COPD

ED study reveals gaps in managing COPD exacerbations


A five-country study of emergency department presentations by patients with acute exacerbations of COPD has shown clinical management is not matching evidence-based guidelines.

The study of more than 400 patients in Australia, New Zealand, Singapore, Hong Kong and Malaysia found the vast majority of patients underwent chest X-ray (93%) and received bronchodilators (80%).

About 66% of patients received corticosteroids and 57% were treated with non-invasive ventilation (NIV) if their pH was less than 7.30.

However the study noted blood gas analysis was only performed in 55% of patients.

“Blood gas analysis to identify respiratory acidosis and hypercapnia is recommended by guidelines in all but mild cases,” the study said.

“The lack of testing may result in under-diagnosis of respiratory acidosis that might benefit from treatment with biPAP and under-diagnosis of clinically significant hypercapnia which may have other implications for treatment, especially oxygen therapy.”

Professor Anne-Maree Kelly, director of the Joseph Epstein Centre for Emergency Medicine Research, Melbourne, told the limbic that management of COPD could be improved both inside and outside the ED.

“We found that chronic medications were probably underused and that perhaps is an area where we could have gains and potentially prevent deterioration and hospital admission.”

She said awareness of guidelines and evidence was one thing, but the translation of that information was also difficult given the ‘cognitive overload in ED’.

“There is just so much going on and so many interruptions to work and workflow that it is very easy to do part of it well – particularly the bronchodilator part of it – and to not concentrate on getting it all right.”

“Our expectation is that if patients are not managed optimally in ED, then it would at least have an influence on length of stay in the hospital and may have implications in terms of additional morbidity.”

She said strategies for overcoming the evidence practice gaps such as structured treatment pathways were urgently needed.

“There are a lot of options, for example the old-fashioned paper pathway approach, although EDs are drowning in separate bits of paper for every condition under the sun.”

“There are also more sophisticated approaches like computerised decision support systems, which are widely used in other situations such as trauma or critical care medicine. They actually show quite a lot of promise.”

“At the moment, we’ve identified some of these issues in the hope that we can encourage solutions developed mutually by respiratory and other physician groups and ED so it works for everybody.”

The Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study is published in Respirology.

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