Assessing and preventing acute exacerbations of COPD
Kelly, C. (2009) An overview of acute exacerbations of COPD. Nursing Times; 105: 13, early online publication.
COPD is a chronic respiratory disorder that is a major cause of morbidity for patients and stress for carers, and is predicted to be the third leading cause of death worldwide by 2020 (Murray and Lopez, 1997). It is characterised by chronic airflow limitation, airway inflammation, structural changes to the airways and parenchyma and some systemic effects (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2008). It is primarily caused by smoking, although other causes such as occupational factors have been identified (NICE, 2004).
This article aims to provide an overview of some important aspects of acute exacerbations of COPD that need to be considered by all healthcare professionals.
Keywords: Early discharge, Prevention, Patient-centred assessment
Carol Kelly, MA, BSc, RGN, is senior lecturer at Edge Hill University, Lancashire/Respiratory Education UK, Liverpool.
An acute exacerbation of COPD (AECOPD) can be defined as: ‘A sustained worsening of the patient’s symptoms from his/her usual stable state that is beyond normal day-to-day variations, and is acute in onset…. The change in these symptoms often necessitates a change in medication’ (NICE, 2004).
This definition of an exacerbation itself can be problematic as it is based on the need for treatment rather than symptoms. Patients’ individual experiences of AECOPD are different and do not always require an alteration in treatment. In addition, the severity of exacerbations can vary between patients and between episodes and there is no recognised classification that is used to measure severity.
Causes of AECOPD can vary between patients but are commonly the result of bacterial infection and/or viruses, although for many the cause may remain unknown (Papi et al, 2006). Other causes may include exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor pollutants (GOLD, 2008).
Why are exacerbations important?
Exacerbations are an extremely important aspect of the course of the disease. The consequences of exacerbations can be viewed from two different perspectives:
- Use of healthcare services;
- The effect on the patient.
Use of healthcare resources
Exacerbations of COPD have been reported to be the second most common cause of admission to hospital (British Lung Foundation, 2007) and uses significant amounts of primary care services (British Thoracic Society, 2006). This results in a financial burden on the UK health economy and puts enormous pressure on already stretched health services, particularly during the winter months.
The effect on the patient
Exacerbations of COPD are a cause of death for many patients. A prospective cohort study of 304 men conducted over five years demonstrated that severe AECOPD have a negative impact on patient prognosis (Soler-Cataluña et al, 2005).
A prospective study demonstrated that 14% of patients will die three months after hospitalisation for an exacerbation and a further 34% will be readmitted to hospital (Roberts et al, 2002). If an exacerbation is accompanied by acute hypercapnic (high CO2 levels in blood gases) respiratory failure, mortality rates increase to 49.1% and readmissions to 79.9% (Chu et al, 2004).
In addition to mortality, AECOPD has been shown to accelerate the decline in the general health of patients with COPD. Frequency of exacerbations has been shown to correlate directly with a decline in lung function (Donaldson et al, 2002) and a decline in health status (Spencer and Jones, 2003). Some patients do not make a complete recovery from an exacerbation (Seemungal et al, 2000) and patients who are hospitalised for more than three exacerbations each year have a higher risk of mortality (Soler‑Cataluña et al, 2005).
These effects on patients’ health and disease progression can have a negative impact on quality of life. Patients adjust their activities of daily living and report that they lack energy and feel depressed, anxious, panicky, angry and guilty (Kessler et al, 2006).
Using qualitative data gathered through interviews, Haughney et al (2005) attempted to quantify the patient’s perspective. They found that the most important attributes of AECOPD from the patient’s point of view were the impact on everyday life and the need for medical care. Patients feared being hospitalised, housebound or confined to bed.
It is important from a healthcare professional’s perspective that we recognise patients’ concerns so that these can be addressed. This will help to define and help achieve meaningful patient-centred goals, rather than address concerns defined by the healthcare professionals.
Assessment of AECOPD
Most patients with an AECOPD experience a change in symptoms. Common symptoms are listed in Box 1.
Box 1. Common symptoms associated with AECOPD
- Worsening breathlessness
- Increased sputum production
- Change in sputum colour
- Upper airway symptoms
- Increased wheeze
- Chest tightness
- Reduced exercise tolerance
- Fluid retention
- Increased fatigue
- Reduced ability to carry out activities of daily living
- Chest pain and fever are uncommon
The initial assessment of a patient presenting with a possible acute exacerbation will involve careful history-taking. The presentation of new or worsening symptoms often helps to establish the diagnosis of an acute exacerbation and, together with pulse oximetry and/or blood gas analysis, can be used to help to determine the severity of the exacerbation. Clinical examination and chest X-ray can help to rule out diagnoses that may be confused with AECOPD, for example pneumothorax, pneumonia or pulmonary embolus.
Assessment of the impact that the exacerbation is having on the patient both socially and psychologically is relevant as it helps to establish the need for extra support during the exacerbation or following recovery.
One potential problem encountered by healthcare professionals assessing a patient in the acute phase of an exacerbation is the variety of terms used by the patient to describe the exacerbation itself. Kessler et al (2006) in a qualitative multinational study established the descriptors used by patients such as ‘lung infection’, ‘crisis’, ‘shortness of breath’ and ‘breathing difficulty’, which may be an indication of patients’ poor perception of the significance of acute exacerbations. The language used oversimplifies the complexity of the condition and leads the patient and healthcare professional into a false sense of security that the condition is less serious than it is.
Management of an AECOPD
Management of AECOPD in primary and secondary care is detailed in NICE (2004) guidelines. These are summarised in Box 2.
Box 2. Management of AECOPD
- Assessment and investigations
- Optimisation of bronchodilator therapy
- Oral corticosteroids
- Antibiotics if sputum is purulent
- Oxygen to maintain oxygen saturation >88–92% (BTS, 2008)
- Non-invasive ventilation as the treatment of choice for persistent hypercapnic (high carbon dioxide) ventilatory failure
- Assessment of the need for hospital treatment
For most healthcare professionals, the initial decision regarding management is to consider where treatment should occur. In most areas of the UK several models of care exist, including early discharge schemes, supported discharge, prevention of admission and rapid assessment units. A systematic review concluded that such schemes were safe and effective and could result in substantial cost savings (Ram et al, 2004). This support for alternatives to hospital admission is further endorsed within guidelines for intermediate care for patients with COPD published by the BTS (2007).
Some patients need to be admitted to hospital owing to the severity of their illness or their social circumstances, or because alternative provision is unavailable. These patients are often very sick.
Standards of care in hospitals vary and often fall below what would ideally be expected. In their third national audit of hospitals in the UK in 2008, the Royal Collage of Physicians and the BTS found that, within 90 days of admission, 33% of patients with COPD are readmitted and almost 14% are dead (RCP and BTS, 2008). These results show little improvement from the audit conducted in 2003 and many deficiencies in standards of care are highlighted, in particular recording of oxygen prescription, management of respiratory failure and information given to patients.
Data from the 2003 audit showed that patients aged over 75 years are less likely to have blood gases measured or spirometry, receive systemic corticosteroids or non-invasive ventilation, or have access to an early supported discharge scheme. Inpatient and 90-day mortality is three times higher in this age group (Connolly et al, 2006). Clearly this variation is unacceptable.
Following discharge from a primary care intervention or hospital admission, a review of the patient by any healthcare professional presents an opportunity for further assessment. This may include monitoring recovery from the exacerbation itself and provides an opportunity to ensure that patients are receiving optimal medication and treatment. It is also a chance to assess their ability to cope at home and to provide education regarding their disease and its management, and advise on preventative strategies. Spirometry and blood gas analysis can help assess disease progression and severity, and referrals to other professionals can be made, for example to a dietitian or physiotherapist.
Prevention of exacerbations
Given the huge burden that AECOPD presents to both patients (their families and carers) and to healthcare services, a preventative strategy seems appropriate. Approaches to prevention include the use of symptom diaries, vaccination, for example against flu and pneumococcal infection, advice regarding avoidance of anybody with cold or flu symptoms, and eating a healthy balanced diet.
Recommendations on weather can be helpful. Cold air, fog and mist can worsen symptoms and make breathing more difficult and very hot and humid conditions can affect breathing.
Other approaches that can help include teaching breathing control exercises. This can enable patients to manage breathlessness more effectively and prevent worsening of symptoms.
Prevention strategies not only focus on primary prevention but also aim to prevent escalation of severity through encouraging the patient to act promptly on symptoms and seek early treatment.
A cohort study of 128 patients in east London found that earlier treatment was associated with faster recovery and that failure to report an exacerbation was associated with an increase in emergency hospitalisation (Wilkinson et al, 2004). Through education, patients are empowered to self-manage their condition more effectively.
Self-management approaches, through patient education, aim to help patients and families and carers to recognise early changes and seek help or instigate early treatment. Early intervention can be achieved by supplying patients with emergency supplies of corticosteroids and antibiotics and a comprehensive management plan and is an approach that is endorsed by guidelines (GOLD, 2008; NICE, 2004). While the evidence base for self-management education in COPD is limited, general consensus recognises that early treatment and prevention of complications is feasible if patients, their families and carers are helped to recognise acute symptoms.
Other management strategies have been found to decrease the frequency of exacerbation (see Box 3). It is outside the remit of this review to explore the evidence base for each but it is worth considering the role of patient education as a means of promoting these aspects of management in the context of exacerbation prevention.
Box 3. Approaches to prevention of exacerbation in COPD
- Education of patients/self management
- Smoking cessation
- Pulmonary rehabilitation and exercise in general
- Adequate nutrition
- Vaccination, for example, with flu vaccine please identify vaccines
- Pharmacological management, including inhaled corticosteroids, inhaled long-acting beta2 agonists and anticholinergics, and oral mucolytics
- Long-term oxygen therapy
There are many resources available to healthcare professionals to help patients with COPD adopt self-management behaviours and enable them to record symptoms and treatment changes.
Exacerbations of COPD are complex events that are not yet fully understood. They carry a significant mortality, morbidity and cost to both individuals and healthcare services. Prevention of exacerbations should be regarded as a vital component of holistic long-term management for patients with COPD.
Reducing the frequency and severity of exacerbations improves general well-being and psychosocial functioning, as well as prognosis. In addition, the strain on healthcare resources may be lessened, in particular during the winter months when admission rates for AECOPD peak.
Follow-up review of patients after an acute exacerbation provides an ideal opportunity for ensuring optimal treatment and management, and education of patients particularly about prevention of future exacerbations.
British Lung Foundation (2007) Invisible Lives: Chronic Obstructive Pulmonary Disease (COPD) – Finding the Missing Millions.
British Thoracic Society (2008) Guideline for emergency oxygen use in adult patients. Thorax;63 (Supp VI): vi1–vi73.
British Thoracic Society (2006) The Burden of Lung Disease: A Statistics Report from the BTS.
British Thoracic Society Standards of Care Committee (2007) Intermediate care: hospital-at-home in chronic obstructive pulmonary disease guideline.Thorax;62: 3, 200–210.
Chu, C.M. et al (2004) Readmission rates and life threatening events in COPD survivors treated with non-invasive ventilation for acute hypercapnic respiratory failure. Thorax; 59: 12, 1020–1025.
Connolly, M.J. et al on behalf of the British Thoracic Society and the Royal College of Physicians Clinical Effectiveness Evaluation Unit (2006) Admissions to hospital with exacerbations of COPD: effect of age-related factors and service organisation. Thorax; 61: 10, 843–848.
Donaldson, G.C.R. et al (2002) Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax; 57: 10, 847–852.
Global Initiative for Chronic Obstructive Lung Disease (2008) Global Strategy for Diagnosis, Management, and Prevention of COPD.
Haughney, J. et al (2005) Exacerbations of COPD: quantifying the patient’s perspective using discrete choice modelling. European Respiratory Journal;26: 4, 623–629.
Kessler, R. et al (2006) Patient understanding, detection and experience of COPD exacerbations: an observational, interview-based study. Chest; 130: 1, 133–142.
Lung and Asthma Information Agency (2001) Trends in Emergency HospitalAdmissions for Lung Disease.
Murray, C.J.L., Lopez, A.D. (1997) Alternative projections of mortality and disability by cause1990–2020: Global Burden of Disease Study. The Lancet; 349: 9064, 1498–1504.
Papi, A. et al (2006) Infections and airway inflammation in COPD severe exacerbations. American Journal of Respiratory and Critical Care Medicine;173: 10, 1114–1121.
Price L C, et al on behalf of the British Thoracic Society and the Royal College of Physicians Clinical Effectiveness Evaluation Unit (CEEu) (2006) UK National COPD Audit 2003: impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax; 61: 10, 837-842
Ram, F.S.F. et al (2004) Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. British Medical Journal; 329: 7461, 315–319.
Roberts, C.M. et al (2002) Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax; 57: 2, 137–141.
Royal Collage of Physicians and British Thoracic Society (2008) Report of The National COPD Audit 2008: Clinical Audit of COPD Exacerbations Admitted to Acute NHS Units Across the UK.
Seemungal, T.A.R. et al (2000) Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine; 161: 5, 1608–1613.
Soler-Cataluña,J.J. et al ( 2005) Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease Thorax; 60: 11, 925–931.
Spencer, S., Jones, P.W. (2003) Time course of recovery of health status following an infective exacerbation of chronic bronchitis. Thorax; 58: 7, 589–593.
Wilkinson, T.M.A. et al (2004) Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine; 169: 12, 1298–1303.