Andrew Shorr, MD, MPH, is an associate director of pulmonary and critical care medicine and the chief of the Pulmonary Clinic at MedStar Washington Hospital Center in Washington, DC. Dr. Shorr’s research interests include resistant pathogens and healthcare-associated bacteremia, and he has published more than 140 original studies.
Why did you develop the BAP-65 Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
I think we were interested in developing the score for two reasons: one, as a purely academic exercises, given that we have risk scores for PE and risk scores for pneumonia, clearly one of the pulmonary disease states where patients are sicker than they look is in COPD. So it was a clear hole in the range of pulmonary-critical care disease states that didn’t have some pulmonary risk stratification tool. And when you tie that together with the fact that COPD is a leading reason for admission in general, you can understand.
Secondly, in the modern era of COPD exacerbation treatment, since there are so many patients who are treated with non-invasive ventilation, their risk stratification becomes tricky, because they can look good at the beginning when you put them on it, but really not respond, and then deteriorate. And so a lot of people who give non-invasive ventilation in a COPD exacerbation are falsely reassured that they’ve given something to make the patient better, and it may not actually achieve that. What I’ve seen is patients who are sick but don’t look that sick, are put on non-invasive ventilation, but because they’re actually a lot sicker, the non-invasive ventilation is a bridge to pneumonia. So what they need is to be on non-invasive ventilation, which is probably the right choice for the vast majority of patients, but they’re at such a high risk for decompensating that they should probably be managed in the ICU, so when they lose their airway, the intubation goes a lot more smoothly.
What recommendations do you have for doctors once they have applied the BAP-65? Can you make any hard recommendations for patients who should go to ICU versus those that can go to the floor?
I think it varies from hospital to hospital, because hospitals have different resources. At my hospital, we have an intermediate care unit where all of our non-invasive ventilation patients have a dedicated respiratory therapist whose job it is to titrate that. So I would never recommend the score be used the same way as in my hospital, where if you get put on non-invasive ventilation and are sent to the floor and have a nurse who may not know how to titrate things to adjust it. I think it very much has to be looked at based on what your resources are. And some hospitals say if you’re on non-invasive ventilation you have to be in the ICU, because that’s the only place you have a dedicated respiratory therapist. It’s very important to understand what your resources are, and interpret that.
If you work in a hospital where you do non-invasive ventilation either on the floor or the ICU and there’s no intermediate care unit, and you’ve got someone with a very high BAP Score, even if they look good now there’s still a 10-20% chance that they’re gonna need the tube. I would make sure that person went to the ICU and not the floor, even if they look good enough for the floor right now, because in the next three hours that might not be the case.
So that’s how I see [the score] helping, with those difficult-to-triage patients. But I also see it helping with the very low-risk patients. We get patients admitted to the hospital for COPD exacerbations who can go home on oral therapy, whether it’s antibiotics, steroids, or both. Sometimes the emergency physicians think they still need to be admitted, and this allows the hospitalist to have a rational discussion and say you know what, this person’s gonna do fine no matter what as long as they get the right therapy, and you can send them home.
That’s especially important in this era where payers can refuse to reimburse for admissions that aren’t justified.
And there’s also the heterogeneity. You should be able to walk into any emergency room in this country and get the same level of care for a COPD exacerbation, but you don’t. And you’re only going to fix that if there’s some objective ways to assess how severely ill the patient is. The other thing that’s unique about the BAP Score over some of the other scores I’ve worked on: I was re-doing my maintenance of certification questions for the ABIM, and it actually showed up in a question. It kind of put a smile on my face, because someone else read what I wrote and felt it deserved a question! So it tells you that people who are writing the general hospital medical questions feel it’s important enough to talk about these issues as well.
Any comment on similar scores for acute exacerbations of COPD, like the DECAF Score out of the UK?
That’s the only other score I’ve seen, and if I recall, it requires a blood gas. I’ve also never seen it validated in a U.S. population. In the U.K., they have a whole different structure for outpatient follow-up and a whole different approach for what needs to go to the ICU versus not, and so I’m not sure how appropriate that would be for a U.S. population.
When we were developing the BAP Score, we did consider including blood gas values, but fewer than 20-30% of the patients with a COPD exacerbation had one done. There are plenty of COPDers who come in with an exacerbation and go to the floor and don’t get a blood gas, because it’s not going to change what you do. You’re going to follow the patient clinically, and follow the respiratory rate, mental status, other vital signs, and that’s adequate. If their pH is a problem or their CO₂ is a problem, they won’t look good. I think that’s the problem with the blood gas: it’s expensive, it’s invasive, and it doesn’t necessarily always change management, so that’s why it’s not obtained.