Case Scenario
A 62-year-old man who regularly presented to the ED for exacerbations of chronic obstructive pulmonary disease (COPD) after running out of his medications presented again for evaluation and treatment. His outpatient care had been poorly coordinated, and he relied on the ED to provide him with the support he needed. This presentation represented his fifth visit to the ED over the past 3 months.
The patient’s medical history was positive for asthma since childhood, tobacco use, hypertension, and a recent diagnosis of congestive heart failure (CHF). Over the past year, he had four hospital admissions, and was currently unable to walk from his bedroom to another room without becoming short of breath. He also had recently experienced a 20-lb weight loss.
At this visit, the patient complained of chest pain and lightheadedness, which he described as suffocating. Prior to these recent symptoms, he enjoyed walking in his neighborhood and talking with friends. He was an avid reader and sports fan, but admitted that he now had trouble focusing on reading and following games on television. He lived alone, and his family lived across the country. The patient further admitted that although he had attempted to quit cigarette smoking, he was unable to give up his 50-pack per year habit. He had no completed advance health care directive and had significant challenges tending to his basic needs.
The Trajectory of COPD
Chronic obstructive pulmonary disease is a common chronic illness that causes significant morbidity and mortality. A 2016 National Health Services report cited respiratory illness, primarily from COPD, as the third leading cause of death in the United States in 2014.1The trajectory of this disease is marked by frequent exacerbations with partial recovery to baseline function. The burden of those living with COPD is significant and marked by a poor overall health-related quality of life (QOL). The ED has become a staging area for patients seeking care for exacerbations of COPD.2
The World Health Organization (WHO) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have defined COPD as a spectrum of diseases including emphysema, chronic bronchitis, and chronic obstructive asthma characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response to noxious particles or gases in the airways and lungs.3 Exacerbations and comorbidities contribute to the overall severity of COPD in individual patients.4
The case presented in this article illustrates the common scenario of a patient whose COPD has become severe and highly symptomatic with declining function to the point where he requires home support. His physical decline had been rapid and resulted in many unmet needs. When a patient such as this presents for emergent care, he must first be stabilized; then a care plan will need to be developed prior to discharge.
Management Goals
The overall goals of treating COPD are based on preserving function and are not curative in nature. Chronic obstructive pulmonary disease is a progressive illness that will intensify over time.5 As such, palliative care services are warranted. However, many patients with COPD do not receive palliative care services compared to patients with such other serious and life-limiting disease as cancer and heart disease.
Acute Exacerbations of COPD
Incidence
The frequency of acute exacerbations of COPD (AECOPD) increases with age, productive cough, long-standing COPD, previous hospitalizations related to COPD, eosinophilia, and comorbidities (eg, CHF). Patients with moderate to severe COPD and a history of prior exacerbations were found to have a higher likelihood of future exacerbations. From a quality and cost perspective, it may be useful to identify high-risk patients and strengthen their outpatient program to lessen the need for ED care and more intensive support.6,7
In our case scenario, the patient could have been stabilized at home with a well-controlled plan and home support, which would have resulted in an improved QOL and more time free from his high symptom burden.
Causes
Bacterial and viral respiratory infections are the most likely cause of AECOPD. Environmental pollution and pulmonary embolism are also triggers. Typically, patients with AECOPD present to the ED up to several times a year2 and represent the third most common cause of 30-day readmissions to the hospital.8 Prior exacerbations, dyspnea, and other medical comorbidities are also risk factors for more frequent hospital visits.