A respiratory therapist-directed protocol for managing inpatients with asthma and COPD incorporating a long-acting bronchodilator

A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure

Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.

Redundant medication use during acute exacerbation of chronic obstructive pulmonary disease in hospitalized patients

Background Few clinical studies have evaluated redundant therapy during an exacerbation of chronic obstructive pulmonary disease in hospitalized patients, but clinical practice guidelines endorse this practice. Objective The aim of this study is to measure the frequency of redundant therapy and explore its association with clinical outcomes, adverse effects, and cost among adults hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Setting Six hospitals within an academic health system in the United States. Method A retrospective cohort study of adults with a principal diagnosis of acute exacerbation of chronic obstructive pulmonary disease between January 1, 2016 and March 31, 2016 was performed. Main outcome measure The primary outcome was the proportion of patients who received redundant therapy during inpatient management of acute exacerbation of chronic obstructive pulmonary disease. Results Overall, 137 patients were included and 99 (72.7%) received redundant medication therapy. Redundant therapy was not associated with significant differences in clinical outcomes such as median hospital length of stay, 30-day readmission, tachycardia, thrush, psychiatric symptoms or urinary retention in the univariate or multivariate analyses. The median medication acquisition cost per patient was nearly 11-fold higher among those receiving redundant medication therapy [$135.14 (49.21) vs 12.50 (17.02); p < 0.001]. After controlling for confounding variables using multivariate linear regression, the cost of redundant medication therapy was $50.20 higher on average (p < 0.001). Conclusion Redundant inhaled therapy for acute exacerbation of chronic obstructive pulmonary disease in the hospital setting was not associated with improved clinical outcomes or more adverse effects but did significantly increase medication cost. The findings of this study should be considered exploratory.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

OBJECTIVES

To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU.

DESIGN

A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics.

METHODS

The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results.

RESULTS

The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written.

CONCLUSIONS

This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Evaluation of Bronchodilator Use During Chronic Obstructive Pulmonary Disease Exacerbation Inpatient Admissions

Background: It is unknown whether the timing of initiation of a long-acting bronchodilator (LABD) during a chronic obstructive pulmonary disease (COPD) exacerbation or the method of short-acting bronchodilator (SABD) delivery may aid in improving patient outcomes. Objective: The goal of this study was to determine the impact of bronchodilator management in the hospital setting on clinical outcomes in patients with COPD exacerbation. Methods: This retrospective, single-center study evaluated patients admitted to the non-intensive care unit setting with a COPD exacerbation as defined by the International Classification of Diseases, Ninth Revision codes. The primary outcome was difference in 30-day readmission rates for early LABD therapy (<24 hours from hospital admission) versus late/no LABD therapy (>24 hours from hospital admission or not during hospitalization). Secondary objectives included length of stay (LOS) for this group, and 30-day readmission rates and LOS for the SABD via inhaler versus nebulizer groups. Results: Two hundred twenty patients were included. There was no difference in 30-day readmission rate (15.2% vs 18.2%, P = .6) and LOS (median 4 [interquartile range, IQR 3-6]) days for both groups, P = .34) between early versus late/no LABD therapy initiation, respectively. No difference was observed in 30-day readmission rate (16.7% vs 16.6%) and LOS (median 2.5 [IQR 1.1-3.9] days vs median 4 [IQR 2-6] days) between inhaler and nebulizer SABD therapy groups. Conclusions: No difference was observed in 30-day readmission rates or LOS when utilizing early LABD compared with late/no LABD therapy or comparing inhaler and nebulizer SABD delivery methods during COPD exacerbation.

A systematic review of the implementation and impact of asthma protocols

BACKGROUND

Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.

METHODS

PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.

STUDY SELECTION

Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.

RESULTS

From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.

CONCLUSIONS

Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.

Preventing and managing exacerbations in COPD--critical appraisal of the role of tiotropium

The course of COPD is punctuated by acute exacerbations that are associated with an increase in the morbidity and mortality related to this chronic disease and may contribute to its rate of progression. Therefore, preventing and treating exacerbations are major goals of COPD management. The role of tiotropium in the prevention of exacerbations has been investigated in several placebo-controlled randomized clinical trials varying in duration from 3 months to 4 years in patients with moderate to very severe COPD. In all of these trials, tiotropium has uniformly reduced the proportion of patients experiencing at least one exacerbation and delayed the time to the first exacerbation compared with placebo. In the longer trials (> or =6 months' duration) tiotropium has also reduced the exposure-adjusted incidence rate of exacerbations. In trials of at least 1 year in duration, tiotropium either significantly reduced the risk of hospitalization for an exacerbation and/or the proportion of patients with an exacerbation-related hospitalization. In a meta-analysis that included 15 trials of tiotropium vs either placebo (n = 13) and/or a long-acting beta-agonist (LABA; n = 4), tiotropium significantly reduced the odds of experiencing an exacerbation compared to placebo as well as a LABA. The potential additive benefits of tiotropium to those of a LABA and/or inhaled corticosteroid in reducing exacerbations require further investigation. The mechanism whereby tiotropium reduces exacerbations is not due to an anti-inflammatory effect but more likely relates to its property of causing a sustained increase in airway patency and reduction in hyperinflation, thereby counteracting the tendency for respiratory insults to worsen airflow obstruction and hyperinflation. For the management of acute exacerbations, an increase in short-acting inhaled bronchodilators is recommended as needed, while the potential role of long-acting bronchodilators, such as tiotropium, in conjunction with short-acting agents, is unclear and warrants further study.

Long-term safety of nebulized formoterol: Results of a twelve-month open-label clinical trial

Formoterol fumarate is a long-acting β2-agonist that is an effective bronchodilator for the maintenance management of patients with chronic obstructive pulmonary disease. The safety profile of the newly developed nebulized formoterol was evaluated over a twelve-month period in an open-label, active-control study. After completing a twelve-week double-blind double-dummy period, 569 subjects with chronic obstructive pulmonary disease entered an open-label extension study and received twice-daily 20 µg formoterol fumarate inhalation solution for nebulization (FFIS) or 12 µg formoterol fumarate dry powder inhalation (FA) for 52 weeks. Most of the FFIS-treated subjects (86%) completed at least six months of open-label treatment with over 90% compliance, comparable to the FA group (88%). Results of safety monitoring for adverse events, laboratory values, and cardiac changes were similar between treatment groups. Three hundred forty (73%) of FFIS-treated subjects and 83 (78%) of FA-treated subjects experienced an adverse event over the course of the study, the majority of which were mild to moderate and considered unrelated to treatment. COPD exacerbation occurred in 15.8% of FFIS-treated and 17.9% of FA-treated subjects. Deaths, serious adverse events, and discontinuations for adverse events occurred in 1.3, 16.2, and 5.4% of the nebulized group versus 1.9, 17.9, and 7.5% of the inhaled group, respectively. There were no clinically important changes from baseline in laboratory tests, including serum potassium and glucose, or vital signs and no treatment-related increases in cardiac arrhythmias, heart rate, or QTc prolongation. We conclude that nebulized formoterol fumarate twice daily is well tolerated over long-term treatment in moderate-to-severe COPD subjects and has a similar safety profile to the DPI formulation.

Formoterol fumarate inhalation solution (Perforomist) for COPD

Formoterol fumarate is an effective treatment for chronic obstructive pulmonary disease (COPD) patients with moderate or greater severity of airflow obstruction. Published studies indicate that formoterol has a rapid onset of bronchodilation, which may enhance compliance, and sustained bronchodilation over 12 h, which produces a cumulative effect when inhaled twice daily. With long-term use, formoterol fumarate increases trough forced expiratory volume in 1 s and improves measures of hyperinflation, which correlate with relief of symptoms and a decreased need for additional short-acting bronchodilators as rescue treatment. The combination of formoterol with anticholinergic bronchodilators, especially the long-acting anticholinergic tiotropium, appears to further improve bronchodilation, decrease hyperinflation, improve symptoms and decrease the need for rescue therapy, compared with either agent alone. The availability of formoterol fumarate inhalation solution (Perforomist) for treatment of COPD now extends these benefits to patients who prefer nebulizer therapy and/or cannot use metered-dose or dry-powder inhalers effectively.

Cost-effectiveness of live attenuated influenza vaccine versus inactivated influenza vaccine among children aged 24-59 months in the United States

BACKGROUND

The US Advisory Committee on Immunization Practices (ACIP) recently expanded the influenza vaccine recommendation to include children 24-59 months of age. In a large head-to-head randomized controlled trial, live attenuated influenza vaccine, trivalent (LAIV) demonstrated a 54% relative reduction in culture-confirmed influenza illness compared with trivalent inactivated influenza vaccine (TIV) among children aged 24-59 months.

OBJECTIVE

To evaluate the relative cost and benefit between two influenza vaccines (LAIV and TIV) for healthy children 24-59 months of age.

METHODS

Using patient-level data from the clinical trial supplemented with cost data from published literature, we modeled the cost-effectiveness of these two vaccines. Effectiveness was measured in quality-adjusted life years (QALY) and cases of influenza avoided. The analysis used the societal perspective.

RESULTS

Due to its higher acquisition cost, LAIV increased vaccination costs by USD7.72 per child compared with TIV. However, compared with TIV, LAIV reduced the number of influenza illness cases and lowered the subsequent healthcare use of children and productivity losses of parents. The estimated offsets in direct and indirect costs saved USD15.80 and USD37.72 per vaccinated child, respectively. LAIV had a net total cost savings of USD45.80 per child relative to TIV. One-way and probabilistic sensitivity analyses indicated that the model was robust across a wide range of relative vaccine efficacy and cost estimates.

CONCLUSIONS

Due to its increased relative vaccine efficacy over TIV, LAIV reduced the burden of influenza and lowered both direct health care and societal costs among children 24-59 months of age.

Anticholinergic agents in asthma: chronic bronchodilator therapy, relief of acute severe asthma, reduction of chronic viral inflammation and prevention of airway remodeling

PURPOSE OF REVIEW

It is difficult to identify specific groups of asthmatic patients who may benefit from acute or chronic use of anticholinergic agents. Therefore, an important consideration is how anticholinergic agents can be used to achieve clinically effective treatment of asthma.

RECENT FINDINGS

A genotype-stratified study revealed that greater bronchoprotective effect of anticholinergic agents was observed in asthmatic patients with the Arg/Arg genotype of the beta2-adrenergic receptor. Anticholinergic agents could add to the bronchodilation obtained with beta2-agonists on acute severe asthma. CD8+ T lymphocytes induced by chronic hepatitis C viral infection causes chronic obstructive pulmonary disease-like inflammation in asthma. Virus-specific CD8+ T lymphocytes may induce cholinergic activation in asthma through M2 receptor dysfunction. Therefore, anticholinergic agents are highly effective for asthma associated with chronic viral infection. In contrast, asthma with chronic obstructive pulmonary disease-like inflammation appears to be poorly responsive to beta2-agonists and can lead to partially irreversible airflow limitation. Moreover, a recent report suggested that treatment with inhaled tiotropium bromide markedly inhibited the increase in airway smooth muscle mass, myosin expression, and contractility in asthma.

SUMMARY

Anticholinergic agents may benefit stable asthmatics, particularly those who have the Arg/Arg genotype. These agents have a demonstrated role in combination with beta2-agonists in the treatment of acute severe asthma, and may benefit asthmatics with chronic obstructive pulmonary disease-like inflammation. Moreover, these agents could be also beneficial in preventing airway remodeling in asthmatic airways.