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.