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1 A Previously Hospitalized Patient Who Is Having Frequent COPD Exacerbations—Specialty House Calls Case 2 The following is a transcript from a web-based CME-certified multimedia activity. This enduring activity is provided by Albert Einstein College of Medicine of Yeshiva University. This enduring activity is supported by an educational grant from AstraZeneca, LP. DR. JILL A. OHAR: Welcome to Specialty House Calls Case 2. I’m Jill Ohar, Professor of Medicine and Director of Respiratory Care and Pulmonary Rehabilitation at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. I’m here with my colleague Dr. Sanjay Sethi, Professor of Medicine and Chief of Pulmonary, Critical Care and Sleep Medicine at the University of Buffalo School of Medicine and Biomedical Sciences in Buffalo, New York. Sanjay, you mentioned you have a previously hospitalized patient who is having frequent chronic obstructive pulmonary disease (COPD) exacerbations and is frequently readmitted. Jill A. Ohar, MD Professor of Medicine Director of Respiratory Care and Pulmonary Rehabilitation Wake Forest Baptist Medical Center Winston-Salem, NC Sanjay Sethi, MD Professor of Medicine Chief of Pulmonary, Critical Care and Sleep Medicine University of Buffalo School of Medicine and Biomedical Sciences Buffalo, NY

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A Previously Hospitalized Patient Who Is HavingFrequent COPD Exacerbations—Specialty House Calls Case 2

The following is a transcript from a web-based CME-certified multimedia activity.

This enduring activity is provided by Albert Einstein College of Medicine of Yeshiva University.

This enduring activity is supported by an educational grant from AstraZeneca, LP.

DR. JILL A. OHAR: Welcome to Specialty House Calls Case 2. I’m Jill Ohar, Professor of Medicine andDirector of Respiratory Care and Pulmonary Rehabilitation at Wake Forest Baptist Medical Center inWinston-Salem, North Carolina. I’m here with my colleague Dr. Sanjay Sethi, Professor of Medicine andChief of Pulmonary, Critical Care and Sleep Medicine at the University of Buffalo School of Medicineand Biomedical Sciences in Buffalo, New York.

Sanjay, you mentioned you have a previously hospitalized patient who is having frequent chronicobstructive pulmonary disease (COPD) exacerbations and is frequently readmitted.

Jill A. Ohar, MDProfessor of MedicineDirector of Respiratory Care andPulmonary Rehabilitation

Wake Forest Baptist Medical CenterWinston-Salem, NC

Sanjay Sethi, MDProfessor of MedicineChief of Pulmonary, Critical Careand Sleep Medicine

University of Buffalo School of Medicineand Biomedical Sciences

Buffalo, NY

DR. SANJAY SETHI: I do. So here is—

I have a 67-year-old woman who presents to the hospital for the second admission this year and hasincreased—with this admission—has increased cough, sputum, and a low-grade temperature andincreased dyspnea, [and] has a past medical history of congestive heart failure (CHF). She has a50-pack/year smoking history, and on examination her lungs show diffuse wheezing.

This is her second admission, so there is a lot of concern, as we all know, about readmissions. Sothe question I was posed was, “How would you reduce the chance of a 30-day readmission in thisparticular individual?”

DR. JILL A. OHAR: I think you can break it down into several different quadrants. First, do we knowthat this is indeed COPD? So, making a diagnosis of COPD—do we have former pulmonary functiontests (PFTs) that documents this clinical diagnosis, would be my first concern.

Not all smoking people have COPD. Maybe as many as 40% of smokers will develop some lung-functionabnormalities. Is this maybe just congestive heart failure that she has—an exacerbation of that?

Next, I think that it’s important to think about, what is she doing that puts herself in harm’s way? Doesshe continue to smoke? Does she take her medications?

DR. SANJAY SETHI: I also find in my practice that many a time the spirometry or pulmonary functiontests are missing in the patient’s records. And they have been diagnosed and told that they have COPDpurely on the basis of the fact that they smoked…

DR. JILL A. OHAR: Absolutely.

DR. SANJAY SETHI: …or are current smokers. So I totally concur that we should be looking for objectiveevidence of COPD and documenting it in these patients. But in this case, she was a bit better off. We knewher underlying forced expiratory volume in 1 second (FEV1) was about 45% predicted.

DR. JILL A. OHAR: So that puts her in a fairly severe category.

DR. SANJAY SETHI: Yes. So the first time she was admitted, she was prescribed a long-acting beta-agonist/inhaled corticosteroid (LABA/ICS) to take home, and along with that was given a short-actingbeta-agonist (SABA) and also put on a nebulizer.

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This time when she came around, when questioned about her medication use, she was very good withusing the nebulizer and the short-acting agent, but did not receive the same benefit with the LABA/ICSand was actually using it relatively infrequently. And for some reason, of course, [she] was not on along-acting muscarinic agent (LAMA).

Clearly though, there was some effort to put her on proper maintenance medication. Issues of adherenceand really an understanding of what the medications do were not addressed adequately in this patient.

DR. JILL A. OHAR: Absolutely. I think it’s important to educate your patients and make their expectationscongruent with reality.

And clearly the drugs in the ICS/LABA combination class have been shown—not only in the literature,but also have an indication from the Food and Drug Administration (FDA)—to decrease exacerbationfrequency. The same is true, though, of the long-acting muscarinic antagonist (LAMA) classification.And so these agents should be used together, especially in a frequent exacerbator. So clearly, she’sprobably not adequately medicated. She probably should be on a LABA, LAMA, and ICS.

Second off, she is not using the medication primarily because she doesn’t understand or doesn’t haveappropriate expectations. And then thirdly, assessing inhaler technique would be critical in this setting.Many patients don’t understand that they actually run out of drug in the canister and that 1 inhalerwon’t be good for 3 or 4 years.

I think some other issues that might be important in discussing her care would be: has she been effectivelytreated while in the hospital?

DR. SANJAY SETHI: There was a large Medicare-based study—and it showed about 80% of patients—which actually looked at patients in the Medicare age who were admitted with COPD exacerbations; so afairly large study, database-based, not a randomized trial. But in that study, what they showed was thatabout…80% of the 20% of patients who did not, for example, receive any antibiotics or the antibioticswere initiated 2 days after admission—those patients had worse outcomes in terms of requiring latemechanical ventilation or still requiring additional treatment. So essentially, it was not optimal care inthose situations. So clearly, there are deficiencies that were there.

The other thing we use is steroids. What has been shown recently is that all you need is 40 mg a day for5 days. And what I do find many times in the patients I get to see [is that] they are still treating them withthis high-dose methylprednisolone (Solu-Medrol) for several days and then tapering them really slowly.

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So, kind of the regimen that was tested 20 years—more than 10 years ago in these patients—but nowwe have moved to shorter regimens.

And it’s not just a matter of having [fewer] steroids on board. It is maybe that longer [use of] steroidscan have other adverse outcomes. So that, I think, needs to be adhered to better in terms of gettingshorter-term, medium-dose steroids to help with their exacerbations.

DR. JILL A. OHAR: I can’t agree with you more. As a matter of fact, I think it’s important to put a boxaround that therapy in the hospital to include antibiotics—broad-spectrum oral (PO) antibiotics reallytargeted in the group of patients that we see as frequent exacerbators at some of the gram-negativesand atypical, rather than the big 3 that we always think about in the textbooks for COPD exacerbation;you know, Moraxella, Haemophilus influenzae, and Streptococcus pneumoniae.

By the time we have a frequent exacerbator, their FEV1 is lower. They tend to be colonized with the gram-negatives, the atypicals that we’re going to need a stronger antibiotic for. So, fluoroquinolones, some ofthe second- and third-generation cephalosporins, etc, may be a better choice for them. Oxygen, which Ithink so often is lost; [and] bronchodilators in the form of both nebulizers early on, but a rapid transitionto the long-acting dry-powder or metered-dose inhalers (MDIs) technology as soon as patients are able.Steroids in the new lower dose, as well, are all important.

I, like you, see patients sometimes even a year later still on a low dose of prednisone. I get at least 2 or3 patients a year in with atypical infections related to an immunosuppressed host from that steroid thathas been left on, or the aseptic necrosis of the hip from patients who have seen repeated, extended bouts.I think it’s so critically important to remember, yes, use those steroids but stop them. Five days, done.

Are there any other problems you see with the inpatient course that may have been reflective in our caseor other cases you’ve seen?

DR. SANJAY SETHI: Yes. So one of the things that I’ve noticed, and one of the things that we tried tochange in our hospital was, they come in. They stay on the nebulizers until the day they leave.

I think what we should be doing is that, as soon as they are over the first—the critical period—put themon the dry-powder inhalers (DPIs), still have the nebulizer on PRN (as-needed) use, and maybe get a dayor so in the hospital to see how they’re doing on those.

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DR. JILL A. OHAR: Absolutely. I think that also gives our respiratory therapists an opportunity to assessinhaler technique in the hospital and also to assess whether this patient can develop enough inspiratoryforce to use an MDI or a DPI. Because I think it’s not really in the top of our thinking of, “Wow, this debil-itated, 67-year-old woman who weighs 110 lbs and also has osteoporosis and some congestive heart fail-ure—she can’t draw that 30 L per minute that she needs to get…in.”

[END OF SEGMENT 1]

VIDEO SEGMENT 2

DR. JILL A. OHAR: You know, this case also throws in the congestive heart failure issue. And congestiveheart failure is so incredibly common, especially among exacerbators and frequent exacerbators.

I know that we have looked back over our frequent-exacerbator population and found that if you have5 or more admissions to the hospital in the previous year, 82% of those patients will have concurrentcongestive heart failure diagnoses.

So I think it’s important for us to help the doctors listening in on the House Call to understand, howdo we differentiate between a CHF exacerbation [and] a COPD exacerbation, or is this both? And so Ithink one of the conundrums we often find ourselves in is the chest x-ray that is relatively nonspecific,the symptoms which are relatively nonspecific, and then you get a B natriuretic protein (BNP), hopingthat that’s going to be the deal breaker or tiebreaker here, and it’s...340.

What do you do with that? Is there a number where you say, “You crossed that line in the sand? You nowhave congestive heart failure, too?”

DR. SANJAY SETHI: I think that it comes down to a good assessment, bedside assessment and clinicaljudgment. The BNP I find useful if I have a baseline BNP. Not that I do it routinely, but if there is a baselinethen you can see if there is a change from there.

To me, the congestive heart failure story in COPD is related to 2 aspects. A) Is it right-sided failure, whichis a consequence of their COPD getting worse? So they were hypoxic at home, and because of that, theircor pulmonale got worse. And that to me—

Because there, yes, I might use some diuretics, but my focus will be on treating the lungs and gettingthe COPD better.

On the other hand, then there are other patients with either biventricular failure or predominant leftventricular failure. In them, it’s a toss-up. It could be that the COPD exacerbation caused some ischemiaand made things worse. So you could end up with concomitant COPD and CHF exacerbations.

So if you treat a patient with steroids and antibiotics and bronchodilators and send them home, andthere was concomitant CHF which you never addressed, the chances are that patient is going to be abounceback.

DR. JILL A. OHAR: Absolutely. And I think you’ve brought up several issues with congestive heartfailure. I know I have read that above 500, you can feel fairly confident that there is left ventriculardysfunction ongoing, that higher or abnormally high levels of BNP below 500 can easily be attributedto right heart strain related to the exacerbation.

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I think also another issue you brought up with right heart strain is for us to begin to think about thedifferential diagnosis of what causes a COPD exacerbation. And while, far and away, infectious etiologiesare important in terms of both bacterial and viral bronchitis and possibly pneumonia, when it is not aninfectious etiology, the next most common thing is a pulmonary embolism (PE).

You know, also in that differential is cardiac ischemia. Is this angina? Is this a myocardial infarction(MI)? So when we’re working these patients up, I think a BNP can be helpful. I think troponins can behelpful. I think an echo[cardiogram] is important because it helps us understand: Is there cardiacpathology? Is there right heart strain from a big new PE? And also, just having your antennae up forhaving an expectancy set of something other than a bacterial infection as the cause.

DR. SANJAY SETHI: For those patients, what I find the most instructive is, again, the clinical presenta-tion of the exacerbation. So, [there’s] nothing like a good history.

So if they presented acutely, it’s very uncommon for an exacerbation because of a bronchitic—you know,what we think of the classic mechanism—to be presenting acutely. Those are always things that developover days, rather than minutes and hours.

So whenever I hear the words, “This started—doc, I was fine and suddenly became short of breath,” PE isway up on my list, many a time leading to a computerized tomography (CT) [scan] [and an] angio[gram].And the other thing I’ve got on my list is a pneumothorax, but usually they have an x-ray, so you can pickthat up by the time they come in the hospital. But those are the 2 things that certainly come to mind.

So that’s what really makes me—kind of pushes me and makes me think of PE, besides the right heartstrain and other findings.

DR. JILL A. OHAR: Sure. Also with the congestive heart failure thing, I get asked all the time aboutphysicians’ anxieties about beta-blockers and COPD. And there are so many papers out there now show-ing that beta-blockers in patients with COPD are not only beneficial, but [also that] patients who dohave that component of heart failure who are treated with beta-blockers actually do markedly betterthan COPD patients who don’t see a beta-blocker. So I think it’s a really important thing to considernot only during the acute hospitalization, but [also] it’s an opportunity to prevent an exacerbation.

If there is an element of heart failure, let’s optimally treat that now as an opportunity to keep this patientfrom coming back in. As you mentioned, the Jencks Centers for Medicare and Medicaid Services (CMS)data from the New England Journal [of Medicine] suggested that up to 70% come from other reasons.

Are there any things you would do in their transition of care, specifically [in] this woman, to keep herout the third time?

DR. SANJAY SETHI: Yes. In a way it’s good that the CMS now has focused on COPD, that now we areapplying these transitions-of-care models to COPD. Ideally, I think this should be a hospital-based programbecause that’s where they stand the most to lose with readmissions, and they should be supporting it. Andit should be applied to every COPD readmission.

They get seen by a team, or at least by an individual from the team, which would affect the transition ofcare, and there are several elements to it. So when they go home, we examine the issues of their: A) Arethey going to get their medications filled? Do they have the resources to get the medications filled? Theirpsychological and social support—is that existing when they go home? Are they able to reach out tosomeone and get advice on a regular basis? And then, contact—to be seen by a healthcare professionalwho is experienced in lung disease and COPD within a week or so is also quite important.

DR. JILL A. OHAR: What would be your discharge prescriptions for this woman?

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DR. SANJAY SETHI: So at this point, because she was on a LABA/ICS—she was not on a LAMA, whichalso reduces exacerbations—she was not taking her LABA/ICS properly. So at this point, I would beinclined to discharge her on a triple therapy and with a nebulizer for PRN use, provided she can take itproperly, and then with a lot of education about being compliant with it.

Now we do end up with scenarios where people are already on triple therapy, and then what do you do?

DR. JILL A. OHAR: You anticipated my question!

DR. SANJAY SETHI: I did, because I’m sure we deal with the same situations. So in those patients, Ithink addition of either roflumilast or azithromycin on a chronic basis can help reduce—clearly reducethe frequency of exacerbations. So those are the choices we have beyond the inhaled therapy.

DR. JILL A. OHAR: What nonpharmacologic therapies would you order for her at discharge?

DR. SANJAY SETHI: Well, clearly, I will make sure the immunizations are up to date, because otherwiseyou are going to get dinged for that. So that’s a quality measure—so you make sure the immunizationsare up to date. Check her oxygen [and] smoking cessation. But I think the most favorite of yours isrehab[ilitation].

So would you start her on rehab right away—or what would you do with that?

DR. JILL A. OHAR: Yes, I would. I think that the reality of the situation is that in a low percentage ofthe time, she would be seen in 7 days. In reality, she would be seen more likely within 14 days.

I know that there is a transitional care billing code for both, and so you get additional dollars for providingtransitional care in the postdischarge period for up to 14 days. In that period of time, or at that visit, Iwould have her evaluated by our pulmonary rehab team for her ability to perform rehab.

Pulmonary rehabilitation provides for you social support and actual didactics for smoking cessation,which is oh so critical in the postdischarge period. They also provide education about medications thatwe have been discussing. They provide education about nutrition, which is often a problem in the post-discharge period—where people have lost weight in the hospital because they felt too ill to eat.

I think the pulmonary rehabilitation in that discharge period provides more than just exercise. And socialsupport. And we haven’t really spent a lot of time talking about depression, which is one of the comorbiditiesthat is oh so common among COPD patients and is so pervasive among the repeatedly admitted patients.

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You’ve talked about, “does this person really have COPD?” and the number of patients who come to youwho really don’t. They’re smokers. So, when do you go ahead and get a follow-up spirogram?

DR. SANJAY SETHI: If I have documented COPD in the past, well documented with proper pulmonaryfunction, I really don’t—you know, unless it’s going to change my management, repeating pulmonaryfunction doesn’t help me much.

I do repeat it in case patients deteriorate slowly—not an exacerbation, but the ones who keep on gettingworse. Because then you start wondering: Is their lung function getting worse or [is it] something elsethat’s precipitated it?

In patients without a diagnosis, I find definitely doing a spirometry, and if you have a full pulmonaryfunction test, [it] is very useful. And my time frame is usually 4 to 6 weeks.

DR. JILL A. OHAR: I’m a little more aggressive. I think, for number one, the vast majority of the patientsI see have never had pulmonary function testing.

And I think the guidelines kind of are sympathetic with my needs in that they say you need at least oneto make a diagnosis. You need follow-up studies after an exacerbation, because up to 30% of patientswill never come back to their baseline. So I think that’s a really important study that we often don’t get.

So I think there is that potential for the loss of lung function over time that goes unrecognized, and Ialso find that the FEV1 is one of the clear and critical elements of prognosis. The FEV1 is the single bestlab test that we have of everything to predict all-cause mortality.

Clearly, what we haven’t spoken about in this case is the significant minority of patients who exacer-bate and will not live the next year. That’s up to 25% of patients who come in for an exacerbation willbe dead in a year.

And trying to ferret out who those are—

And while FEV1 is not the be-all, end-all, it is an important predictor, along with [a] number of comor-bidities that we’ve talked about today.

Also important is home oxygen; the need for that, whether patients have been ventilated—and it’simmaterial whether it’s invasive or noninvasive. And clearly their age is another important factor.

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What do you feel about diabetes and acute kidney injury or chronic kidney injury as a comorbidity thathas the potential to bring this patient back in [the] postdischarge period? Do you do anything specialabout that? Do you look at a hemoglobin A1C (HbA1c)? Do you factor in your antibiotic choices whenyou’re thinking about chronic kidney disease?

DR. SANJAY SETHI: You know, hyperglycemia makes you more prone to infections, so if your diabetes ispoorly controlled, the chances are you are going to get more infections, including infections of the lung.And again, you need to know the renal function to use your medications properly, to dose them properly.So those are clearly important issues and should be paid attention to, and they are comorbidities in COPD.

I think what we both are talking about is emphasizing how to treat the patient, especially if you want toprevent readmission, rather than just treat the lungs.

DR. JILL A. OHAR: I think this really highlights some of the challenges we all face and some of theapproaches we can consider. I hope this has been helpful to the audience, and I want to thank theaudience for joining us today.

I also urge you to participate in the first Specialty House Call Case and other COPD activities availableon myCME.com: the Medically Speaking roundtable webcast and the Current Medical Opinion withQ&A session. And thank you again.

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