COPD has vaulted to the third-leading cause of death in the United States and continues to tax healthcare systems nationwide. The disease is complicated by frequent and recurrent acute exacerbations, which result in high morbidity and substantial healthcare expenditures. Exacerbations of COPD result in more than 100,000 deaths and over 500,000 hospitalizations each year (Figure 1). There is also a large economic burden associated with the medical care that is required for these patients. Exacerbations are the largest direct cost for the treatment of COPD. A major component to the overall cost is hospitalizations, which represent more than half of the total costs relating to the disease. In addition to the financial burden of treating these patients, other costs, such as days missed from work and severe limitations in quality of life, are important features of COPD.
Exacerbations have been defined as events in the natural course of COPD that are characterized by changes in baseline dyspnea, cough, and/or sputum that go beyond normal day-to-day variations. They are acute in onset and may warrant changes in regular medication. Patients with COPD will likely experience symptoms of the disease on an ongoing basis, making it challenging for clinicians to know if the symptoms are part of day-to-day life or signs of a true exacerbation. “The key is to look for symptoms that are worse than usual,” says Reynold A. Panettieri, Jr., MD. “Unfortunately, exacerbations can occur even when patients are doing everything in their power to prevent them, including getting appropriate vaccinations, taking steps to avoid infections, and using medications as prescribed.”
Develop an Action Plan for COPD
Physicians who are managing patients with COPD should develop action plans for patients and their caregivers so that they can deal with exacerbations when they occur, according to Dr. Panettieri. “When an effective action plan is in place, patients are empowered to address exacerbations safely and effectively,” he says. “COPD action plans should be written down, and patients should be educated on the specific symptoms that signal the need to seek treatment from their doctor or care at an emergency room.” COPD exacerbation symptoms may include yellow, green, or brown phlegm, increased production of phlegm, chest pain, fever, ankle swelling, insomnia, headaches, dizziness, and increased shortness of breath.
COPD action plans should also address the management of future flare-ups with medication (Figure 2). If acute exacerbations occur, the medication plan that physicians have established should be initiated when symptoms arise. “In some cases, medications may be provided to patients to take at home during exacerbations,” adds Dr. Panettieri. “This may involve the use of therapies patients are already taking, including short-acting bronchodilators, antibiotics, and oral corticosteroids, or a combination of these agents. Pulmonary rehabilitation is another treatment strategy. The key is to develop plans that help patients know how to prevent COPD exacerbations at the right time based on their individual characteristics.”
Quality measures for diabetes are here to stay and have contributed to at least some of the momentum toward improved care in recent years.
Keep COPD Exacerbations in Check
Acute exacerbations of COPD should not be viewed as part of the natural course of the disease, according to Dr. Panettieri. “There are several preventive therapies of proven efficacy, but it’s important to review available evidence from the literature to identify high-risk patients and provide treatments accordingly.” Recent studies have shown that chronic maintenance therapy for COPD can significantly decrease the frequency of exacerbations. Long-acting bronchodilators, including long-acting â-agonists (LABAs), longacting anticholinergics, and roflumilast, can reduce COPD exacerbations. These effects have also been reported with combination therapy involving inhaled corticosteroids and LABAs. Studies have also demonstrated that reducing the frequency of exacerbations significantly decreases hospitalizations and healthcare utilization.
Awareness of COPD Strategies
Awareness of optimal strategies to manage COPD is lacking among many clinicians, especially those in primary care. “It’s important that physicians become more familiar with COPD assessment techniques and use spirometry testing regularly to monitor patients,” Dr. Panettieri says.
“A greater emphasis on smoking cessation programs, exercise training, and pulmonary rehabilitation are also paramount as they can make a significant impact on patient quality of life.” In addition to continued monitoring of patients taking medications for COPD, Dr. Panettieri recommends that clinicians actively advocate proper vaccinations. “In order to make a serious impact on the burden of COPD, clinicians need to take action early and work collaboratively with other providers. We can’t wait until patients reach late-stage COPD before initiating these treatments. Continued discussions with patients each step of the way during management of the disease may ultimately help reduce rates of exacerbations in the future.”
Rowe BH, Bhutani M, Stickland MK, Cydulka R. Assessment and management of chronic obstructive pulmonary disease in the emergency department and beyond. Expert Rev Respir Med. 2011;5:549-559.
Han MK, Martinez FJ. Pharmacotherapeutic approaches to preventing acute exacerbations of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2011;8:356-362.
Postma D, Anzueto A, Calverley P, et al. A new perspective on optimal care for patients with COPD. Prim Care Respir J. 2011;20:205-209. Available at: http://www.thepcrj.org/journ/vol20/20_2_205_209.pdf.
Price D, Crockett A, Arne M, et al. Spirometry in primary care case-identification, diagnosis and management of COPD. Prim Care Respir J. 2009;18:216-223.
Marin JM, Carrizo SJ, Casanova C, et al. Prediction of risk of COPD exacerbations by the BODE index. Respir Med. 2009;103:373-378.
Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363:1128-1138.