COPD: treatment and prevention of acute exacerbations
Early recognition and treatment of acute exacerbations of COPD is critically important to reduce the risk of hospitalisation, further exacerbations and even death. Prevention, as far as it is possible, is also essential
People with chronic obstructive pulmonary disease (COPD) suffer from symptoms such as productive cough and chronic dyspnoea which may impact on their ability to carry out the basic activities of daily living that most of us take for granted. Exacerbations are said to occur when these symptoms become acutely worse, necessitating additional therapy and in some cases, hospitalisation. The key predictor of future exacerbations is a previous history of exacerbations. Having an exacerbation leads to decreased lung function which may lead to an increased risk of further exacerbations and even death. In this article, the importance of early recognition and treatment of exacerbations is discussed, along with current evidence about the prevention of exacerbations.
IS THIS AN EXACERBATION OF COPD?
The report of an acute and sustained increase in breathlessness with more (and/or more purulent) sputum production is synonymous with an exacerbation of COPD.2 Although Martha is used to having all of these symptoms to some extent it is the change in the severity in the symptoms that suggests an acute flare up of her COPD. More than 50% of exacerbations have an infective cause so developing a temperature can be a sign that an exacerbation may be imminent.3
THE IMPACT OF EXACERBATIONS
An acute exacerbation of COPD (AECOPD) has immediate and long-term consequences. The immediate effect is to make the patient feel unwell and breathless and this may mean that they are unable to carry out normal tasks such as personal hygiene, housework, cooking or shopping. This can also affect their mood and quality of life, leading to depression, which is also known to increase the risk of further AECOPD.4 In the longer term, AECOPD increase the risk of mortality and also lead to reductions in FEV1, which may be permanent and which may further increase the risk of future exacerbations.5 A study by Soler-Cataluna et al demonstrated that the highest risk of dying is in those patients who have three or more exacerbations per year.6 This study also suggested that the severity of the exacerbation dictates mortality risk, irrespective of the underlying stage of COPD that the individual is diagnosed at, so this once again highlights the importance of early identification and treatment of exacerbations. Many patients fail to report exacerbations,7 but Martha has been made aware of the importance of treating AECOPD after her previous episode and she sought assistance relatively early on. She had also increased her use of her short acting bronchodilator to help with her symptoms of breathlessness. This had helped a little but she had now realised that she needed further support to manage her condition.
EXACERBATION TYPES
AECOPD may present with increased breathlessness, an increase in sputum production, the production of more purulent sputum or a mixture of all of these symptoms. Statistically, most exacerbations have an infective cause and so patients may experience pyrexia as well as an increase in dyspnoea and sputum production at the start of an exacerbation. These symptoms may benefit from different approaches to management; for example an infective element is likely to require antibiotics whereas an exacerbation that presents primarily as breathlessness will need oral steroids. The presence of green sputum greatly increases the likelihood of an infective exacerbation in people with COPD.8
TREATMENT OPTIONS
According to NICE,1 the recommended intervention for an infective AECOPD should be to offer a broad spectrum antibiotic such as amoxicillin 500mg tds for a week or doxycycline at a dose of 200mg on day one and 100mg for another six days, then review the patient to assess for improvement. Antibiotics have been shown to reduce mortality rates in people suffering from infective exacerbations.9 If breathlessness is a feature, the advice has been to offer prednisolone 30mg for 1-2 weeks. The recent REDUCE study, however, compared giving shorter courses of oral steroids with the usual dosing regimen. REDUCE found that a shorter (5 day) course of prednisolone 40mg had the same outcome as the longer course of treatment, in terms of the time to recovery and number of re-exacerbations, but that the side effects, such as raised blood pressure and blood glucose, were fewer.10 The study demonstrated that when comparing prednisolone 40mg given for 5 days and 14 days, 56 people had another exacerbation within six months in the 5 day group as opposed to 57 patients given 14 days of oral steroid treatment. In terms of the length of time to the next exacerbation, this was 43.5 days in those treated for 5 days and 29 days in the 14 day treatment group. This provides some evidence for giving a shorter course of treatment and reviewing the patient at the end of the 5 days to assess response. Martha was showing symptoms which suggested a mixture of symptoms of breathlessness and an increase in purulent sputum so both treatments – antibiotics for a week and a 5 day course of prednisolone – were prescribed for her with advice on how to take them.
PLACE OF CARE – HOME, HOSPITAL OR HOSPITAL-AT-HOME?
Although most AECOPD can be managed in the community setting, some people may require hospitalisation. NICE provides a list of possible indications for admission, and these include the severity of the exacerbation, the existence of significant co-morbidities and the inability to self-care at home.1 If any of these apply, admission may still not be necessary as each area of the country will have access to different resources, services and support networks which will allow people to stay out of hospital. It is worthwhile finding out about services available locally before deciding whether to advise admission. Many patients will prefer to avoid an admission if possible, so schemes such as hospital-at-home can be a welcome alternative to admission and have been shown to result in similar outcomes as in-patient care. However, in some cases admission may be unavoidable and indeed preferable – for example in patients who are likely to benefit from assessment of blood gases or non-invasive ventilation (NIV). NIV should be considered for patients with severe COPD and acute respiratory failure as it has been shown to improve symptoms and reduce the length of the hospital stay.11 Martha was keen to stay at home, and a review of the NICE decision tree suggested that it was safe for her to do so.
REVIEW AND FOLLOW UP
As previously stated, regular follow up is essential both during and after the AECOPD to ensure that the individual is improving and importantly, that they are not getting any worse. People with more severe COPD are at greater risk of AECOPD but are also at risk of cor pulmonale – right sided heart failure which is the result of chronic lung disease.12 Cor pulmonale may present with similar symptoms of breathlessness and increased sputum production and may easily be mistaken for a standard exacerbation. However, other symptoms may be present, such as hypoxia and peripheral oedema, which may necessitate the use of oxygen therapy and diuretics. People with cor pulmonale will need specialist diagnosis and follow up. For patients like Martha, who have had an infective AECOPD without complications, review can be carried out every few days until her condition has improved; follow up after admission should include a full review at 4-6 weeks.
PREVENTION OF EXACERBATIONS
The post-AECOPD review should include an assessment of how to prevent and manage further exacerbations. The elements of self-care that are included in a standard pulmonary rehabilitation (PR) programme have been shown to improve overall wellbeing in people with COPD,13 and the benefits of the PR programme should be explained to Martha, with encouragement to attend. Smoking cessation advice should be seen as a treatment for COPD, not as an optional extra. Flu and pneumonia immunisation should be encouraged as infections are not only responsible for AECOPD but are also known to be a trigger for heart failure.14 The NICE guidelines for the management of COPD suggest that inhaled corticosteroid/long acting beta2 agonist (ICS/LABA) combination therapies should be used in people who have a history of exacerbations.1 Martha was using a SABA and a LAMA and it may be that other therapies should now be considered, although there is evidence for a reduction in exacerbations with both long acting muscarinic antagonist therapy, and long acting beta2 agonists. 15–17 There are currently five ICS/LABA combination inhalers licensed for COPD and they should be selected according to their risk: benefit profile, patient ability to use the device and patient preference.18 The brand names of these inhalers are Seretide Accuhaler, Symbicort Turbohaler, Fostair pMDI, Relvar Ellipta and Duoresp Spiromax. More information on these inhalers can be found on the Electronic Medicines Compendium website, http://www.medicines.org.uk/emc/. Following a discussion with Martha about the treatment options available, including sharing of information about the risks and benefits of treatment, she decided that she would like to try an ICS/LABA combination and the final choice was made based on her preferred inhaler device and her ability to use it.
SELF-MANAGEMENT
NICE recommends that all people with COPD who are at risk of an exacerbation should be given a self-management plan which enables them to recognise any flare up of symptoms and treat them promptly,1 and there is evidence to say that these plans can help reduce the risk of a serious exacerbation and the need for hospital admission.19 However, the British Lung Foundation’s suggested content for self-management plans goes much further than simply including advice on managing AECOPD. It describes a broader concept of self-management with an action plan for AECOPD being just one part of that plan.20, 21 The BLF website has a wealth of resources to help people understand and manage their condition: health care professionals, patients and carers can access a range of tools, including DVDs and written materials, to help them do so. Suggested content for a self-management plan is summarised in Box 1.
It is important that patients are involved in developing their plans as this makes them more likely to be used. It also means that the content can be personalised to that individual. However, there is some evidence to suggest that people who have action plans for managing AECOPD have poorer outcomes than those who do not have them.22 Although the reasons for this are not clear, it may be because there has been a lack of explanation of how to use the plan and possibly a feeling that it is not necessary to have any contact with the surgery if medication is already to hand. This underlines the importance of developing the plan together so that there is an opportunity for discussion and explanation.
Martha had not been given a self-management plan before, but found the BLF website and the practice’s COPD information pack and action plan very informative. She shared the information she had learned with her family and also discussed it with her local Breathe Easy group.
CONCLUSION
AECOPD are common, especially in people with more severe COPD in terms of lung function, symptoms or both. They are linked to increased morbidity and mortality and can put the individual at further risk of exacerbations in the future. Appropriate management of AECOPD includes antibiotics and prednisolone, and these may be started by the patients themselves using a rescue pack with appropriate, personalised, written advice. There is some evidence to suggest that a shorter course of prednisolone may be as effective as a longer course but with fewer side effects. Careful assessment of each case should be made to decide where the best place is to manage the exacerbation and NICE has a list of criteria which may help with this decision. Measures to prevent AECOPD should be considered and implemented: these include flu vaccinations, pulmonary rehabilitation and appropriate use of inhaled and other therapies. As each individual person and each individual AECOPD is different, a personalised approach to care is essential.
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