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    Patent Pending

    BAP-65 Score for Acute Exacerbation of COPD

    Predicts mortality in acute COPD exacerbation.
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    INSTRUCTIONS

    Use in patients >40 years of age presenting to the emergency department with acute COPD exacerbation. Use the worst variables on the day of admission.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients >40 years of age presenting to the emergency department with acute COPD exacerbation. Do not use in patients ≤40 years old, as asthma is a confounder in this population.

    • Does not require COPD-specific information such as FEV₁ or 6 Minute Walk Test.
    • Variables are easily obtained at the time of presentation. Only requires one laboratory value.
    • Excludes patients who had an alternative primary diagnosis other than acute COPD exacerbation.
    • May predict need for mechanical ventilation within 48 hours of admission.
    • Based on data from ICD-9 and DRG codes, which may be imprecise and may lead to coding bias or up-coding.
    • Both internal and external validation were completed in retrospective cohorts of patients from a research database.
    • May assist in clinical decision-making to risk-stratify patients to a higher level of care, or potentially observation or early discharge.
      • Higher scores predict which patients may require mechanical ventilation, and these patients may be appropriate for higher level of care.
      • Lower scores predict which patients may not require mechanical ventilation and have low in-hospital mortality, and these patients may be appropriate for observation or early discharge.
    • With higher scores, there may be higher in-hospital mortality, risk of mechanical ventilation, length of stay, and cost.
    • The DECAF Score is an alternative that can be used to calculate in-hospital mortality for patients admitted to the hospital with an acute COPD exacerbation and may outperform BAP-65 in this regard.
    About the Creator
    Dr. Andrew Shorr
    Content Contributors

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Consider early non-invasive ventilation and/or ICU care in patients with higher in-hospital mortality.
    • May predict the need for mechanical ventilation within 48 hours, and these patients should be considered for higher level of care to provide non-invasive and/or invasive ventilation.
    • There may be a role for early discharge or observation in lower BAP-65 classes.

    Management

    Was not studied to dictate management or treatment options. The score should not replace clinical judgment regarding workup, diagnosis, or treatment.

    Critical Actions

    • Should only be used in patients presenting to the ED with a primary diagnosis of an acute COPD exacerbation, not in the outpatient setting or in patients whose COPD is stable.
    • BAP-65 class V have the highest risk of in-hospital mortality and need for mechanical ventilation, and these patients should be closely monitored.

    Formula

    Addition of the selected points, then class assigned by age:

     

    0 points

    1 point

    BUN ≥25 mg/dL (8.9 mmol/L)

    No

    Yes

    Altered mental status*

    No

    Yes

    Pulse ≥109 beats/min

    No

    Yes

    Class

    BAP

    Age

    I

    0

    <65 years

    II

    0

    ≥65 years

    III

    1

    Any age

    IV

    2

    Any age

    V

    3

    Any age

    *Initial GCS<14, or disorientation, stupor, or coma as determined by physician.

    Facts & Figures

    Interpretation:

    BAP-65 Class

    In-hospital mortality

    Need for mechanical ventilation within 48 hours

    Recommendation

    I

    0.3%

    0.3%

    Routine management of COPD exacerbation

    II

    1.0%

    0.2%

    III

    2.2%

    1.2%

    Consider early non-invasive ventilation and/or ICU care

    IV

    6.4%

    5.5%

    V

    14.1%

    12.4%

    Data from validation cohort in Tabak 2009.

    Evidence Appraisal

    The original BAP-65 Score was derived by examining a cohort of 88,074 patients from the Cardinal Health Clinical Outcomes Research Database. Patients studied were >40 years of age, with a primary/principal discharge diagnosis of acute exacerbation of COPD (using ICD-9 codes). Patients with a primary diagnosis of acute respiratory failure and secondary diagnoses of acute exacerbation of COPD were excluded. The authors selected four variables with the highest discriminative power for mortality to create the BAP-65 Score. The original study was internally validated, and a separate cohort in the same database was used as an additional validation.

    The BAP-65 was also externally validated in a retrospective cohort of 34,669 patients using a different database than the original study. In the external validation, patients with a primary diagnosis of acute respiratory failure were also included (in the original study, these patients were excluded). The external validation found that BAP-65 correlates well with in-hospital mortality, need for mechanical ventilation, length of stay, and cost.

    Dr. Andrew Shorr

    From the Creator

    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.

    About the Creator

    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.

    To view Dr. Andrew Shorr's publications, visit PubMed

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