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COPD is a major cause of hospital admissions in the UK,
accounting for over one million in-patient bed days each year
1.
Exacerbations of COPD are a major cause of hospitalisations.
COPD exacerbations are a significant burden for patients and the
health service, particularly those that result inadmission to
hospital2. They are distressing and disruptive for patients and
account for a significant proportion of thetotal healthcare costs
of COPD3. However, with proactive management, exacerbations can be
reduced and when they dooccur, treating to minimise duration will
have a positive impact on patients health status.
This simple guide aims to show how you can help manage and
prevent exacerbations in your COPD patients, reducingthe impact on
your patients and your practice.
We are calling on your support to make preventing COPD
exacerbations a key aim for primary care.
The treatment
and prevention ofexacerbations in
COPD:the role of primary care
Dame Helena Shovelton
Chief Executive,
British Lung Foundation
Kindly sponsored by GlaxoSmithKline
Professor David PriceGPIAG Professor of Primary Care Respiratory
Medicine,Dept of General Practice and Primary Care,University of
Aberdeen
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Is it an exacerbation?The key features typically associated with
exacerbations are one or more of the following: Worsening
breathlessness Changing sputum colour Increased sputum volume
Increased cough Fev er Reduction in activity levels
Long-term management of patient post-exacerbation
Review: Patient understanding/personal action plan
Non-pharmacological strategies:o Smoking cessationo Exerc iseo
Pulmonary rehabilitation
Pharmacological strategies:o Optimise long-term maintenance
therapy in line with guidelines ie. long-acting
bronchodilator (2 agonist and/or anticholinergic), ICS (usually
in combination withlong-acting beta agonist) and mucolytics if
chronic productive cough
o Inhaler techniqueo Ensure annual influenza vaccination is
offered, together with offering pneumococcal
vaccination
Adapted from NICE 20043
Manage the patient at home Admit the patient to hospital
Manage acute exacerbations Add or increase bronchodilator
use:
o Review inhaler deviceo Review inhaler technique
Prescribe antibiotics if sputum becomes purulent Consider oral
corticosteroids Pulse oximetry if severe exacerbation Increase
social support if necessary
AGREE TO FOLLOW UP AND REVIEW THE PATIENTTO REASSESS THEIR
COPD
Protocolfor the treatment and prevention of exacerbations in
COPD
The treatment and prevention of exacerbations in COPD:the role
of primary care
WHAT IS AN EXACERBATION OF COPD?
An exacerbation is a sustained worsening of the patients
symptoms from their usualstable state, which is beyond normal
day-to-day variations and is acute in onset 3.
Commonly reported symptoms are3: Worsening breathlessness Cou gh
Increased sputum production Change in sputum colour Change in
ability to carry out daily activities
The change in these symptoms usually necessitates a change in
medication3.
FREQUENCY OF EXACERBATIONS
Exacerbations are frequent among patients with COPD at any
stage, even thosewith an FEV1 of 50% predicted10.
The majority of patients report two or more exacerbations a
year, regardless oflung function10.
HOW DO PATIENTS PRESENT?
Patients tend to play down the symptoms of exacerbations; in
fact a studyshowed that patients experiencing a median rate of 2.4
exacerbations per yearreported less than half of these to
healthcare professionals, yet there were nosignificant differences
in lung function, symptom score or recovery times betweenreported
and unreported exacerbations11.
To encourage patients to present to their healthcare
professional, it is importantthey understand that prevention and
prompt treatment of exacerbations is criticalto their own long-term
health.
All patients require education to help them know what to do
whentheir condition deteriorates. The provision of personal
actionplans may help develop their understanding of the
condition.
These plans could include key written prompts to help them
identify:
Their keytriggers for an exacerbation, eg: Weather changes (eg.
cold spells, muggy/close) Viral epidemics, in particular winter
influenza epidemics
Exposure to a smoky environment High pollen levels
Exposure to viral or bacterial infections
When to seek help, eg:
You get much more breathless than you did before You find
yourself generally less able than you were before
When they have experienced an exacerbation, eg: You produce more
sputum than before Your sputum becomes discoloured
You feel feverish or unwell
Patients at risk of having an exacerbation of COPD shouldalso be
given self-management advice that encourages
them to respond promptly to the symptoms of anexacerbation by3:
Starting oral corticosteroid therapy if their increased
breathlessness interferes with activities of daily living
(unlesscontraindicated)
Starting antibiotic therapy if their sputum is purulent
Adjusting their bronchodilator therapy to control their
symptomsPatients given personal action/self-management plans should
be
advised to contact a healthcare professional if they do not
improve3.
IMPACT OF EXACERBATIONS ON THE PATIENT
Exacerbations may lead to an irreversible decline in lung
function anddisease progression4, 5.
Frequent exacerbations are associated with: Faster lung function
(FEV1) decline6,7
Increased airway inflammation Worsening health status8
All of these factors contributeto more admissions and longer
hospital stays forthe patient.
Lung function declines up to 25% faster each year in patients
with frequentexacerbations4; and as FEV1 declines, exacerbations
become increasingly morecommon and more severe9.
Following each severe episode a patient is unlikely to regain
their pre-exacerbationhealth status.
Airflow obstruction is defined as a reduced FEV 1 (forced
expiratory volume inone second) of less than 80% predicted and
FEV1:FVC (forced vital capacity)ratio of less than 70%. Based on
the level of percentage predicted FEV1when the patients condition
is stable, the degree of COPD obstruction canbe classified as
follows3: Mild (50-80% predicted) Moderate (30-49% predicted)
Severe (
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ContributorsDr Antony CrockettGP, Shrivenham, Wiltshire
Dr Lisa DaviesConsultant Chest PhysicianUniversity Hospital
Aintree, Liverpool
Dr Rupert JonesMRCGP, GP, PlymouthClinical Research Fellow,
Peninsula Medical School, Plymouth
Professor David PriceGPIAG Professor of Primary Care Respiratory
Medicine,Dept of General Practice and Primary Care, University of
Aberdeen
Jane ScullionRespiratory Nurse Consultant, LeicesterChair of the
Respiratory Nurses Forum
Dr Mike ThomasAsthma UK Research Fellow,Dept of General
Practice, University of AberdeenGP, Minchinhampton,
GloucestershireHospital Practitioner Respiratory Medicine, Stroud
Hospital
References1 National Respiratory Training Centre. Impact of
Respiratory Conditions: aguide for Primary Care Organisations.
Warwick: NRTC (2002).
2 National Asthma and Respiratory Training Centre. Respiratory
conditions:are health needs being met? Warwick: NARTC (2000).
3 National Collaborating Centre for Chronic Conditions. Chronic
ObstructivePulmonary Disease: National clinical guideline on
management of adults
with chronic obstructive pulmonary disease in primary and
secondary care.NICE guideline 12. Thorax 2004;59 (Suppl I):
1-232.
4 Donaldson GC, Seemungal TAR, Bhowmik A, Wedzicha JA.
Relationshipbetween exacerbation frequency and lung function
decline in chronicobstructive pulmonary disease. Thorax 2002;57:
847-852.
5 Kanner RE, Anthonisen NR, Connett JE. Lower respiratory
illness promoteFEV1 decline in current smokers but not ex smokers
with mild chronicobstructive pulmonary disease. Results from Lung
Health Study. Am J RespirCrit Care Med 2001;164: 358-364.
6 Seemungal TAR, Donaldson GC, Bhowmik A, Wedzicha JA. Frequent
COPDexacerbators show accelerated decline in lung function. Am J
Respir Crit
Care Med 2001;163(5): A772.7 Seemungal TAR, Donaldson GC,
Bhowmik A, Wedzicha JA. Frequent COPDexacerbators have more severe
exacerbations. Am J Respir Crit Care Med2001;163(5): A769.
8 Seemungal TAR, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ,
Wedzicha JA.Effect of exacerbation on quality of life in patients
with chronic obstructivepulmonary disease. Am J Respir Crit Care
Med 1998;157: 1418-1422.
9 Pauwels RA, Buist AS, Calverley PMA, Jenkins CR, Hurd SS.
Global strategyfor the diagnosis, management and prevention of
chronic obstructivepulmonary disease. Am J Respir Crit Care Med
2001;163: 1256-1276.
10 OReilly JF, Williams AE, Rice L, Holt K. Incidence and impact
of
healthcare-defined exacerbation amongst a cohort of primary care
COPDpatients. Presented at European Respiratory Society Annual
Congress, 4-8September 2004, Glasgow, UK.
11 Seemungal TAR, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha
JA. Timecourse and recovery of exacerbations in patients with
chronic obstructivepulmonary disease. Am J Respir Crit Care Med
2000;161: 1608-1613.
To request furthercopies ofThetreatment andprevention
ofexacerbations inCOPD: the role ofprimary careguide,please call
theinformation andpublications line020 7688 5555
British Lung Foundation73-75 Goswell RoadLondon EC1V 7ER
T: 020 7688 5555E: [email protected]
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