Key learning points:
– Smoking is the main cause of COPD
– When a patient with COPD has had an exacerbation further preventions should be arranged
– Patients at most risk of future exacerbations can be identified through communication discussing past events/history
Chronic obstructive pulmonary disease (COPD) is very common and is part of a spectrum of lung diseases. The main cause of COPD is smoking.1 COPD can only be diagnosed by post-bronchodilator spirometry, when the forced expiratory volume in one second to vital capacity (FEV1/VC) ratio is less than 0.7 and the patient has a relevant exposure history (eg, tobacco smoke exposure). Related lung conditions include emphysema (a diagnosis based on loss of alveoli, seen on a computed tomography (CT) scan) and chronic bronchitis (a clinical diagnosis based on cough and regular production of phlegm). There is an overlap in symptoms between COPD and asthma, and between COPD and bronchiectasis. However, the causes, treatment and outlook of these conditions are different. It is important where possible to make a distinction. Sometimes this is not possible and patients are labelled as having ‘overlap’ syndromes such as asthma-COPD overlap syndrome (ACOS).2
Loss of lung function occurs as part of healthy ageing. COPD is usually characterised by accelerated decline in lung function. Although, a similar pattern on spirometry may be seen in people who have never reached their maximum lung size (for example, because they were born prematurely).3 As lung function decreases in COPD, symptoms of breathlessness, cough, wheeze and phlegm develop.
The course of COPD is punctuated by intermittent periods of increased symptoms – these are called ‘exacerbations’. It is thought that most exacerbations are caused by infection, for example with rhinovirus – a viral cause of the common cold. Environmental factors such as pollution may also be associated with the development of an exacerbation.
Other medical conditions (co-morbidities) are common in COPD and there may be other reasons why a patient with COPD develops worsening symptoms. These include other lung diseases such as pneumonia, and problems in other organs such as heart failure or anxiety. Conditions that mimic exacerbation should always be thought about prior to starting treatment for an exacerbation. Exacerbations are really important events; the number of exacerbations relates to the quality of a patient’s life, the risk of hospitalisation, death and healthcare costs. There is a higher risk of a second exacerbation developing in the weeks following a first event. Some patients appear more prone to developing exacerbations than others, and this is a relatively stable trait4 such that if a person has had many exacerbations this year they are at high risk of frequent exacerbations next year too. This is important because we now have lots of effective ways to reduce COPD exacerbations.5 Patients who have had more than two exacerbations needing treatment with antibiotics and/or steroids per year can be considered ‘frequent exacerbators’ and should be targeted for exacerbation prevention. With this background in mind, our five-step approach to a post-exacerbation visit is described below.
1. Has the patient recovered
Recovery from an exacerbation can be slow and take many weeks, but is generally progressive. Ask about symptoms, especially breathlessness, and exercise capacity. Check the oxygen saturations and compare these to previous readings when the patient was stable. Question the patient about the character of the sputum, focusing on sputum colour, thickness and volume and compare this to sputum character when the patient is well.
Reassure the patient that recovery continues long after returning home, and after the specific exacerbation treatment has stopped. Encourage the patient to be active. There are plans in the UK to specify post-exacerbation pulmonary rehabilitation, and if this occurs encourage the patient to attend. If there is anything to suggest that recovery is not continuing (for example, symptoms are deteriorating, or oxygen saturations are low) then this would require a full assessment as for a patient presenting with a new exacerbation.
2. Have all the appropriate strategies to prevent further exacerbations been put in place?
The recovery visit after an exacerbation, especially an event that has been severe enough to result in hospital care, is a useful opportunity to ensure that all the appropriate management strategies to prevent future exacerbations have been put in place. We use therapy in COPD based on evidence of efficacy and cost-effectiveness.
First and foremost, if the patient continues to smoke then support the patient to attempt quitting smoking. You may have the skills to do this yourself or you may decide to refer the patient to a smoking cessation advisor for more intensive input. Either way, it is important to follow this up and record a successful quit attempt.
Secondly, for those patients who have continuing breathlessness (grade 3 or above on the Medical Research Council’s breathlessness scale) recommend a pulmonary rehabilitation (PR) programme and make the referral. These education and exercise programmes are as effective as the best inhalers in reducing symptoms and increasing exercise performance, and also reduce exacerbations.6 PR is more cost-effective than inhalers. Patients may be reluctant to participate or be anxious that PR will be too hard. Support and encouragement will be key in their decision to attend.
Thirdly, recommend seasonal influenza vaccine and, if the patient has not received it before, pneumococcal vaccination.
Additionally, review their medicines. Drugs are used to treat COPD in line with the international GOLD (Global initiative for Obstructive Lung Disease) guidance that classifies patients and recommends therapy based on their symptom burden, severity of lung function impairment, and frequency of exacerbations.7 Discuss with a prescriber if you think that the choice of medications is not correct. The regular medication may have changed while in hospital. If there is a new drug or device it is important to make sure the patient knows how and when to take the drug. Inhaler technique should be assessed and optimised during the review and for this reason patients should be asked to bring their medication with them to the review. The use of a spacer increases the lung deposition and therefore effectiveness of metered-dose inhalers.
Living with COPD can be difficult. Recommending the patient contacts local organisations such as the British Lung Foundation ‘Breathe Easy’ groups for further information and support can be very helpful (see Resources section).
Finally, a holistic approach is needed when ensuring all the strategies are in place to reduce exacerbations and hospital admissions. For example, consider if the patient is coping at home, if not, would support from social services be appropriate? This is important because an exacerbation may have resulted in a change in their functional status (eg, the ability to complete activities of daily living).
3. Plan for the next exacerbation
Even with effective therapy, exacerbations will happen from time to time and patients should have an individualised written action plan of what to do if they think they are having an exacerbation. This might include a prescription of a ‘rescue pack’ of antibiotics and/or a steroid such as prednisone. However, this is only appropriate after education about how to use such packs, ideally backed up with support from a healthcare professional, which may be in the practice, hospital, or via a community respiratory team. When educating a patient on the correct use of a rescue pack, it is essential that they understand their baseline symptoms (breathlessness, wheeze, cough, sputum character) and daily variability in these to be able to differentiate day-to-day variation from an exacerbation. Inadequate education in this area can result in the overuse of antibiotics and steroids and avoidable side effects. Inform the GP if a rescue pack is started and make a clear record in the notes.
There are more complex issues to consider around exacerbations for patients with advanced COPD, such as whether or not they wish not to be admitted to hospital again or, if admitted, what the ceiling of care should be.
4. Check the discharge summary
Exacerbations are diverse, and patients with COPD can have many other conditions (co-morbidities). We recommend always reading through the discharge summary to make sure any outstanding issues have been tackled. For example, if the patient had pneumonia and needs a follow-up chest X-ray, has this been arranged? Perhaps the patient was noted to be anaemic, or have co-existent heart problems and needs assessment for those? Anxiety, depression and other mental health conditions are common co-morbidities in COPD and should not be overlooked.
5. When is the next COPD annual review
Check when the next COPD annual review is due and remind the patient. If the diagnosis is in doubt, find the original trace and review with the COPD lead in your practice. If a patient is attending for a review but has no previous diagnosis of COPD, it is important to schedule diagnostic spirometry – but not until the exacerbation has fully recovered. Diagnostic spirometry can be performed from six weeks after an exacerbation if the patient has recovered well.
Finally, give the patient time to ask any questions they may have. If all of this takes too long then consider a second appointment in a week or two that will allow you to be sure they are recovering well and give them the space to raise their own concerns and anxieties.
British Lung Foundation resources on COPD–
Association of Respiratory Nurse Specialists – arns.co.uk/
Global initiative for Obstructive Lung Disease (GOLD)–
The Primary Care Respiratory Society, COPD–
NHS Choices, COPD–
1. NHS Choices. Chronic obstructive pulmonary disease – Causes.
nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Causes.aspx (accessed 10 December 2015).
2. GINA/GOLD Asthma. COPD and Asthma COPD Overlap Syndrome (ACOS). goldcopd.org/uploads/users/files/AsthmaCOPDOverlap.pdf (accessed 27 November 2015).
3. Lange P, Celli B, Agustí A, Boje Jensen G, Divo M, Faner R, Guerra S, Marott JL, Martinez FD, Martinez-Camblor P, Meek P, Owen CA, Petersen H, Pinto-Plata V, Schnohr P, Sood A, Soriano JB, Tesfaigzi Y, Vestbo J. Lung-Function Trajectories Leading to Chronic Obstructive Pulmonary Disease. The New England Journal of Medicine 2015;373:111-122.
4. Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EF, Wedzicha JA. Susceptibility to exacerbation in chronic obstructive pulmonary disease. The New England Journal of Medicine 2010;363:1128-1138.
5. Aaron SD. Management and prevention of exacerbations of COPD. British Medical Journal 2014;22;349:g5237.
6. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015; 23;2:CD003793. DOI: 10.1002/14651858.CD003793.pub3.
7. Global initiative for Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD, Updated January 2015. goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html (accessed 27 November 2015).