Assessment and Management of Chronic Obstructive Pulmonary Disease in the Emergency Department and Beyond

Brian H Rowe; Mohit Bhutani; Mike K Stickland; Rita Cydulka 09/16/2011 Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are common, can result in emergency department presentation and often result in hospitalization. After confirming the diagnosis and treating comorbidities, management of severe AECOPD includes bronchodilators, systemic corticosteroids, antibiotics, noninvasive ventilation and, occasionally, endotracheal intubation. Once discharged, delayed follow-up and suboptimal management often occurs. Antibiotics, systemic corticosteroids and optimization of nonpharmacological interventions (e.g., smoking cessation, immunization and pulmonary rehabilitation) are important discharge considerations. Improving linkages to primary providers who adhere to management involving a pharmacological and nonpharmacological evidence-based treatment plan is critical to preventing future AECOPDs, reducing healthcare utilization and maintaining the quality of life of patients following an AECOPD. Chronic obstructive pulmonary disease (COPD) is one of the few major chronic diseases in which mortality has been increasing over the past decade. Global mortality due to COPD is forecast to more than double over the next 30 years, which would make it the third leading cause of death worldwide by 2020. Individuals with COPD are prone to exacerbations of their illness, which are characterized clinically by symptoms of worsening dyspnea, cough, sputum production and sputum purulence, as well as by worsening of their airflow obstruction. It is difficult to predict expected exacerbation rates for individual patients; however, most patients with moderate-to-severe COPD experience one to four exacerbations per year. Exacerbations become more frequent with an increasing severity of disease. In the USA in 2000, there were 8 million physician office or hospital outpatient visits for COPD, 1.5 million emergency department visits and 673,000 hospitalizations. Patients who live with COPD are prone to developing a worsening of their symptoms, which can lead to acute exacerbations. Experts define an acute exacerbation of COPD (AECOPD) as 'a sustained worsening of dyspnea, cough or sputum production, for at least 2 days, leading to an increase in the maintenance medications and/or supplementation with additional medications'. There are a number of consequences of an AECOPD, including loss of lung function, impairment of quality of life (QoL), increased mortality (both short and long term) and increased healthcare utilization. Thus, treatment and prevention of an AECOPD are two of the most important goals in the management of this disease.

While exacerbations are more frequent and severe as COPD progresses, patients with COPD may exacerbate for a variety of reasons. For example, pollution, cigarette smoke and upper respiratory tract infection may cause increased secretions and worsening airway obstruction. Nonadherence or inadequate medical management may also play a role in exacerbations. In a subgroup evaluation of the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study, exacerbations defined as events that resulted in a provider prescribing antibiotics and/or corticosteroids or that led to hospitalization (severe exacerbations) were examined. In this study of over 2000 patients and 3 years of follow-up, patients with two or more exacerbations during the year were considered to have frequent exacerbations (Figure 1). Targeting these patients was proposed as an intervention strategy and perhaps these patients should also be targeted in the emergency department (ED) stetting. Patients with AECOPD commonly present to the ED or other acute care settings and may be unaware that they have COPD. In one trial, approximately 10% of enrolled patients received their diagnosis of COPD in the ED setting. In addition, patients with AECOPD often demonstrate fairly advanced disease in the ED setting. For example, in a recent North American study, over 59% of patients presenting to the ED with COPD symptoms required hospitalization. ED length of stay was nearly 6 h and mechanical ventilation was higher than in other acute respiratory presentations such as asthma. Given the severe nature and high mortality rates of AECOPD, it is not surprising that a number of guidelines have been developed to direct the management of the disease and improve early diagnosis. Despite the availability of these guidelines, there exists an evidence gap between what is known and what is practiced. This is, in part, owing to the rapidly changing understanding of the pathophysiology and treatment of COPD and to the difficulty of keeping up with the medical literature and rapidly multiplying number of medical guidelines. Chronic obstructive pulmonary disease is a chronic and frequently debilitating disease. The pharmacologic and nonpharmacologic treatment approaches outlined above to control bronchial inflammation and infection provide an approach for expediting the return to activities, reduced symptoms and improved QoL in the subacute period following an exacerbation. In addition, referral to smoking cessation programs, immunization and rehabilitation programs, along with prescribing appropriate preventive medication, will provide patients with the best opportunity possible to maintain an optimal QoL. http://www.medscape.com/viewarticle/749612_8