X: Manage eXacerbations

An exacerbation is an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD ¹¹

Acute exacerbations of COPD often require hospital admission for treatment of respiratory failure. A record linkage study in WA²²³ demonstrated that the rate of hospital admission for COPD has been declining. The risk of readmission was highest within three months of discharge and more than half of all patients were readmitted within 12 months. About 10% of patients with a primary diagnosis of COPD died either during admission or within the same year. Median survival from first admission was five years in men and eight years in women. The poorest survival was among older patients with recognised emphysema. In one study of more than 1000 patients admitted to several hospitals with an acute exacerbation of severe COPD, about 50% were admitted with a respiratory infection, 25% with congestive cardiac failure, and 30% with no known cause for the exacerbation.¹⁷ A study of 173 patients with COPD reported an average of 1.3 (range 0–9.6) exacerbations annually. An ecological study of hospital admissions for COPD in Victoria found higher rates of admission in rural and remote areas with greater socioeconomic disadvantage and higher rates of smoking. ²³⁴

In patients with COPD the normally sterile lower airway is frequently colonised by Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. While the number of organisms may increase during exacerbations of COPD, the role of bacterial infection is controversial.^235-243Exacerbations can also be caused by viral infection²⁴⁴ and by non- infectious causes, such as left ventricular failure, pulmonary embolus, and possibly other factors, such as air pollution.²⁴⁵ Chest trauma and inappropriate use of sedatives can lead to sputum retention and hypoventilation.

Early diagnosis and prompt management of exacerbations of COPD may prevent progressive functional deterioration and reduce hospital admissions.^101,247 Education of the patient, carers, other support people and family may aid in the early detection of exacerbations. A self-management plan developed in conjunction with the patient's GP and specialist to indicate how to step-up treatment may be useful (see examples at http://www.lungnet.com.au/content/view/1/3/). This plan might indicate which medications to take, including antibiotics and oral glucocorticoids. The plan should also require patients to contact their GPs or community nurses to allow rapid assessment (see section D).

X1. Home management

The shortage of hospital beds, especially in winter, has prompted interest in home care for management of COPD exacerbations, with involvement of multidisciplinary teams assisting GPs. Economic studies of such programs have shown mixed results.^{101,247,248,249}

Up to a quarter of carefully selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. A systematic review of 7 RCTs found no significant differences in readmission rates or mortality, and ‘Hospital at Home’ schemes were preferred by patients and carers²⁵⁰[ [evidence level I]. However, further research is needed because the studies reviewed were small and trialed different interventions.

A recent randomised controlled trial from Italy assigned 104 elderly patients with acute exacerbations of COPD to a general medical ward or hospital in the home.²⁵¹ Patients managed at home had a longer mean length of stay, but there was a significantly reduced risk of readmission over the following 6 months. Only those managed at home demonstrated improvements in depression and quality of life [evidence level II]. It is not clear whether this system could be successfully applied in Australia, as the lengths of stay were longer and readmission rates were higher than observed here.