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374 Smoking Cessation Intervention Among Adults Hospitalized With Asthma Exacerbation
Research Forum Abstracts persistently high prevalence of smoking suggests the inadequacy of current measures to manage tobacco use in these high-risk patients with asthma.
373
Prospective Exploratory Pilot Study of Hyperlactatemia After Albuterol Therapy
Ramich JL, Timm EG, Robak N, Ata A, Cohen J/Albany Medical Center, Albany, NY
Background and Study Objective: Case reports and recent sub-analysis of data from an unrelated study have described a potential association between high dose short-acting b2 agonist therapy and elevation in lactic acid concentrations in patients with refractory dyspnea. However, this association has not yet been established in observational cohort studies. It has been postulated that an association can be attributed to altered cellular metabolism, similar to epinephrine creating a Type B lactic acidosis; as opposed to the more common type A lactic acidosis caused by inadequate tissue perfusion. While a large controlled study will be necessary to establish causation and clinical relevance, we devised a prospective pilot study to explore if there is any association between standard dosing albuterol in patients with mild and moderate dyspnea and increases in serum lactate concentrations. Additionally, we sought to evaluate some of the confounding from worsening of disease by monitoring vital signs during the study period. Methods: This study was an IRB-approved prospective, observational pilot study. A convenience sample of eligible emergency department (ED) patients requiring albuterol treatment for dyspnea thought secondary to bronchoconstriction were enrolled. Subject demographics, concurrent medications known to cause type B lactic acidosis, prior albuterol administration, and albuterol treatments while in the ED were recorded. Blood sample and heart rate were collected at baseline (prior to albuterol therapy in the ED or as soon as possible) and after 2 hours or at discharge, whichever came first. Blood samples were processed for lactic acid concentrations with results blinded to the treating health care team. All treatment decisions were determined by the primary team. Data was analyzed using a paired t-test. Results: A total of 44 subjects were enrolled over 3 months, 34 having complete data. The average age of subjects was 54 years old (18-93). Twenty-one subjects were female (62%), 15 had asthma (44%), 9 had COPD (26.5%), and 3 (8.8%) had both asthma and COPD. The average total dose of albuterol was 9.5 mg (2.5-28). Two patients were concurrently receiving metformin. In our population, lactic acid concentrations increased from a mean baseline of 1.38 mmol/L 95% CI [1.17, 1.59] to a 2-hour concentration of 1.64 mmol/L 95% CI [1.29, 2.0]. This increase was significant with a P < .05. During this same interval, there was no significant change in average heart rate [(-)4.5bpm 95% CI [-10.69, 1.65] (P > .05)]. Conclusions: Standard albuterol administration for the treatment of dyspnea in the emergency department is associated with a statistically significant elevation of serum lactic acid. Our data was consistent with this elevation occurring despite lack of increase in metabolic demand, as measured roughly by patient heart rate. Significant further study is necessary to validate this data, and to characterize any dose response relationship, mechanism, and other associated variables. A deeper understanding of the relationship between albuterol and lactic acid production may prove clinically relevant as alternate explanation for elevated lactate levels in patients receiving albuterol. Additionally, it is possible that an iatrogenic lactic acidosis could lead to increased work of breathing, leading to further unnecessary therapy.
374
Smoking Cessation Intervention Among Adults Hospitalized With Asthma Exacerbation
Bittner JC, Hasegawa K, Silverman RA, Camargo CA, Jr./Massachusetts General Hospital, Boston, MA; North Shore-LIJ Health System, New Hyde Park, NY
Study Objectives: Prior studies have shown a high prevalence of smoking among emergency department (ED) patients presenting with asthma exacerbations, with one recent multicenter study (Silverman et al) confirming that one-third of these patients were smokers at the time of their ED visit. This percentage has not materially changed over the past 15 years, despite steady decreases in current smoking in the overall US adult population. These findings suggest that asthmatic adults who smoke are not receiving effective smoking cessation interventions. In the current study, we investigate the prevalence of smoking among patients
S136 Annals of Emergency Medicine
hospitalized for asthma excerbation, and, more importantly, the proportion and characteristics of these patients who received an inpatient smoking cessation intervention. Methods: We performed a secondary analysis of data from MARC-37, a multicenter chart review study, to determine the proportion of current smokers (patients who smoke or quit smoking within 28 days from hospitalization) at the time of their hospitalization, and whether an inpatient smoking cessation invention was provided (y/n). We identified all adults (age 18-54) hospitalized in 25 US hospitals for acute asthma (ICD-9-CM code, 493.xx) in 2012-2013. Investigators from each site underwent a one-hour training and tested with practice charts before reviewing randomly selected patient charts from their hospital. Of 615 adult patients hospitalized (including hospitalization to the ED observation unit) for asthma exacerbation, 597 (97%) had data on smoking status and were included in this analysis; eligible patients who received a smoking cessation intervention while in the hospital included 215 current smokers. To determine independent predictors for patients who receive the inpatient smoking cessation intervention, we fit a multivariable logistic regression model with generalized estimating equations accounting for clustering of patients within hospitals. Results: Among the 597 adults, 36% (95% CI, 32-40%) were current smokers, and 55% (95% CI, 48-62%) of these current smokers received an inpatient smoking cessation intervention (ie, brief counseling and/or pharmacotherapy). In the multivariable model, compared to having private insurance, having public insurance (OR, 0.34; 95% CI, 0.13-0.91) and no insurance (OR, 0.37; 95% CI, 0.17-0.83) were associated with a lower chance to receive an inpatient smoking cessation intervention. By contrast, a marker of chronic severity (ie, current use of inhaled corticosteroids) was associated with higher chance to receive a smoking cessation intervention (OR, 1.96; 95% CI, 1.04-3.69). Conclusion: Approximately one-third of adult patients were smokers at the time of their asthma-related hospitalization; however, only half of these patients received an inpatient smoking cessation intervention. We also found significant discrepancies in smoking cessation management by insurance status. Our findings concur with other studies showing a persistent excess of smokers among US patients with serious asthma exacerbations. We extend these findings by showing that the inpatient stay remains an underutilized opportunity to perform a smoking cessation intervention that is likely to improve the patient’s asthma but would also provide many other important health benefits.
375
Epidemiology and Management of Patients With LifeThreatening Asthma in an Urban Emergency Department
Mahan KS, Elm CM, Soto E, O’Brien-Lambert A, Leatherman JW, Prekker ME/ Hennepin County Medical Center, Minneapolis, MN; University of Washington, Seattle, WA
Study Objectives: Bronchodilators and systemic corticosteroids have been the mainstay of emergency department (ED) management of patients with life-threatening asthma for years, with invasive mechanical ventilation reserved for non-responders. We sought to describe the prevalence and characteristics of patients presenting to an urban ED with life-threatening asthma and evaluate contemporary trends in the use of nontraditional therapies. Methods: In this retrospective review from 2009 to 2014, we queried the electronic health record of an urban, county hospital with 105,000 annual ED visits to identify all adults with a primary or secondary ED diagnosis of asthma (ICD-9-CM codes 493.00-493.92). To identify the subgroup of patients with life-threatening asthma, we reviewed the medical records of patients triaged to our ED stabilization room by emergency medical services (EMS) or ED providers. The stabilization room is a 4-bed unit where emergency physicians resuscitate critically ill patients and perform all endotracheal intubations. We summarize the characteristics of patients with lifethreatening asthma using descriptive statistics and compare the frequencies in which noninvasive ventilation (NIV), a helium-oxygen gas mixture (heliox), and invasive mechanical ventilation were used. Results: Over five years, 5,764 patients made 11,160 ED visits with an initial diagnosis of asthma. A total of 371 visits (3%) were deemed potentially life-threatening and were triaged to the stabilization room for emergent management. In more than one-third of these visits (36%, N¼134), a condition other than acute asthma was
Volume 66, no. 4s : October 2015
373
Prospective Exploratory Pilot Study of Hyperlactatemia After Albuterol Therapy
Ramich JL, Timm EG, Robak N, Ata A, Cohen J/Albany Medical Center, Albany, NY
Background and Study Objective: Case reports and recent sub-analysis of data from an unrelated study have described a potential association between high dose short-acting b2 agonist therapy and elevation in lactic acid concentrations in patients with refractory dyspnea. However, this association has not yet been established in observational cohort studies. It has been postulated that an association can be attributed to altered cellular metabolism, similar to epinephrine creating a Type B lactic acidosis; as opposed to the more common type A lactic acidosis caused by inadequate tissue perfusion. While a large controlled study will be necessary to establish causation and clinical relevance, we devised a prospective pilot study to explore if there is any association between standard dosing albuterol in patients with mild and moderate dyspnea and increases in serum lactate concentrations. Additionally, we sought to evaluate some of the confounding from worsening of disease by monitoring vital signs during the study period. Methods: This study was an IRB-approved prospective, observational pilot study. A convenience sample of eligible emergency department (ED) patients requiring albuterol treatment for dyspnea thought secondary to bronchoconstriction were enrolled. Subject demographics, concurrent medications known to cause type B lactic acidosis, prior albuterol administration, and albuterol treatments while in the ED were recorded. Blood sample and heart rate were collected at baseline (prior to albuterol therapy in the ED or as soon as possible) and after 2 hours or at discharge, whichever came first. Blood samples were processed for lactic acid concentrations with results blinded to the treating health care team. All treatment decisions were determined by the primary team. Data was analyzed using a paired t-test. Results: A total of 44 subjects were enrolled over 3 months, 34 having complete data. The average age of subjects was 54 years old (18-93). Twenty-one subjects were female (62%), 15 had asthma (44%), 9 had COPD (26.5%), and 3 (8.8%) had both asthma and COPD. The average total dose of albuterol was 9.5 mg (2.5-28). Two patients were concurrently receiving metformin. In our population, lactic acid concentrations increased from a mean baseline of 1.38 mmol/L 95% CI [1.17, 1.59] to a 2-hour concentration of 1.64 mmol/L 95% CI [1.29, 2.0]. This increase was significant with a P < .05. During this same interval, there was no significant change in average heart rate [(-)4.5bpm 95% CI [-10.69, 1.65] (P > .05)]. Conclusions: Standard albuterol administration for the treatment of dyspnea in the emergency department is associated with a statistically significant elevation of serum lactic acid. Our data was consistent with this elevation occurring despite lack of increase in metabolic demand, as measured roughly by patient heart rate. Significant further study is necessary to validate this data, and to characterize any dose response relationship, mechanism, and other associated variables. A deeper understanding of the relationship between albuterol and lactic acid production may prove clinically relevant as alternate explanation for elevated lactate levels in patients receiving albuterol. Additionally, it is possible that an iatrogenic lactic acidosis could lead to increased work of breathing, leading to further unnecessary therapy.
374
Smoking Cessation Intervention Among Adults Hospitalized With Asthma Exacerbation
Bittner JC, Hasegawa K, Silverman RA, Camargo CA, Jr./Massachusetts General Hospital, Boston, MA; North Shore-LIJ Health System, New Hyde Park, NY
Study Objectives: Prior studies have shown a high prevalence of smoking among emergency department (ED) patients presenting with asthma exacerbations, with one recent multicenter study (Silverman et al) confirming that one-third of these patients were smokers at the time of their ED visit. This percentage has not materially changed over the past 15 years, despite steady decreases in current smoking in the overall US adult population. These findings suggest that asthmatic adults who smoke are not receiving effective smoking cessation interventions. In the current study, we investigate the prevalence of smoking among patients
S136 Annals of Emergency Medicine
hospitalized for asthma excerbation, and, more importantly, the proportion and characteristics of these patients who received an inpatient smoking cessation intervention. Methods: We performed a secondary analysis of data from MARC-37, a multicenter chart review study, to determine the proportion of current smokers (patients who smoke or quit smoking within 28 days from hospitalization) at the time of their hospitalization, and whether an inpatient smoking cessation invention was provided (y/n). We identified all adults (age 18-54) hospitalized in 25 US hospitals for acute asthma (ICD-9-CM code, 493.xx) in 2012-2013. Investigators from each site underwent a one-hour training and tested with practice charts before reviewing randomly selected patient charts from their hospital. Of 615 adult patients hospitalized (including hospitalization to the ED observation unit) for asthma exacerbation, 597 (97%) had data on smoking status and were included in this analysis; eligible patients who received a smoking cessation intervention while in the hospital included 215 current smokers. To determine independent predictors for patients who receive the inpatient smoking cessation intervention, we fit a multivariable logistic regression model with generalized estimating equations accounting for clustering of patients within hospitals. Results: Among the 597 adults, 36% (95% CI, 32-40%) were current smokers, and 55% (95% CI, 48-62%) of these current smokers received an inpatient smoking cessation intervention (ie, brief counseling and/or pharmacotherapy). In the multivariable model, compared to having private insurance, having public insurance (OR, 0.34; 95% CI, 0.13-0.91) and no insurance (OR, 0.37; 95% CI, 0.17-0.83) were associated with a lower chance to receive an inpatient smoking cessation intervention. By contrast, a marker of chronic severity (ie, current use of inhaled corticosteroids) was associated with higher chance to receive a smoking cessation intervention (OR, 1.96; 95% CI, 1.04-3.69). Conclusion: Approximately one-third of adult patients were smokers at the time of their asthma-related hospitalization; however, only half of these patients received an inpatient smoking cessation intervention. We also found significant discrepancies in smoking cessation management by insurance status. Our findings concur with other studies showing a persistent excess of smokers among US patients with serious asthma exacerbations. We extend these findings by showing that the inpatient stay remains an underutilized opportunity to perform a smoking cessation intervention that is likely to improve the patient’s asthma but would also provide many other important health benefits.
375
Epidemiology and Management of Patients With LifeThreatening Asthma in an Urban Emergency Department
Mahan KS, Elm CM, Soto E, O’Brien-Lambert A, Leatherman JW, Prekker ME/ Hennepin County Medical Center, Minneapolis, MN; University of Washington, Seattle, WA
Study Objectives: Bronchodilators and systemic corticosteroids have been the mainstay of emergency department (ED) management of patients with life-threatening asthma for years, with invasive mechanical ventilation reserved for non-responders. We sought to describe the prevalence and characteristics of patients presenting to an urban ED with life-threatening asthma and evaluate contemporary trends in the use of nontraditional therapies. Methods: In this retrospective review from 2009 to 2014, we queried the electronic health record of an urban, county hospital with 105,000 annual ED visits to identify all adults with a primary or secondary ED diagnosis of asthma (ICD-9-CM codes 493.00-493.92). To identify the subgroup of patients with life-threatening asthma, we reviewed the medical records of patients triaged to our ED stabilization room by emergency medical services (EMS) or ED providers. The stabilization room is a 4-bed unit where emergency physicians resuscitate critically ill patients and perform all endotracheal intubations. We summarize the characteristics of patients with lifethreatening asthma using descriptive statistics and compare the frequencies in which noninvasive ventilation (NIV), a helium-oxygen gas mixture (heliox), and invasive mechanical ventilation were used. Results: Over five years, 5,764 patients made 11,160 ED visits with an initial diagnosis of asthma. A total of 371 visits (3%) were deemed potentially life-threatening and were triaged to the stabilization room for emergent management. In more than one-third of these visits (36%, N¼134), a condition other than acute asthma was
Volume 66, no. 4s : October 2015