X: Manage eXacerbations
Acute exacerbations of COPD often require hospital admission for treatment of
respiratory failure. Hospital mortality for such patients is about 10%, reaching
40% at one year after discharge, and higher for patients aged over 65 years.19,213,214
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.19
A study of 173 patients with COPD
reported an average of 1.3 (range,
0–9.6) exacerbations annually. 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.215-223Exacerbations can also be caused by
viral infection and by
non-infectious causes, such as left
ventricular failure, pulmonary
embolus, and possibly other factors,
such as air pollution.224
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.143,
209
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).
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.143,209,226,227[
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 carers228[ [evidence level I]. However, further research is needed because the studies reviewed
were small and trialed different interventions.