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.