Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Twelve Trials of Christmas!

Day 7 of Christmas- NAC for COPD.

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the seventh of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

The next ED study I would like to see is Nacetylcysteine (NAC) for COPD.  Initially, the BRONCHUS trial in 2005 looked at 523 patients using once daily 600mg NAC for prevention of flares and mproving FEV1. They found no benefit.  Two studies in the last two years have looked at twice daily dosing of NAC, finding decreased exacerbations, and a third showing NAC potentiated the bronchodilatory effect of ipratropium.

 

Given the above, a trial of NAC in the ED may provide some benefit in helping patients get over the initial hump, and perhaps, lead to an early discharge. (Perhaps akin to early systemic steroids in addition to the patients inhaled steroid regimen during exacerbations).  At the least, it may cause pulmonology to reconsider giving NAC to their patients on the outside world and help it come standard of care.

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Cardiology, Cardiology, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Twelve Trials of Christmas!

Day Five of Christmas- where’s the Obs EBM?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the fifth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

I believe that the longer a patient stays in the hospital, the more likely they are to develop new and exciting pathology (pulmonary emboli, VRE, general deconditioning, an unhealthy affinity for tuna sandwiches, etc).  t’s not that I want to throw people out so to so to speak, it’s that their risk of developing hospital acquired badness is higher than their risk of adverse outcome from their diagnosis (like, say, low / no risk chest pain).  As such, I’ve recently taken an affinity towards our observation unit to see which, if any, of the classically admitted COPD’ers / CHF’ers, etc, can be placed in observation for <24 hours (actually need to be there), and do well.

We need to see some studies for who is a candidate for observation – and perhaps some data on why ED providers put no risk chest pain and other similar low yield findings in observation. There is little to no data on observation units, despite over a third of hospitals in the US having them.  Despite guidelines for observation, there are few evidence based guidelines.  We know that increasing age is associated with an increased rate of admission from observation status (about 26% vs 18 %); and there are also cellulitis guidelines for observation units, but that is about it.  While there are Ottawa guidelines for admission for CHF and COPD, and the famous PORT scores, these rules were designed to identify low risk patients, not necessarily those that needed a day or two in the hospital.

 So, perhaps, much like we have recently begun to risk stratify PE’s into going home and being lysed, so we will have to do the same for utilization of observation & inpatient resources.  What delineates which patients in the grey area between obvious discharge home and ICU admission can go to observation – not just the ED provider saying “yeah, they look ok for observation” – some actual evidence that suggests the patient can be turned around in under 24-36 hours.  I suspect for CHF, we’ll see that most of these patients, once properly cared for in the ED (cough, nitro nitro nitro, cough), can go to observation, which will likely surprise most ED & inpatient providers – thus, hopefully decreasing the risk of hospital acquired badness for these patients.

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Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Radiology, Radiology

Good thing you caught that Chest Cold early.

There has been recent discussion in the #FOAM world in regards to labeling otherwise benign conditions (such as GERD in pediatrics) and the patient & family perception requiring medications for this.
Seth Trueger (@mdaware), at ACEP13, brought to my attention an interesting paper in regards to another common labeling of a benign condition, acute bronchitis.

In 2005, 459 patients were presented with a written scenario describing a typical acute respiratory infection in which they were labeled either to have a “chest cold”, “viral infection” or “acute bronchitis” and also were provided with a treatment plan that excluded antibiotic treatment. There is no changes in satisfaction or dissatisfaction with the diagnostic label however, 26% of patients were dissatisfied with treatment 1 provided with the label “bronchitis”and not provided a prescription for antibiotics compared to 13% for a chest cold and 17% for a viral illness respectively. There was no differences in regards to patient’s satisfaction based on age, sex, or education level.

The authors also note that patient pressure is a significant role in antibiotic overprescribing. They note that 54% pediatricians feel parental pressure to inappropriately prescribe antibiotics. For adults, 77% of the time when providers were questioned about antibiotics, they were prescribed first 29% of the time when providers were not asked.

So, to want to decrease your patient dissatisfaction, might I suggest, in the words of Hoffman & Bukata:

“It seems to be a chest cold. Good thing you caught it early before it turned into bronchitis!”

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PMID: 16322409

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Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary

NIV for Pneumonia

It is by and large a foregone conclusion that non-invasive ventilation (NIV) saves intubations (and lives) in COPD and CHF. There has not been too much #FOAM specifically for pneumonia and NIV, so let’s dive in.

Recently, there was a publication stating that NIV treatment failure was significantly higher for pneumonia vs COPD (49% vs 12%). This was a small study (under 80 patients), but does this mean we should not try NIV for pneumonia? More importantly, do pneumonia patients have worse outcomes than they otherwise would if they were intubated sooner? Is it worthwhile to give a NIV trial in pneumonia?

To start, 127 patients with respiratory failure secondary to community-acquired pneumonia (CAP) were examined prospectively. 25% of these patients failed NIV. Those that failed NIV were more likely to have confusion at presentation, were >65 years old, had worsening chest films over time, and lack of improvement at 1 hour on NIV.  A second study of similar ilk (CAP placed on NIV) examined 64 patients in which 43% of patients successfully avoided intubation (ie, 57% failed NIV). Success was associated with a lower APACHE II score, higher pH at the end of NIV trial (7.34 vs 7.44), and lower respiratory rate (28 vs 23 breaths/minute).

Now that flu season is upon us, let’s examine the 685 patients with confirmed influenza A that were studied in Barcelona in a prospective observational registry.  489 patients were intubated in the ED and 177 received NIV.  NIV was effective 40.6% of the time, and associated with shorter LOS.  Key details in this study were that not requiring vasopressors, the absence of renal failure, and fewer than one lobe involvement on CXR were all significantly associated with successful NIV. Most importantly, the delay in intubation did not affect mortality (26.5% for ETT, 24.2% for NIV).  Thus, for every 100 NIV patients in whom the decision to intubate was made, there was ~25% mortality – roughly the same rate as those that were intubated without a NIV trial – so the delay does not worsen outcomes.

For the immunocompromised, an evaluation of 120 patients came to similar conclusions: higher APACHE II scores and a need for vasopressors were associated with failure of NIV.  Underlying disease did not affect NIV duration rates or outcomes.  Again, the authors found that the mortality rate of failed NIV patients that required intubation was similar to those that were intubated from the start.

Conclusions?  If you need to start pressors, or have new onset renal insufficiency, you may want to skip NIV and reach for the intubation kit first.  Otherwise, with 40-75% success rate of NIV, and without an adverse outcome for delayed intubation in pneumonia patients, it seems reasonable for the patient to first have a trial of non-invasive ventilation.

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PMID: 24814916

PMID: 25043135

PMID: 20435435

PMID: 22404211

PMID: 22944604

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Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Pulmonary, Radiology

How do you PE part 2

Last PE post, we discussed PEITHO, TOPCOAT, MOPPETT, and the lysis of massive and submassive PEs.  So what do we do for the un-submassive and unmassive PEs?

     The Outpatient Treatment of Pulmonary Embolism (OTPE) study compared outpatient vs inpatient treatment of low-risk patients with acute PE.  Patients were treated with lovenox bridge to coumadin either as outpatient or inpatient (171 v. 168 patients). Patients were followed for 90 days, with follow up calls at days 1-7, 14, 30, 60, 90.  Only 1 outpatient developed a recurrent VTE, two outpatients developed “major bleeding” within 2 weeks – both IM hematomas.  Neither recurrent VTE or major bleeding between the two groups was statistically significant.  Likewise, one person in each group died from non-VTE and nontreatment-related causes. 99% of participants completed the Press-Ganey, satisifaction survey with 92% of outpatients and 95% of inpatients being satisfied or very satisfied with their care.  As for bounce backs?  Readmissions, ED visits, and PMD visits were similar in the two arms.  The total number of home nursing visits was higher among outpatients (14% vs 6% of patients), but the mean time spent in the hospital was obviously greater for inpatients (3.9 days vs 0.6 days).

     I question whether or not outpatient treatment at most facilities would be >90% satisfied, but certainly intriguing.  Gazing into my crystal ball, I suspect the day will come when we are either admitting & providing lytics, or discharging from the ED on Xarelto / Pradaxa / other.  For PE risk score, you may use Hestia or PESI .

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Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. PMID: 21703676
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Critical Care, Improving Outcomes, Improving Throughput, Pulmonary

How do you PE?

We have MOPETT, PEITHO, and now, TOPCOAT.

    MOPETT looked at 121 patients, and found that tpa led to a decrease in pulmonary hypertension (22 vs 8 mm Hg) at 28 month follow up, and a decreased LOS (2.2 vs 4.9 days). This drew some backlash and claims that there was an unusually high incidence of pulmonary HTN in this trial.

    PEITHO looked at 1,005 patients, with “intermediate risk” which they defined as RV strain on echo or CT, plus a positive troponin. Patients were randomized to weight based tenecteplase as a bolus + standard anticoagulation vs standard anticoagulation only. Essentially, death at 7 & 30 days were similar – 1.2% vs 1.8% (lytics vs no lytics) at 7 days and 2.4% vs 3.2% at 30 days (lytics vs no lytics). Stroke at 7 days was 2.4% in the lytic treatment arm vs 0.2% without lytics, while hemodynamic compromise defined as persistent hypotension, pressor requirements, intubation and CPR, was higher in the no lytics group (1.6% vs 5%). They make no mention of pulmonary hypertension at follow up. So really, the patient has a 3% chance of death either way.

    Now, there is TOPCOAT. Normotensive patients with PE and RV strain (either on echo or BNP), were given either tenecteplase bolus + standard anticoagulation or standard anticoagulation only. The study, unfortunately, enrolled only 83 patients, with 40 receiving tenecteplase. 16 non-lytic patients vs 6 lytic patients had an adverse outcome, defined as death, shock, intubation, major bleeding within 5 days, recurrent PE, poor functional capacity (RV dysfunction + dyspnea at rest or exercise intolerance), or an SF36 Physical component score <30 at 90 day follow up. Basically, since only 1 patient died and 2 required intubation of the 16 non-lytic patients, the main difference here is functional capacity and quality of life. More on SF36 here: http://www.sf-36.org, though it is essentially a composite score measuring quality of life).

    For submassive PE’s, the general trend is that a shared decision will need to be made: mortality is essentially the same, 2-3%, no matter the treatment. Would they rather it be from PE or from its treatment, but knowing that they have a chance at better quality of life months to years down the line? There are potential legal landmines on either side of this discussion. Document well, my friends!

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Unusually high incidence of pulmonary hypertension in MOPETT trial. PMID: 23764652

Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). PMID: 23102885

Fibrinolysis for patients with intermediate-risk pulmonary embolism. PMID: 24716681

Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at three months (TOPCOAT): Multicenter double-blind, placebo-controlled randomized trial. PMID: 24484241

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Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pulmonary, Pulmonary

Most PO antibiotics are equivalent to their IV counterpart.

If you have ever said to a patient – and meant it – that they needed to stay for “antibiotics in the IV” and you were not giving CefeVancoSyn, read further and take your educational beating.  There is a paucity of data on IV being equivalent to PO, but at least there is some – and its reviewed in this post.  However, there is no significant data on an IV antibiotic being better, faster, stronger than its PO counterpart – for just about anything clinically significant, except for very antibiotic-specific instances (example: IV vs PO vanco, for SSTI or CDiff).

In a comparison of PO Augmentin vs IV Augmentin transitioned to PO Augmentin vs IV Cephalosporin transitioned to PO Cephalosporins for lower respiratory tract infections, there were no significant differences between clinical outcome or mortality. Patients in the PO only group, shockingly, had a reduced hospital stay.

In a Cochrane Review, oral treatment has been show to be an acceptable alternative to IV antibiotic treatment in febrile neutropenic patients without pneumonia or skin / soft tissue infection, organ failure, or central line infection, who are also hemodynamically stable. Mortality and treatment failure were similar. I am not saying to discharge them on oral antibiotics from the ED – despite MASCC saying you can – but you may transition them home sooner and stop the snowball effect “the need for IV antibiotics” can have on a patient.

There are a handful of studies which show PO antibiotics equivalent to IV antibiotics for initial management of pediatric pyelonephritis – with comparable renal scarring, adverse reactions, and treatment failure as well.

Next time you start IV Levaquin for “a loading dose” on a patient that can tolerate oral antibiotics, think about this post, the added cost to the patient, and nursing time spent setting up IV treatment. Stop the snowball effect in the ED, the patient can continue PO on the floor, and likely leave the hospital sooner, without compromising safety.

Do NOT even consider “an IV dose in the ED and go home.”

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Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. PMID: 15495074

Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. PMID: 7787537

Are oral antibiotics equivalent to intravenous antibiotics for the initial management of pyelonephritis in children? PMID: 21358894

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