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Initiatives to improve outcomes for chronic obstructive pulmonary disease

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Chris Fehrenbach, RGN.

Senior Nurse Respiratory Medicine, Portsmouth Hospitals NHS Trust

Acute exacerbations of chronic obstructive pulmonary disease (COPD) occur on average one to three times per year in patients with the condition. These account for at least half the direct costs of treatment of the disease (Hilleman et al, 2000), have a high mortality (Cydulka et al, 1997), and contribute to both poor prognosis and a decline in health status (Vilkman et al, 1997).

Acute exacerbations of chronic obstructive pulmonary disease (COPD) occur on average one to three times per year in patients with the condition. These account for at least half the direct costs of treatment of the disease (Hilleman et al, 2000), have a high mortality (Cydulka et al, 1997), and contribute to both poor prognosis and a decline in health status (Vilkman et al, 1997).

While the incidence of heart disease and stroke is falling, COPD rates are increasing (Murray and Lopez, 1997). Of those patients who require hospital admission for COPD, 50% will require intensive treatment, 10% will die in hospital, 33% will die within six months of discharge and 43% will be dead within a year (Stoller, 2002).

In a survey carried out by the British Lung Foundation (2003), 83% of 1400 respondents with COPD strongly agreed that the fear of having an exacerbation limited their ability to do things they enjoy, 64% lived in fear of an exacerbation being a burden to their family, 26% said they had spent a week or more in hospital in the previous 12 months as a direct result of COPD; and 10% of patients reported spending at least a month in hospital. For some of these patients their stay lasted six months or longer.

Patients who did not spend time in hospital following an exacerbation were likely to be recuperating at home. A large minority - 44% - spent more than a month in the previous 12 months recovering at home from the effects of an exacerbation. For 25% that meant being virtually housebound for three months or longer.

COPD has a major impact on patients' lives, with 80% of people admitted to hospital with an exacerbation describing their experience as 'worse than death' (O'Reilly et al, 2003).

Preventing exacerbations
In the past, COPD was considered to have few therapeutic options, but today is it acknowledged to be treatable and the past few years have seen the emergence of increasing evidence to support pharmacological and non-pharmacological treatments (National Collaborating Centre for Chronic Conditions, 2004).

Guidance from the National Institute for Clinical Excellence (NICE, 2004) uses symptoms rather than degree of airflow limitation to determine the choice of treatment option. A combination of long-acting bronchodilators and corticosteroid medication has been shown to reduce exacerbations to a significant degree (Calverley, 2003a). Patients should always be able to use their chosen inhaler adequately - it is, therefore, important to teach them the technique for doing so before prescribing and to follow this up with regular checks.

A novel statement in the guideline relates to the use of mucolytic therapy in reducing exacerbations and improving symptoms. Chronic cough and sputum are common symptoms of COPD and can have a significant role in impairing quality of life in this group of patients. Mucolytics are believed to work by affecting the nature and amount of mucous, making it less viscous and thus easier to expectorate (Poole and Black, 2001). Other treatments, such as influenza and pneumonia immunisations, that help to reduce exacerbation frequency should also be implemented.

The impact of exacerbations can be minimised by giving self-management advice on responding promptly to the symptoms, which include increased breathlessness, increased sputum and purulent sputum. The patient will have a reserve course of antibiotics and oral steroids to start at home. They should contact a health professional if their symptoms do not improve. Education packages should take account of the different needs of patients at different stages of their disease.

People with COPD dread the onset of cold weather. A scheme being piloted in 26 primary care trusts aims to keep people out of hospital by predicting when they are most at risk. This involves acting on forecasts from the Meteorological Office, which provides information on poor air quality and cold - in such weather conditions people with lung conditions tend to become more ill. The scheme involves contacting patients at risk one week in advance of the predicted change in weather conditions, to enable them to pick up early signs.

Tobacco use is the single most preventive cause of COPD. Health professionals should also offer to help patients quit the habit at every opportunity.

Management initiatives
Despite the number of patients with COPD, there is still no national service framework for the disease - as a result, it has not attracted the funding for the service afforded to other conditions. Current UK service provision is inadequate and is behind the rest of developed countries. However, in the past year initiatives have been launched to address the absence of provision. The COPD guidance from NICE and the implementation of the General Medical Services Contract (GMS) have also served to raise the profile of the disease.

One of the key elements of the GMS framework on quality and outcome is to identify patient with COPD, to ensure correct diagnosis and to provide regular follow-up. It encourages nurses in general practice to take preventive measures to avoid COPD exacerbations by assessing patient symptoms and self-management techniques on a regular basis. Research will be necessary to evaluate whether the preventive approach can be successful in preventing the deterioration of COPD patients.

Pharmacological treatment may be successful in reducing the incidence of exacerbations (Calverley et al, 2003b) in patients who have a forced expiratory volume of less than 50% predicted in one second and who have had two exacerbations in the previous 12 months.

Community approaches
To relieve pressure on medical beds, schemes have been set up to provide care at home for this group of patients. These are either admission avoidance or early assisted discharge schemes. The development of nurse-led respiratory care in the community has yielded many benefits for the nurse, the patient and the NHS. A postal survey of 82 patients with COPD in London confirmed a strong preference for home versus hospital (Barta et al, 2002).

There are several models of care, such as the triage of COPD patients in A&E who are discharged to nurse-led home follow-up. The Acute Chest Triage Rapid Intervention Team is one example of such a scheme based in an A&E department, which was developed at North Mersey Community NHS Trust (Callaghan, 1999).

In Glasgow, the implementation of a community respiratory care team made it possible for 68% of patients (962) in one 21-month trial to be managed entirely at home during an exacerbation of COPD (Gravil et al, 1998). The trial introduced a programme of patient education and monitored patient concordance with treatment. It also monitored patient progression through daily nurse visits.

There is evidence to suggest that such initiatives not only improve clinical outcomes but are also cost-effective as they lead to a decreased use of NHS resources (Gibbons et al, 2001; Ram et al, 2004).

The preventive approach to chronic disease is part of the Department of Health strategy on supporting people with long-term conditions. This will see the introduction of 1000 community matrons by the end of this year, who will look after level 3 patients in the community - the matrons will develop personalised care plans, be able to order tests, update medical records and review medications for patients with multiple chronic diseases, including those with COPD. The Government expects this strategy to reduce the number of emergency bed days by 5% over the next three years.

Organisation of care
The organisation of care can have a major effect on clinical outcomes. In 1997, an audit of patient outcomes related to COPD in England and Wales for the British Thoracic Society/Royal College of Physicians (BTS/RCP) (Roberts et al, 2003) showed wide variation in mortality rates; the conclusion drawn was that this was due to differences in care organisation and resources.

The COPD audit was repeated in 2003. Data were collected from 95% of acute trusts and covered 8000 episodes of care. The repeat audit found that 89% of units provided non-invasive ventilatory support, 64% had pulmonary rehabilitation and only 14% of admissions entered an early discharge scheme. Some 45% of units had a nurse-led scheme (Roberts et al, 2003).

It is hoped to undertake the audit once more this year, this time to measure patient satisfaction. Assessment will be made on the impact of development of hospital-at-home, early discharge policies and pulmonary rehabilitation programmes across the UK, including the effects on hospital-bed occupancy.

No drug treatment has as yet been shown to prolong survival in COPD patients, but there is good evidence in favour of using long-term oxygen therapy (National Collaborating Centre for Chronic Conditions, 2004), non-invasive ventilation (Brochard et al, 1995) and pulmonary rehabilitation (Griffiths et al, 2000). There are plans to introduce new guidance on oxygen therapy provision from October, which should result in a more integrated modernised service with assessment and provision originating in secondary care (DH, 2004).

Non-invasive ventilation is a method of providing ventilation that does not require the placement of an endotracheal tube. It is used for treating respiratory failure and can be used outside the intensive care unit. The BTS/RCP audit showed only 37% of patients with an arterial blood gas pH of <7.35 received="" ventilation="" despite="" the="" national="" guidelines="" (roberts="" et="" al,="" 2003).="" when="" patients="" are="" started="" on="" non-invasive="" ventilation,="" there="" should="" be="" a="" clear="" plan="" covering="" what="" to="" do="" in="" the="" event="" of="" deterioration="" and="" maximum="" levels="" of="" therapy="" should="" be="" agreed.="" resuscitation="" is="" also="" a="" topic="" copd="" patients="" may="" wish="" to="" discuss="" during="" a="">

Pulmonary rehabilitation (PR) is a multidisciplinary exercise and education programme for people with COPD. It has been shown to be a cost-effective intervention to improve quality of life and reduce acute exacerbations. However, despite overwhelming evidence PR is not widely available, with the recent RCP audit showing 50% of trusts providing the service. Last June, Breathe Easy, the patient arm of the British Lung Foundation presented a petition to the prime minister demanding that pulmonary rehabilitation should be available to everyone who needs it (British Thoracic Society, 2001).

Support and self-help
Depression, anxiety and low quality of life are common among COPD patients. Multidisciplinary health-care support needs to be provided to support them. Self-help groups are also beneficial. The British Lung Foundation supplies many educational leaflets on self-management, medication, sex and holiday advice for patients with the condition. Psychological support has been shown to improve outcomes and the foundation also runs support groups throughout the UK.

Conclusion
Acute exacerbations of COPD are the second most common cause of acute medical admission in the UK. The enormity of the resulting socio-economic burden of care is matched only by the high death rate during and shortly after admission. This is a cause of major concern and anxiety for patients and their families. Successful management of the condition necessitates best therapy, delivered appropriately and received successfully by patients. Many new initiatives are in progress to help patients with COPD, some of which have proved beneficial, but they will require further evaluation to determine whether they can improve outcomes for patients in the long term.

Key points
- COPD is a chronic disabling condition in which the patient's airways have become obstructed, causing persistent and progressive breathlessness

- The disease is predominantly caused by smoking

- In the UK some 900,000 people have been diagnosed with COPD and there are many who remain undiagnosed

- COPD is the fifth commonest cause of death in England and Wales, accounting for approximately 30,000 deaths a year. Latest policy
NICE guidance on the treatment of COPD (NICE, 2004)

COPD patients will have a wide range of care needs. The guidelines stress the need for patients to have access to a multidisciplinary team across primary, secondary and tertiary care to:

- Diagnose COPD

- Begin pulmonary rehabilitation

- Encourage the patient to stop smoking

- Use non-invasive ventilation

- Ensure the patient has effective inhaled therapy

- Help the patient to manage exacerbations.

Author's contact details
Chris Fehrenbach, Senior Nurse Respiratory Medicine, Portsmouth Hospital NHS Trust. Email: chris.fehrenbach@porthosp.nhs.uk

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