic model was developed which had an estimated area under the receiver operating characteristic curve ('c') of 74.7% after bootstrapping that was more discriminating than the clinicians (P = 0.033) and was well calibrated. DISCUSSION This study has produced an outcome prediction model with slightly better discrimination and much better calibration than the participating clinicians. It has the potential to support risk adjustment and clinical decision making about admission to intensive care.
Collapse
Affiliation(s)
- M J Wildman
- Sheffield Thoracic Institute, Northern General Hospital, Herries Road, Sheffield, UK.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Creagh-Brown B, Shee C. Noninvasive ventilation as ceiling of therapy in end-stage chronic obstructive pulmonary disease. Chron Respir Dis 2009; 5:143-8. [PMID: 18684789 DOI: 10.1177/1479972308089234] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The benefits of noninvasive ventilation (NIV) for acute hypercapnic respiratory failure caused by chronic obstructive pulmonary disease (COPD) are well recognized and consequently its use is widespread. Prognostication in advanced COPD is imperfect, limiting accurate identification of 'end-stage' COPD. Decisions regarding withholding invasive ventilation are largely dependent upon prognostication. In patients where 'invasive' ventilation is not considered to be in their best interests, NIV will be the ceiling of therapy. In this patient group, NIV is extremely valuable in reducing mortality and providing valuable symptomatic benefit. We discuss the use of NIV in the management of an acute exacerbation of 'end-stage' COPD where NIV is the ceiling of therapy, the use of advanced directives and the implications of the Mental Capacity Act 2005 on decisions regarding end-of-life care. We highlight areas where further research would be useful.
Collapse
Affiliation(s)
- Bc Creagh-Brown
- Respiratory and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, UK .
| | | |
Collapse
|
21
|
Davidson AC. Towards a Comprehensive Ventilatory Strategy for Acute Exacerbations of COPD. J Intensive Care Soc 2008. [DOI: 10.1177/175114370800900102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- A Craig Davidson
- Consultant, Departments of Respiratory & Critical Care Medicine, Guys & St Thomas' Foundation Trust, London
| |
Collapse
|
22
|
Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D, Young D, Rowan K. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ 2007; 335:1132. [PMID: 17975254 PMCID: PMC2099544 DOI: 10.1136/bmj.39371.524271.55] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether clinicians' prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival. DESIGN Prospective cohort study. SETTING 92 intensive care units and three respiratory high dependency units in the United Kingdom. PARTICIPANTS 832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two. MAIN OUTCOME MEASURES Outcome predicted by clinicians. Observed survival at 180 days. RESULTS 517 patients (62%) survived to 180 days. Clinicians' prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units. CONCLUSIONS Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians' prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.
Collapse
|
23
|
Abstract
Scarce resources may cause doctors to be pessimistic about prognosis and refuse critical care admissions
Collapse
|
24
|
Wildman MJ, Harrison DA, Welch CA, Sanderson C. A new measure of acute physiological derangement for patients with exacerbations of obstructive airways disease: the COPD and Asthma Physiology Score. Respir Med 2007; 101:1994-2002. [PMID: 17616454 DOI: 10.1016/j.rmed.2007.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 04/02/2007] [Accepted: 04/04/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Decisions about how to treat patients with acute exacerbations of obstructive airways disease-chronic obstructive pulmonary disease (COPD), asthma or mixed diagnoses-often require an understanding of prognosis. This depends on the severity of the acute deterioration and the patient's functional reserve. There are currently no validated disease-specific scores that measure the severity of the acute exacerbation. OBJECTIVE To develop an acute physiology score for exacerbations of obstructive airways disease. DESIGN Secondary analysis of a high-quality clinical database, the Case Mix Programme Database. SETTING One hundred and sixty-eight adult, general critical care units in England, Wales and Northern Ireland. RESULTS A total of 8527 patients with obstructive airways disease were identified with a mean (SD) age of 65.9 (9.7) years and hospital mortality of 35.5%. The COPD and Asthma Physiology Score (CAPS) was developed using logistic regression. The CAPS included eight variables: heart rate, mean arterial blood pressure, pH, sodium, urea, creatinine, albumin and white blood cell count. The score had fair discrimination with an area under the receiver operating characteristic curve of 0.718. This performance was reproduced in a further validation dataset of 7957 patients. The discrimination of the CAPS in these validation data exceeded that of the acute physiology scores from APACHE II and III and the physiological components of SAPS II. CONCLUSION The CAPS can be used to estimate the prognostic impact of physiological derangements accompanying an acute exacerbation of obstructive airways disease and has the potential for even greater predictive performance when combined with measures of a patient's functional reserve.
Collapse
Affiliation(s)
- Martin J Wildman
- Department of Respiratory Medicine, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
| | | | | | | |
Collapse
|
25
|
Chakrabarti B, Calverley PMA. Management of acute ventilatory failure. Postgrad Med J 2006; 82:438-45. [PMID: 16822920 PMCID: PMC2563765 DOI: 10.1136/pgmj.2005.043208] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 12/03/2005] [Indexed: 01/09/2023]
Abstract
Acute ventilatory failure is a challenging yet increasingly common medical emergency reflecting the growing burden of respiratory disease. It is not a diagnosis in itself but the end result of a diversity of disease processes culminating in arterial hypoxaemia and hypercapnia. This review focuses on key management issues including giving appropriate oxygen therapy, treatment of the underlying aetiology as well as any precipitant factors and provision of assisted ventilation if required. Ventilatory assistance can be provided both invasively and non-invasively and the indications for either or both forms of assisted ventilation are discussed. Further emphasis is needed regarding advanced directives of care and clinicians should be aware of ethical issues regarding assisted ventilation.
Collapse
Affiliation(s)
- B Chakrabarti
- Aintree Chest Centre, University Hospital Aintree, Liverpool, UK.
| | | |
Collapse
|
26
|
López messa J, Prieto gonzález M, De san luis gonzález L, Pascual palacín R, Treceño campillo J. Análisis coste-efectividad en procesos que requieren ventilación mecánica. Estudio de los GRD 475 y 483. Med Intensiva 2004. [DOI: 10.1016/s0210-5691(04)70080-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|