The treatment and prevention of exacerbations in COPD:

the role of primary care

COPD is a major cause of hospital admissions in the UK, accounting for over one million in-patient bed days each year1. Exacerbations of COPD are a major cause of hospitalisations. COPD exacerbations are a significant burden for patients and the health service, particularly those that result in admission to hospital2. They are distressing and disruptive for patients and account for a significant proportion of the total healthcare costs of COPD3. However, with proactive management, exacerbations can be reduced and when they do occur, treating to minimise duration will have a positive impact on patients health status. This simple guide aims to show how you can help manage and prevent exacerbations in your COPD patients, reducing the impact on your patients and your practice. We are calling on your support to make preventing COPD exacerbations a key aim for primary care. Dame Helena Shovelton Chief Executive, British Lung Foundation Professor David Price GPIAG Professor of Primary Care Respiratory Medicine, Dept of General Practice and Primary Care, University of Aberdeen

Kindly sponsored by GlaxoSmithKline

The treatment and prevention of exacerbations in COPD:

the role of primary care
WHAT IS AN EXACERBATION OF COPD?
An exacerbation is a sustained worsening of the patients symptoms from their usual stable state, which is beyond normal day-to-day variations and is acute in onset3. Commonly reported symptoms are3: Worsening breathlessness Cough Increased sputum production Change in sputum colour Change in ability to carry out daily activities The change in these symptoms usually necessitates a change in medication3.

MANAGEMENT OF ACUTE EXACERBATIONS

Exacerbations can often be managed in primary care. Pharmacological treatment includes bronchodilators, antibiotics and oral corticosteroids. Bronchodilators Increase dose of short-acting bronchodilator Patients should be informed of maximum dose Ensure effective delivery system Check inhaler technique Antibiotics3 Use to treat exacerbations in patients who develop purulent sputum. If no improvement is seen, further antibiotic treatment may be required. Recent evidence has shown that a change to green colour sputum is indicative of a new infection Initial treatment options include: o Aminopenicillin (eg. amoxicillin) o Macrolide (eg. erythromycin) o Tetracycline (eg. tetracycline) Seven days of treatment is usually sufficient Frequent use of the same antibiotic may lead to resistance (in which case sputum culture and sensitivity can be valuable) Patients with more severe disease may harbour resistant organisms Oral corticosteroids3 Early addition of oral corticosteroids should be considered in patients who have an exacerbation with significant increase in breathlessness (in the absence of significant contraindications) Typical administration: 30mg per day for 7-14 days Oral corticosteroids should seldom be continued long term; patients should be made aware of the optimal length of treatment as well as the adverse effects of prolonged therapy Patients, particularly those discharged from hospital, should be given clear instructions about why, when and how to stop their corticosteroid treatment
3

PREVENTION OF EXACERBATIONS
NON-PHARMACOLOGICAL TREATMENTS3
Smoking cessation Even after diagnosis, stopping smoking will have a significantly positive impact on patients health and disease progression Encouraging smoking cessation will help improve cough and sputum, and slow disease progression (cessation may lead to a temporary increase in cough and sputum) Activity Many people with COPD are frightened to take daily activity for fear that being breathless may harm them and as a result patients can become unfit, tired and even more breathless Exercise is important in keeping the lungs healthy and feeling breathless is a natural consequence of physical exercise Encourage all patients to take or continue daily activity to help prevent deconditioning Pulmonary rehabilitation This is an individually tailored programme comprising exercise, education, emotional support and optimising treatment. Pulmonary rehabilitation is designed to improve an individuals physical/mental well-being and autonomy Pulmonary rehabilitation should be available to all patients who could benefit from it

Protocol

for the treatment and prevention of exacerbations in COPD

Is it an exacerbation?
The key features typically associated with exacerbations are one or more of the following: Worsening breathlessness Changing sputum colour Increased sputum volume Increased cough Fever Reduction in activity levels

IMPACT OF EXACERBATIONS ON THE PATIENT

Exacerbations may lead to an irreversible decline in lung function and disease progression4, 5. Frequent exacerbations are associated with: Faster lung function (FEV1) decline6, 7 Increased airway inflammation Worsening health status8 All of these factors contribute to more admissions and longer hospital stays for the patient. Lung function declines up to 25% faster each year in patients with frequent exacerbations4; and as FEV1 declines, exacerbations become increasingly more common and more severe9. Following each severe episode a patient is unlikely to regain their pre-exacerbation health status. Airflow obstruction is defined as a reduced FEV1 (forced expiratory volume in one second) of less than 80% predicted and FEV1: FVC (forced vital capacity) ratio of less than 70%. Based on the level of percentage predicted FEV1 when the patients condition is stable, the degree of COPD obstruction can be classified as follows3: Mild (50-80% predicted) Moderate (30-49% predicted) Severe (<30% predicted) Lung function alone does not accurately correlate with a patients symptoms. A true assessment of disease severity should include several factors such as a review of health status, exercise capacity, breathlessness (MRC scale) and the frequency of exacerbations.

IF YES TO ANY

IF NO

Factors prompting consideration of home management vs. hospital admission

Coping at home Normal level of consciousness Experiencing only mild breathlessness Maintaining usual level of activity Eating and drinking normally Little change to usual general condition Easy access to help if required Lack of significant co-morbidity

PHARMACOLOGICAL TREATMENTS3
Optimising pharmacological therapy may help reduce the frequency of exacerbations. Optimise bronchodilator therapy with one or more long-acting bronchodilator (2 agonist or anticholinergic) For patients on short-acting bronchodilators with persistent symptoms, to reduce the frequency of exacerbations. Add inhaled corticosteroids (usually in combination with long-acting bronchodilators) For patients suffering more than two exacerbations a year and FEV1<50% predicted, to reduce exacerbation frequency and rate of decline in health status. Mucolytic therapy For consideration in patients with a chronic cough productive of sputum. Should be continued if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production).

IF YES TO MOST

IF NO TO MOST

Manage the patient at home

Admit the patient to hospital

Manage acute exacerbations

Add or increase bronchodilator use: o Review inhaler device o Review inhaler technique Prescribe antibiotics if sputum becomes purulent Consider oral corticosteroids Pulse oximetry if severe exacerbation Increase social support if necessary

FREQUENCY OF EXACERBATIONS
Exacerbations are frequent among patients with COPD at any stage, even those with an FEV1 of 50% predicted10. The majority of patients report two or more exacerbations a year, regardless of lung function10.

AGREE TO FOLLOW UP AND REVIEW THE PATIENT TO REASSESS THEIR COPD

PATIENT EDUCATION THE PROVISION OF PERSONAL ACTION PLANS

All patients require education to help them know what to do when their condition deteriorates. The provision of personal action plans may help develop their understanding of the condition. These plans could include key written prompts to help them identify: Their key triggers for an exacerbation, eg: Weather changes (eg. cold spells, muggy/close) Viral epidemics, in particular winter influenza epidemics Exposure to a smoky environment High pollen levels Exposure to viral or bacterial infections When to seek help, eg: You get much more breathless than you did before You find yourself generally less able than you were before When they have experienced an exacerbation, eg: You produce more sputum than before Your sputum becomes discoloured You feel feverish or unwell Patients at risk of having an exacerbation of COPD should also be given self-management advice that encourages them to respond promptly to the symptoms of an exacerbation by3: Starting oral corticosteroid therapy if their increased breathlessness interferes with activities of daily living (unless contraindicated) Starting antibiotic therapy if their sputum is purulent Adjusting their bronchodilator therapy to control their symptoms Patients given personal action/self-management plans should be advised to contact a healthcare professional if they do not improve3.

Long-term management of patient post-exacerbation

Review:
Patient understanding/personal action plan Non-pharmacological strategies: o Smoking cessation o Exercise o Pulmonary rehabilitation Pharmacological strategies: o Optimise long-term maintenance therapy in line with guidelines ie. long-acting bronchodilator (2 agonist and/or anticholinergic), ICS (usually in combination with long-acting beta agonist) and mucolytics if chronic productive cough o Inhaler technique o Ensure annual influenza vaccination is offered, together with offering pneumococcal vaccination Adapted from NICE 20043

HOW DO PATIENTS PRESENT?

Patients tend to play down the symptoms of exacerbations; in fact a study showed that patients experiencing a median rate of 2.4 exacerbations per year reported less than half of these to healthcare professionals, yet there were no significant differences in lung function, symptom score or recovery times between reported and unreported exacerbations11. To encourage patients to present to their healthcare professional, it is important they understand that prevention and prompt treatment of exacerbations is critical to their own long-term health.

Contributors
Dr Antony Crockett GP, Shrivenham, Wiltshire Dr Lisa Davies Consultant Chest Physician University Hospital Aintree, Liverpool Dr Rupert Jones MRCGP, GP, Plymouth Clinical Research Fellow, Peninsula Medical School, Plymouth Professor David Price GPIAG Professor of Primary Care Respiratory Medicine, Dept of General Practice and Primary Care, University of Aberdeen Jane Scullion Respiratory Nurse Consultant, Leicester Chair of the Respiratory Nurses Forum Dr Mike Thomas Asthma UK Research Fellow, Dept of General Practice, University of Aberdeen GP, Minchinhampton, Gloucestershire Hospital Practitioner Respiratory Medicine, Stroud Hospital

To request further copies of The treatment and prevention of exacerbations in COPD: the role of primary care guide, please call the information and publications line 020 7688 5555

References
1

National Respiratory Training Centre. Impact of Respiratory Conditions: a guide for Primary Care Organisations. Warwick: NRTC (2002). National Asthma and Respiratory Training Centre. Respiratory conditions: are health needs being met? Warwick: NARTC (2000). National Collaborating Centre for Chronic Conditions. Chronic Obstructive Pulmonary Disease: National clinical guideline on management of adults with chronic obstructive pulmonary disease in primary and secondary care. NICE guideline 12. Thorax 2004;59 (Suppl I): 1-232. Donaldson GC, Seemungal TAR, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57: 847-852.

British Lung Foundation 73-75 Goswell Road London EC1V 7ER T: 020 7688 5555 E: enquiries@blf-uk.org www.lunguk.org registered charity no: 326730 Helpline number: 08458 50 50 20 Monday to Friday 10am 6pm

Kanner RE, Anthonisen NR, Connett JE. Lower respiratory illness promote FEV1 decline in current smokers but not ex smokers with mild chronic obstructive pulmonary disease. Results from Lung Health Study. Am J Respir Crit Care Med 2001;164: 358-364. Seemungal TAR, Donaldson GC, Bhowmik A, Wedzicha JA. Frequent COPD exacerbators show accelerated decline in lung function. Am J Respir Crit Care Med 2001;163(5): A772. Seemungal TAR, Donaldson GC, Bhowmik A, Wedzicha JA. Frequent COPD exacerbators have more severe exacerbations. Am J Respir Crit Care Med 2001;163(5): A769.

Seemungal TAR, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157: 1418-1422. Pauwels RA, Buist AS, Calverley PMA, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001;163: 1256-1276. OReilly JF, Williams AE, Rice L, Holt K. Incidence and impact of healthcare-defined exacerbation amongst a cohort of primary care COPD patients. Presented at European Respiratory Society Annual Congress, 4-8 September 2004, Glasgow, UK.

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Seemungal TAR, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000;161: 1608-1613.
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