Managing Acute Exacerbations of COPD: A Scorecard

As readers of the Journal know all too well, the long-term course of COPD is punctuated, characterized really, by acute exacerbations (AECOPD) that occur about once a year on average, mainly in the more severe stages, GOLD stages III and IV. These events cause a great deal of morbidity that may persist for weeks or months (1). They also cause not inconsiderable mortality, and probably a stepwise decline in lung function and health status with each event. They are also expensive, such that managed care and health insurance companies are as eager as the medical profession to reduce their number and severity. Over the last decade, studies have shown that most of our maintenance COPD therapies can achieve reductions in the frequency of AECOPDs, each by very roughly 15–30%. These facts need to be more widely known and exploited.

Just as important as preventing the acute exacerbation is managing it when it occurs. The former mayor of New York City, Ed Koch, used to go regularly into the Manhattan streets and randomly ask the citizenry “How’m I doin’?” Whether to follow his excellent example or not, New York City's pulmonologists have adopted his practice (if not his methodology) by asking themselves the same question. In the excellent and fascinating report by Yip and colleagues in this issue of the Journal (2) we get some of the answers. The study was large, covering more than 1,600 exacerbations in 5 New York City hospitals that serve essentially all segments of the urban population and continued through 2 full seasonal cycles so that, apart from the demographic only being representative of a big metropolis, the management practices they identified are probably fairly representative of the U.S. nation if not other developed countries. There is a lot to learn so, dispensing with finger-pointing, let me draw up a scorecard of those aspects of AECOPD management that, in my opinion, and in this demographic, were being well done and deserve honorable mention and those that needed rectification.

One notes that only 83% of patients had a prior history, i.e., diagnosed COPD. So, 17% had bad enough COPD to be experiencing AECOPDs but had not been diagnosed, -and presumably not appropriately treated. That is not as bad as some estimates (3, 4), but still not acceptable. Also not good are the following findings: that fewer than half the patients who were recovering from an AECOPD and who were current smokers received smoking cessation counseling; that influenza vaccination status was assessed in only 79% of patients during the influenza season, and that vaccination itself was only provided to a quarter of those who were eligible to receive it. Despite the recent reports that influenza vaccine probably does not reduce mortality outside the ‘flu season’ as previously thought (5), there is no question that it saves lives during most winters and is cost effective. Also not good was that only fewer than half the recovering patients were prescribed a maintenance bronchodilator on discharge; and, even more surprising, that only a quarter were prescribed any regular inhaled therapy at all on discharge.

Note also that the last two figures mean that at least a quarter of the patients must have been discharged from hospital with an inhaled corticosteroid or some other nonbronchodilator inhalation as their only maintenance therapy unless I’ve miscalculated. Steroid monotherapy would only be consistent with guidelines for asthma, not COPD. Certainly not now that there appears to be a slight increase in the risk of pneumonia in COPD patients who receive an inhaled steroid (6).

What is good however, is that, as the authors state, management of the AECOPD episode was mostly consistent with published guidelines. One does not learn about the details: which medications? what doses? for how long were they given? However, almost all patients received bronchodilators and systemic corticosteroids (a short course one presumes); and 80% received an antibiotic. Arterial oxygenation was assessed in 75%, which seems about right; and spirometry and sputum cultures, both of which cost money but tend not to be helpful in guiding therapy, were seldom performed. In-hospital mortality was relatively low at 3.6%. So in summary, it seems that management of the acute episode gets a B+ grade, while the grade for discharge management gets a generous C minus.

This disparity in performance is, in my experience, a fairly systematic feature of U.S. medical practice where responsibility for the care of a patient may fall between 2 different sets of caregivers, resulting in a discontinuity between in- and out-patient phases of a disease. With the increasing preponderance of the ‘hospitalist’ this trend might be expected to intensify. To address this problem, I believe it is not enough to have guidelines. The guidelines need to be understood and widely disseminated. The pulmonary specialist community and COPD subspecialists in particular, need to educate our primary care colleagues who see and treat most COPD patients, certainly those who practice outside the urban centers. Simple measures like regular immunizations, referral to smoking cessation clinics, appropriate use of short- and long-acting bronchodilators and corticosteroids, all of these are, in the authors’ words, “opportunities for improving care”, contributing to fewer AECOPDs and better outcomes for patients. I hope the authors of this paper get many invitations to address primary caregiver meetings and CME events where basic measures can be reinforced.

Before concluding let me draw attention to 2 other instructive features one notices: the gender difference in AECOPDs, at 5 females to 4 males, is consistent with CDC's mortality data for COPD which showed that female deaths overtook males in 2002. COPD is now clearly becoming a predominantly female disease. Secondly, co-morbidities were documented in well over half the patients, and many had multiple co-morbidities, cardiovascular ones being the most predominant. It should be generally recognized that co-morbidities are an almost universal feature of COPD, particularly in moderate or worse stages. Most common are cardiovascular co-morbidities and smoking related malignancies, of-course. But the clinician must also be alert to hypertension, hyperlipidemia, depression, cataracts, and osteoporosis all of which are now eminently treatable.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.