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1st April 2022
Both dysnatraemia and dyskalaemia, especially, hyponatraemia and hypokalaemia are common electrolyte disorders among emergency department patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD). However, the presence of these disturbances do not negatively impact on outcomes such as re-admission, the need for intensive care treatment or mortality. This was the conclusion of a study by a team from the Department of Internal and Emergency Medicine, Solothurn, Switzerland.
Electrolyte disorders often affect patients prescribed diuretics attending an emergency department (ED). For example, one study found that 4% of patients had hyponatraemia on admission, 12% hypernatraemia, 11% hypokalaemia and 4% hyperkalaemia. Furthermore, the presence of dysnatraemia upon on admission to an intensive care unit, is an independent risk factors for poor prognosis. Equally, dyskalaemia has been found to occur in 1 of 11 ED patients and is associated with both inpatient admission and mortality.
Although dysnatraemia, in particular, hyponatraemia at discharge is associated with an increased risk of recurrence in hospitalised patients with pneumonia, much less is known about the effect of both dysnatraemia and dyskalemia in patients admitted to an ED with an acute exacerbation of COPD.
Consequently in the present study, the Swiss team retrospectively examined the prevalence and extent of both dysnatraemia and dyskalemia and the associated outcomes in patients visiting an ED with an acute exacerbation of COPD. For the purposes of the study, baseline hyponatraemia and hypernatraemia were defined by a serum sodium level of below 135mmol/l and above 145mmol/L respectively. Similarly, hypokalaemia and hyperkalaemia were defined as < 3.5mmol/l and > 5mmol/l respectively. Additional clinical and demographic data were also collected from hospital charts. For comparative purposes, similar data were collected for a sample of patients with community-acquired pneumonia. The outcomes of interest were intensive care unit (ICU) admission, the need for mechanical ventilation, length of hospital stay, 30- and 180-day re-admission rates and hospital mortality.
Dysnatraemia and dyskalemia and outcomes for those with acute COPD
A total of 19,846 consultations for which serum sodium and potassium levels were available were used in the analysis, of which 102 patients, with a mean age of 73 years (46.1% male), had an acute exacerbation of COPD. The mean baseline serum sodium and potassium levels were 137mmol/l and 4.0mmol/l respectively. Overall, upon admission, 23% of patients had hyponatraemia and 5% hypernatraemia, whereas 16% and 4% had hypokalaemia and hyperkalaemia, respectively. Compared with those without COPD, hyponatraemia was significantly more common (p = 0.001) as was hypernatraemia (p < 0.001) although levels of dyskalaemia were non-significant.
In regression analysis neither dysnatraemia or dyskalaemia were significantly associated any of the outcomes of interest such as the need for ICU admission, invasive or non-invasive mechanical ventilation, re-admission or mortality.
The authors concluded that while dysnatraemia and dyskalaemia were commonly encountered in those presenting at an ED with acute exacerbations of COPD, neither disorder was associated with adverse outcomes.
Lindner G et al. Sodium and potassium disorders in patients with COPD exacerbation presenting to the emergency department BMC Emerg Med 2022
15th November 2021
Using dark field x-ray, a team from the Department of Physics, Munich School of BioEngineering, Germany, were able to diagnosis emphysema in patients with COPD which to date has not been possible with conventional x-ray methods. Emphysema is caused by the irreversible destruction of alveolar walls, leading to enlargement of distal airspaces. Although this leads to changes in the lung structure, it is not possible to detect the early stages of emphysema with a conventional chest x-ray. As x-rays are subject to other effects such as refraction and ultra small-angle scattering which are not visualised with a conventional X-ray imaging system, in DFX, the contrast is produced by these multiple refractions on microstructures in the object. Hence, the dark-field signal enables visualisation of structural information that is inaccessible with conventional medical x-ray systems and dark field imaging has, for example, enabled the identification of acute lung inflammation in animal models.
With the potential to identify changes at the micro-structural level with dark field x-ray, indicative of emphysema, the German team undertook their study to examine whether this approach could improve the medical lung assessment in patients with COPD. Included patients were those with an initial indication of emphysema as revealed by a CT scan but still absent based on spirometry readings. However, a small number of patients with moderate to severe emphysema were also included. COPD classification was based on the post forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) as proposed by GOLD classification and patients with a FEV1/FVC value of 0.70 were assessed as having no COPD. Dark field x-rays were performed and visually assessed by five readers.
A total of 77 patients with a mean age of 65.9 years (male) and 63.3 years (female) were recruited with the majority (83%) at GOLD stage 0. Focusing on the first patient examined, the researchers described how the DFX showed that most parts of the lung yielded dark field values comparable with a healthy lung. A group of 42 patients from the cohort underwent diffusion capacity testing and it was found that the dark field signal gave a strong correlation than with either the CT emphysema index or the visual emphysema grading based on the CT-images.
Commenting on their findings, the authors reported that “in direct comparison, dark-field images and visual evaluation of CT images yield consistent findings regarding emphysema diagnosis.” They also added that the visual features seen with the dark field appeared to provide a greater diagnostic value than conventional emphysema charactering parameters. Moreover, while noting that there are currently no commercially available dark field systems available, their study has shown how the system does not require specialist knowledge and that it is operationally comparable to conventional radiography systems.
In their conclusion, they noted how DRX could offer a low radiation alternative to CT in patients with COPD adding that “x-ray dark-field chest imaging could contribute to improving the detection, diagnosis, and thus treatment and care of pulmonary disorders.”
Willer K et al. X-ray dark-field chest imaging for detection and quantification of emphysema in patients with chronic obstructive pulmonary disease: a diagnostic accuracy study. Lancet Digit Health 2021
14th September 2021
Asthma is caused by inflammation and a narrowing of the small airways and leads to the symptoms of cough, wheeze, shortness of breath and chest tightness. According to figures from the World Health Organisation, in 2019, globally, an estimated 262 million people had asthma and the condition resulted in 461,000 deaths. Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death and in 2019 led to 3.23 million lives lost. Inhaled medication is the most common medical intervention used to control the symptoms of both asthma and COPD and effective management of both relies upon patients having the correct inhaler technique. However, in a 2016 systematic review, it was found that the prevalence of a correct technique was only 31%. Furthermore, in a 2018 review of inhaler errors in both asthma and COPD, found an association between inhaler errors and worse health outcomes, highlighting the importance of having some form of inhaler technique service. In fact, studies have shown that an inhaler technique service to asthmatic patients improved both inhaler technique scores and disease control.
Exacerbations of both asthma and COPD can result in hospitalisation and a team from the Department of Medicines Management and Pharmacy Services, Leeds Teaching Hospital, Leeds, UK, examined the impact of an inhaler technique service on respiratory wards. Included patients were those admitted to hospital with an exacerbation of either asthma or COPD at the teaching hospital in Leeds and the service was provided by pharmacy support workers. Using an inhaler standards and competency document, the staff scored inhaler technique as optimal, satisfactory or unsatisfactory. Patients whose technique was deemed unsatisfactory or satisfactory received training from the pharmacy staff and where necessary, recommended to prescribers that an inhaler device should be changed. The outcomes of interest were the rate of moderate-to-severe exacerbations of asthma and COPD and hospital admissions due to such exacerbations, in the six months prior to and after receipt of inhaler technique training.
The inhaler technique service was provided to 266 patients with a mean age of 60.5 years (53% female), of whom 28% had asthma. Each patient was prescribed a mean of 2.3 inhalers and a total of 616 inhaler technique assessments were undertaken during the study period. Inhaler technique at baseline was deemed optimal in 28.6%, satisfactory in 49.4% and unsatisfactory for 22.1%. After training, the proportion of patients whose technique was deemed optimal increased to 91.5%. These improvements were achieved from a change of inhaler device (21.8%), optimising therapy without a change of device (34.9%) with the remainder due to training with the same device.
Six-month exacerbation and hospital admission data were available for 164 (62%) of all patients. Following the inhaler technique service and compared to pre-service levels, there was an overall and significant, 37% reduction in the mean number of exacerbations over a 6-month period (risk ratio, RR = 0.63, p < 0.05). This reduction occurred for both asthma (RR = 0.58, p < 0.05) and COPD (RR = 0.66, p < 0.05). Similarly, the overall rate of hospital admissions was also significantly reduced (RR = 0.56, p < 0.05) and again this occurred for both conditions. In addition, the inhaler technique service reduced the average length of hospital stay and cost of hospital admission for disease exacerbations.
The authors concluded by recommending that a ward-based inhaler technique service should be a core component of the care of patients with asthma and COPD.
Capstick TGD et al. Ward based inhaler technique service reduces exacerbations of asthma and COPD. Resp Med 2021