Translating a physical finding or a symptom directly into a diagnosis truly tests the skill and expertise of physicians and other providers. We spend years learning and studying, even more years practicing, and this is where the art of differential diagnosis separates the superior clinicians from the rest of us. This is the fundamental basis of all of our encounters with our patients on a daily basis – we know this.
In the hospital setting, we see countless patients who have various breathing problems, with dyspnea a common complaint, abnormal lung findings frequently seen, and with wheezing and rales among the most commonly described abnormalities on these exams. Let us focus on this subgroup of patients with respiratory complaints and pulmonary findings. Two of the most common diseases in the hospital with this dyad are patients with COPD and patients with CHF. This forms the basis of the simplistic explanation that I learned in medical school, “all that wheezes is not asthma“, because they didn’t want us to start treating CHF patients with steroids or bronchodilators just because they were wheezing – otherwise known as cardiac asthma. Wrong thing to do. Patients with either disorder can be dyspneic, both groups can have abnormal lung findings, but the treatment is profoundly different. The fundamentals for the heart failure treatment are effective diuresis, GDMT, monitoring weight and stabilizing vital signs, as well as treating comorbidities. For COPD exacerbations requiring hospitalization, inhaled bronchodilators are the foundational therapy often combined with guideline-specified dosages of corticosteroids. This leads us to the caution and concern that we need to know we are using respiratory therapy treatments for our patients with COPD exacerbation and not for patients with heart failure. How can we find out how well we are doing? Can we document that we are doing the right thing for our patients? The following will be a brief exercise in population management.
To examine our current reality, we should start with looking at the data, and proceed to analyze the results to grasp our current practices. Using my limited facilities for population management, I queried Epic to find all of the hospitalized inpatients who are getting respiratory therapy with inhaled bronchodilators delivered by a respiratory therapist. Looking at one point in time, I found that we had 188 patients receiving respiratory therapy with some combination of albuterol and ipratropium, sometimes with inhaled corticosteroids. With a concurrent total census of 750 patients at all of our sites, that is a striking 25% of all patients in the hospital.
My initial observations looking at the numbers were twofold. First, there is a profound resource commitment to having to employ sufficient nursing and respiratory therapy staff to deliver this treatment to 25% of our patients, each of whom is receiving these treatments multiple times per day. The second observation is that our data previously have never suggested anywhere near 25% of our patients are admitted with a diagnosis of COPD exacerbations. We treat many people with that diagnosis, but typical numbers be that they represent less than 10% of our patients.
Another observation from looking at these charts is how many patients are being treated for dual diagnoses – CHF and COPD. Sometimes a trifecta of CHF, COPD, and pneumonia. Is it possible to have all of these things together? Of course it is. But we see it so often, that there is concern, supported by random chart review, that we are not digging into the history, examination, findings, lab data, and prehospital records sufficiently to pinpoint the correct principal diagnosis. Sometimes the easiest thing to do is to treat for all 3, so we feel more secure that we won’t miss the right diagnosis even when we’re not convinced ourselves that all 3 diagnoses are present. We have to avoid this shotgun therapeutic approach much as possible and identify and focus on the key diagnosis. Even if someone may have all three diagnoses (not always clear from some of the records we have seen), something triggered the cascade and wherever possible we want to document what the real reason was this patient came to the hospital.
Beyond the cost of such care, we have to be concerned about patient harm. We are spending a lot of time making sure our heart failure patients are getting beta blockade. However, the reports tell us that we are also simultaneously giving a large number of our heart failure patients beta agonists. Just based on their heart failure diagnosis, this does not make sense. Some of these patients have a diagnosis of COPD as well, although it is not always well documented whether it is currently active and symptomatic. Yet looking at the patient population in Epic who are getting respiratory therapy with beta agonists, a large number of them have no pulmonary diagnosis at all on their list, just heart failure. This may be extremely poor documentation, or it may be providing the wrong care, but it has to be one or the other. I cannot logically come to any other conclusion. But we see this on many patients every day that we look.
Unrelated to heart failure, we often see beta agonists provided to patients who have pneumonia without any other respiratory diagnoses. Maybe it is the right thing to do. To fill in my knowledge gaps, I did a literature search to review the studies, guidelines, and reports in the world’s literature supporting the use of inhaled beta agonists for pneumonia. So far, either my Ovid literature search is taking a very, very long time to find the articles, or I have stumped the search engine. I will offer a special prize to the first person who can find and send me any good study showing the value of LABA’s (or LAMA’s – we actually use both) in pneumonia patients.
Likewise, we give inhaled anticholinergics (LAMA’s) to patients who were not getting them on an outpatient basis, suggesting that they are not an appropriate treatment. Anticholinergics can cause many side effects, so using them as ubiquitously as we do in patients with no pre-existing COPD diagnosis only puts our patients at risk for side effects and complications without any clinical benefit, and requires tremendous resource consumption for this very labor-intensive procedure.
This first look at our processes and procedures with inhaled respiratory therapy is a little bit discouraging. However, several important positive notes. First, these patients are very complicated and nothing about their care is simple, but when you look at these patients as a group, it is clear that we have opportunities for improvement. Second, we are not unique and the same care issues occur nationwide. There is always a tendency quickly to turn to respiratory therapy when someone is wheezing or has rails or is dyspneic. It just happens in complicated patients. We are not an outlier, but still we must to better. Finally, we can do better. This is the first step – raising our level of awareness, refocusing our attention to this important clinical matter, and rightsizing our care. Our patients expect nothing less from us.
