Oral Positive Expiratory Pressure Device for Excessive Dynamic Airway Collapse Caused by Emphysema.

Excessive dynamic airway collapse (EDAC) contributes to breathlessness and reduced quality of life in individuals with emphysema. We tested a novel, portable, oral positive expiratory pressure (o-PEP) device in a patient with emphysema and EDAC. MRI revealed expiratory tracheal narrowing to 80 mm2 that increased to 170 mm2 with the o-PEP device. After 2-weeks use of the o-PEP device for 33% to 66% of activities, breathlessness, quality of life, and exertional dyspnea improved compared with minimal clinically important differences (MCID): University of California-San Diego Shortness of Breath questionnaire score declined 69 to 42 (MCID, ≥5), St. George's Respiratory Questionnaire score decreased 71 to 27 (MCID, ≥4), and before and after the 6-minute walk test Borg score difference improved from Δ3 to Δ2 (MCID, ≥1). During the 6-minute walk test on room air without the use of the o-PEP device, oxyhemoglobin saturation declined 91% to 83%; whereas, with the o-PEP device, the nadir was 90%. Use of the o-PEP device reduced expiratory central airway collapse and improved dyspnea, quality of life, and exertional desaturation in a patient with EDAC and emphysema.

Multidisciplinary Team Utilizing Pharmacists in Multimodal, Bundled Care Reduce Chronic Obstructive Pulmonary Disease Hospital Readmission Rates.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major contributor of morbidity and mortality in the United States resulting in high hospitalization and readmission rates. For health systems, identifying an effective strategy to reduce COPD readmissions has remained difficult. Multiple COPD care bundles have been developed with varying degrees of success. Bundles that were multidisciplinary and included pharmacists were successful in reducing readmissions. OBJECTIVE: To describe and assess a multidisciplinary, 5-element, COPD care bundle that was implemented in an academic, urban safety-net hospital to reduce COPD readmissions and the role of pharmacists in bundle implementation. METHODS: A multidisciplinary team collaborated to develop a 5-element COPD care bundle that met unmet patient needs. The bundle elements included the following, with pharmacy responsible for the first two: optimization of COPD inhalers, 30-day supply of insurance-compatible inhalers, individualized patient inhaler teaching, provision of standardized discharge instructions, and scheduling of a 15-day discharge follow-up appointment. Bundle was implemented with multiple Plan-Do-Study-Act (PDSA) cycles to develop intra- and interdepartment processes. RESULTS: Prior to bundle implementation, the health system COPD readmission rates were 22.7%. Reliable implementation of the bundle reduced readmissions to 14.7% over a 6-month period. Pharmacy adherence to completion of the bundle was over 95% over 2 years of bundle use. CONCLUSION: Pharmacists have a crucial role in hospital-based transitions of care to reduce COPD readmissions.

Pragmatic Challenge of Sustainability: Long-Term Adherence to COPD Care Bundle Maintains Lower Readmission Rate.

Long-term sustainability of successful improvement initiatives remains a pragmatic challenge with limited literature guidance. A chronic obstructive pulmonary disease (COPD) care bundle was developed and implemented to mitigate care-delivery failures and unmet patient needs at University of Cincinnati Medical Center that led to a 35% reduction in 30-day all-cause readmissions. Here, two-year outcomes and the method of achieving sustainability are presented. METHODS: After implementation of the COPD care bundle, 30-day all-cause readmissions reduced from 22.7% to 14.7%. In 2016 the project transitioned from implementation to the sustainability phase. A four-member sustainability team was formed (pulmonologist, hospitalist, respiratory therapist, and pharmacist) with clearly defined roles for monitoring and facilitating sustainability actions. The process of bundle delivery was purposefully designed for higher reliability. Staff education and daily operations were updated to incorporate the new process. Outcome (readmission rate) and process (bundle adherence) measures were monitored monthly. Any significant drop (special cause variation) would be reviewed by the team and further action taken, if needed. The National Health Service sustainability model was used, with adjustments made to meet our contextual needs. RESULTS: The 30-day all-cause readmission rate remained the same as during the initial implementation phase (14.9%). Adherence to COPD care bundle components was 87.7%. During the two-year period, three occasions triggered a team discussion and detailed review. CONCLUSION: Sustainability requires a purposefully designed, resilient process; standard work; engagement of the team and leadership; and a monitoring system of key process and outcome measures. Application of sustainability models should be adjusted for specific contextual needs.

Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science.

BACKGROUND: Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed. OBJECTIVES: Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence. SETTING: An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015. METHOD: We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and 'Model for Improvement', we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions. RESULTS: Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45). CONCLUSION: System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.

Update on ultra-long-acting ß agonists in chronic obstructive pulmonary disease.

INTRODUCTION: For the last two decades, long-acting ß agonists (LABAs) have been a cornerstone in the management of chronic obstructive pulmonary disease (COPD). They relax airway smooth muscle and augment expiratory airflow, which reduces hyperinflation and improves dyspnea, functional capacity and quality of life. In recent years, Indacaterol, a LABA with an ultra-long duration of action (ultra-LABA), which only requires once-daily dosing, was approved by the FDA. The clinical efficacy of indacaterol is comparable, and, in some aspects better, than the currently available LABAs. AREAS COVERED: This article reviews the pharmacological properties, clinical efficacy, safety and potential role of the ultra-LABAs in COPD management. EXPERT OPINION: Ultra-LABAs are effective bronchodilators with a prolonged duration of action. By decreasing dosing frequency, ultra-LABAs potentially may improve respiratory medication adherence, which is associated with better survival and less healthcare utilization. In addition to their salubrious benefits, ß agonists may produce untoward effects. Increased mortality and hospitalizations among patients with left ventricular heart failure, who were treated with ß agonists, has caused concern about their use in patients with COPD and heart disease. Further experience and testing will determine the optimal role of ultra-LABAs in the management of COPD.

Dynamic hyperinflation correlates with exertional oxygen desaturation in patients with chronic obstructive pulmonary disease.

BACKGROUND: Dynamic hyperinflation (DH) causes exercise limitation and exertional dyspnea in patients with chronic obstructive pulmonary disease (COPD). Exertional desaturation (ED) also occurs commonly in COPD but neither routine physiologic parameters nor imaging predict ED accurately. In this study we evaluated the relationship between DH and ED during 6-min walk testing (6MWT). METHODS: We measured ED and DH in patients with stable COPD. SpO2 was measured by continuous pulse oximetry during 6MWT. ED was defined as a decline in SpO2 (ΔSpO2) ≥4 %. DH was determined by measuring inspiratory capacity (IC) before and after the 6MWT using a handheld spirometer. DH was defined as ΔIC >0.0 L. We correlated DH and ED with clinical and pulmonary physiologic variables by regression analysis, χ (2), and receiver operator curve (ROC) analysis. RESULTS: Thirty males [age = 65 ± 9.4 years, FEV1 % predicted = 48 ± 14 %, and DLCO % predicted = 50 ± 21 % (mean ± SD)] were studied. ΔSpO2 correlated with ΔIC (r = 0.49, p = 0.005) and age (r = 0.39, p = 0.03) by univariate analysis; however, only ΔIC correlated on multivariate regression analysis (p = 0.01). ΔSpO2 did not correlate with FEV1, FVC, FEF25-75, RV, DLCO % predicted, BMI, smoking, BORG score, or distance covered in 6MWT. DH strongly correlated with ED (p = 0.001). On ROC analysis, DH had an area under the curve of 0.92 for the presence of ED (sensitivity = 90 %; specificity = 77 %, p < 0.001). CONCLUSION: Routine pulmonary function test results and clinical variables did not correlate with ED in patients with stable COPD. Dynamic hyperinflation strongly correlates with exertional desaturation and could be a reason for this desaturation.

Orbital aspergillus infection mimicking a tumour: a case report.

A 14-year-old male presented to the neurosurgical clinic with swelling just above the right eye which had been growing slowly for the last eight years. The swelling first appeared following a non-penetrating trauma eight years ago. On examination it was a non-tender, non-erythematous, firm, round swelling causing marked proptosis and diplopia on downward gaze only. The visual acuity was intact. MRI showed an intraorbital, extraconal mass isointense on T1 and hypointense on T2 imaging. A diagnosis of orbital tumor was made. A white, friable mass consistent with meningioma was resected. However histopathology report later showed it to be an Aspergilloma. The patient was successfully treated with anti-fungal medicine and was disease-free at one year follow-up.

Perinatal outcomes in pregnancy with asthma.

OBJECTIVE: To examine the relationship between asthmatic pregnancies and selected maternal and neonatal outcomes in a representative cohort. METHODS: A retrospective cohort study was conducted at the Aga Khan University Hospital during the year 2004. A random selection was made of 65 asthmatic and 63 non-asthmatic singleton births. The neonatal outcomes studied were birth weight, premature birth and Apgar scores at 1 and 5 minutes. The maternal outcomes studied were number of hospital admissions, and number of documented UTI during the studied pregnancy and past history of abortions and stillbirths. RESULTS: The mean age of asthmatics and nonasthmatics were 28.0 +/- 4.9 years and 27.7 +/- 3.6 years respectively. The average parity among asthmatic women was 2.97 while that in controls was 2.57 (p < 0.137). Neonates born to asthmatic mothers had shorter mean gestational age with increased risk of premature birth and lower Apgar scores. Asthmatic mothers had a greater risk of abortions and low birth weight babies. They also had higher rates of UTIs and hospital admissions. CONCLUSION: Asthmatic pregnancies are more likely to result in abortion, premature delivery and low birth weight babies. The asthmatic pregnancies were also linked with higher rates of maternal UTI. Thcrefore a more vigilant monitoring is required in asthmatic pregnancies.