Frequent exacerbations in chronic obstructive pulmonary diseaseBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1434 (Published 04 April 2011) Cite this as: BMJ 2011;342:d1434
- Christina George, medical student1,
- Will Zermansky, general practitioner2,
- John R Hurst, clinical senior lecturer1
- 1Academic Unit of Respiratory Medicine, University College London Medical School, London NW3 2PF, UK
- 2Highgate Group Practice, London, UK
- Correspondence to: JR Hurst
- Accepted 14 February 2011
A 62 year old smoker with confirmed chronic obstructive pulmonary disease (COPD) has received his third course of steroids and antibiotics for apparent exacerbations in a year. He is anxious about the frequent flare ups and additional treatment he is being prescribed.
What you should cover
COPD is characterised by poorly reversible airflow obstruction and progressive symptoms. Exacerbation of COPD is a clinical diagnosis of exclusion and there are many causes of worsening symptoms in a patient with underlying COPD that should be considered. The frequency of exacerbations varies between patients, and the best predictor is a patient’s history of exacerbations. Patients who have frequent exacerbations have a more rapid decline in lung function, poorer quality of life, and greater mortality. Preventing exacerbations is therefore a key goal of COPD management.
Are the episodes of deteriorating symptoms really exacerbations of COPD, or are there other explanations?
Have all available interventions to reduce exacerbations been recommended (box)?
Is the patient taking prescribed medication as directed?
Does the patient understand the impact of exacerbations and the importance of early treatment?
What you should do
Consider alternative diagnoses
Establish whether these events are truly exacerbations, rather than other causes of deteriorations in a patient with underlying COPD. The symptoms of exacerbation include increasing breathlessness; increasing sputum volume; and more purulent sputum, developing over a period of hours to days, and typically lasting for around one week.
Specifically ask for symptoms that may suggest additional respiratory diagnoses such as large volumes of phlegm (bronchiectasis), and weight loss or haemoptysis (lung cancer). If suspected, investigate further. High resolution chest computed tomography is effective in detecting bronchiectasis, which can coexist with COPD.
Seek symptoms and signs that may suggest diagnoses in other organ systems such as pallor (anaemia), orthopnoea, and ankle oedema for cardiac failure (though COPD and heart failure need not be mutually exclusive). Rapidity of symptom changes may suggest anxiety. To identify anxiety and depression use a validated questionnaire. Treat comorbidities when present.
If the patient is truly having frequent exacerbations (two or more treated exacerbations in a twelve month period) then:
Maximise pharmacological interventions in a stepwise fashion according to the latest National Institute of Health and Clinical Excellence (NICE) guidance (see useful resources box). There is no role for long term oral corticosteroids in reducing COPD exacerbations, and no established role for long term or rotating antibiotics.
Assess whether patient is following prescribed therapy correctly, such as evaluation of inhaler technique.
Refer for pulmonary rehabilitation (effective in reducing exacerbation frequency).
Recommend the seasonal influenza vaccine and pneumococcal vaccination.
Explain the treatments and explore patient’s concerns (anxieties, understanding of medication, and side effects).
Exclude respiratory failure with screening oximetry: underuse of long term oxygen therapy has been associated with increased risk of hospital readmission. Patients with oxygen saturations ≤92% breathing room air at rest and when stable should be referred for blood gas assessment.
Frequent exacerbations despite maximal therapy, or other diagnoses, may require referral for a specialist opinion, as described in the British Thoracic Society 2008 statement (www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Good%20Clinical%20Practice/hospreferalthorax.pdf).
Prompt treatment of exacerbation can lead to speedier recovery. Patients may therefore benefit from home rescue packs of antibiotics or steroids. Advise patients to start rescue antibiotics if they notice a change in sputum colour or volume, with steroids if there is a deterioration in breathlessness, worse than a bad day. A suitable regime would be seven days of oral prednisone (30 mg daily (no need to taper the dose)) with amoxicillin (500 mg three times daily). A macrolide or tetracycline would be appropriate in a penicillin allergic patient. Thresholds for presentation vary between patients and individually tailored education is key. Encourage and motivate the patient to quit smoking.
Support and palliative care
Regional British Lung Foundation “Breathe Easy” groups can provide peer support and advice to patients with COPD in the UK (www.lunguk.org).
Where progressive symptoms may represent disease severity rather than exacerbation, ask about supportive care needs. Referral for social support may be appropriate, and palliative care services may be able to advise on the management of intractable symptoms.
The symptom management approach to preventing exacerbation is best achieved through a multidisciplinary team coordinated through a primary care doctor. Respiratory nurses can provide ongoing education and training to patients, with physiotherapists often leading pulmonary rehabilitation programmes.
Interventions shown to reduce exacerbation rate and admissions to hospital
See current NICE guidelines for specific indications (useful resources box)
Long acting β agonists
Long acting antimuscarinics
Phosphodiesterase type 4 (PDE4) inhibitors
Long term oxygen therapy
Domiciliary non-invasive ventilation
Lung volume reduction surgery
National Institute for Health and Clinical Excellence (NICE). Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care update guideline. 2011. http://guidance.nice.org.uk/CG101
Primary Care Respiratory Society UK. Diagnosis and management of COPD in primary care: a guide for those working in primary care. 2010. www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf
Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010;363:1128-38. www.nejm.org/doi/full/10.1056/NEJMoa0909883
Drug and Therapeutics Bulletin. Preventing exacerbations in chronic obstructive pulmonary disease. BMJ 2011;342:c7207. doi: 10.1136/bmj.c7207
Cite this as: BMJ 2011;342:d1434
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Competing interests: CG and WZ have no competing interests. JRH has received honorariums for presentations from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, and Pfizer. He has sat on advisory boards for AstraZeneca and Bayer.
Provenance and peer review: Not commissioned; externally peer reviewed.