ATLANTA – Data suggest that only about a third of patients hospitalized for chronic obstructive pulmonary disease receive appropriate care, but a number of steps – beginning with decisions about when to admit and ending with proper discharge management – can be taken to improve outcomes, according to Dr. Darcy Marciniuk.
Although scientific guidance on when patients should be admitted is lacking, guidelines and consensus statements suggest that patients with an exacerbation should be admitted:
Dr. Darcy Marciniuk
• If they experience a marked increase in dyspnea.
• If they have severe underlying COPD with little reserve, "such that there’s no room for error."
• If they fail to respond to initial management.
• If they have comorbidities, including heart failure, arrhythmias, or renal impairment.
• If they have advanced age.
• If they experience frequent severe exacerbations.
• If they have insufficient home support.
Once a patient is admitted, controlled appropriate supplemental oxygen should be administered as directed by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, noninvasive ventilation should be used when indicated, aggressive therapies should be used at the outset, and use of antibiotics or systemic corticosteroids should be considered, said Dr. Marciniuk, AACP president, and head of the division of respirology, critical care, and sleep medicine at the University of Saskatchewan, Saskatoon, Canada.
An effort should also be made to identify the precipitating factor, to recognize and optimize, or prevent comorbid conditions, to prevent complications, and to address depressions and anxiety, he said.
With respect to supplemental oxygen, the GOLD guidelines will help ensure there is "always enough, but never too much," Dr. Marciniuk said.
"Now, with saturation monitors, life is good; it’s very easy to make sure patients receive appropriate therapy," he added.
He also spotlighted noninvasive ventilation. It has revolutionized in-hospital COPD management, lowering intubation rates by 60% and substantially decreasing in-hospital mortality, he said.
"Noninvasive ventilation has been incredible for our patients," he said.
Although it was first used in the 1980s, it is now "really the treatment of choice for acute hypercapnic respiratory failure in this setting," he added.
Contrary to some beliefs about outcomes with COPD in the intensive care unit, mortality is actually much lower than for many other conditions. For example, mortality in COPD patients in the ICU is about half that of patients with sepsis or acute respiratory distress syndrome.
"So, even though a patient may look short of breath, and someone may think they have a poor quality of life, it is the patients who should be judging that," he said, adding: "There needs to be that comfort, that back-up, of the ICU, because data would suggest the outcomes are pretty good."
There is significant evidence of benefit with the use of noninvasive ventilation, particularly with respiratory acidosis of pH less than 7.35, PCO2 greater than 45, and significant dyspnea, which is easily detected by clinical means, he added.
Depression in COPD patients is also particularly important to address.
Studies show that patients with depression have longer hospital stays (twice as long, according to one observational study), more frequent exacerbations in the year following discharge, and higher mortality rates, he said, acknowledging that "our understanding of the co-presence of depression and anxiety (in COPD patients) is growing, but our understanding that it appears to [have an impact] in this setting is also growing."
As for discharge planning, appropriate methods and practices must be put in place for reducing the future risk of acute exacerbations, he said.
Dr. Marciniuk reported having no financial disclosures, with the exception of research funding directed to and managed by his institution.