Preventing Hospitalization for COPD Exacerbations

 

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ABSTRACT

Severe chronic obstructive pulmonary disease (COPD) exacerbations requiring hospitalization are a major cause of morbidity and mortality. Recognition of the importance of COPD exacerbations has led to the knowledge that prevention of exacerbations and early treatment are important goals of COPD therapy.

Preventive management of COPD aiming at reducing exacerbations complicated by hospital admissions includes vaccination, avoiding pollutant exposure, and, when indicated, long-term oxygen therapy. Landmark studies have shown benefits of long-acting inhaled bronchodilators and combined long-acting inhaled bronchodilators with corticosteroids. The combination of a long-acting muscarinic antagonist with a long-acting β₂ agonist and inhaled corticosteroids offers the best possibility to reduce the risk of exacerbations requiring hospital admissions. Pulmonary rehabilitation in COPD patients at risk of being hospitalized and regular physical activity have been shown to be associated with a lower risk of hospital admissions. Recent advances in the delivery of evidence-based care including a collaborative multicomponent self-management intervention can reduce the risk of COPD hospital admissions.

If physicians meet best practice, this will have potential clinical implications, including a reduction of hospitalizations. Novel pharmacological therapy, which can prevent disease progression and exacerbations, is still needed. New self-management strategies such as a written action plan that helps patients recognize their exacerbation and promptly access treatment may have great potential. This needs to be evaluated in a properly designed randomized clinical trial before it becomes the standard of care for COPD patients.

REFERENCES

• 1 Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations.  Chest. 2000;  117(5, Suppl 2) 398S-401S
  CrossrefPubMedGoogle Scholar
• 2 Donaldson G C, Seemungal T A, Bhowmik A, Wedzicha J A. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease.  Thorax. 2002;  57 847-852
  CrossrefPubMedGoogle Scholar
• 3 Wedzicha J A, Seemungal T A. COPD exacerbations: defining their cause and prevention.  Lancet. 2007;  370 786-796
  CrossrefPubMedGoogle Scholar
• 4 Bourbeau J, Ford G, Zackon H, Pinsky N, Lee J, Ruberto G. Impact on patients' health status following early identification of a COPD exacerbation.  Eur Respir J. 2007;  30 907-913
  CrossrefPubMedGoogle Scholar
• 5 Donaldson G C, Wedzicha J A. COPD exacerbations, I: Epidemiology.  Thorax. 2006;  61 164-168
  CrossrefPubMedGoogle Scholar
• 6 Miravitlles M. Epidemiology of chronic obstructive pulmonary disease exacerbations.  Clin Pulm Med. 2002;  9 191-197
  CrossrefPubMedGoogle Scholar
• 7 Seemungal T, Sykes A. ICEAD Contributors . Recent advances in exacerbations of COPD.  Thorax. 2008;  63 850-852
  CrossrefPubMedGoogle Scholar
• 8 Anzueto A, Sethi S, Martinez F J. Exacerbations of chronic obstructive pulmonary disease.  Proc Am Thorac Soc. 2007;  4 554-564
  CrossrefPubMedGoogle Scholar
• 9 Almagro P, Calbo E, Ochoa de Echagüen A et al.. Mortality after hospitalization for COPD.  Chest. 2002;  121 1441-1448
  CrossrefPubMedGoogle Scholar
• 10 Groenewegen K H, Schols A M, Wouters E F. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD.  Chest. 2003;  124 459-467
  CrossrefPubMedGoogle Scholar
• 11 Soler-Cataluña J J, Martínez-García M A, Román Sánchez P, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease.  Thorax. 2005;  60 925-931
  CrossrefPubMedGoogle Scholar
• 12 Patil S P, Krishnan J A, Lechtzin N, Diette G B. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease.  Arch Intern Med. 2003;  163 1180-1186
  CrossrefPubMedGoogle Scholar
• 13 Chapman K R, Mannino D M, Soriano J B et al.. Epidemiology and costs of chronic obstructive pulmonary disease.  Eur Respir J. 2006;  27 188-207
  CrossrefPubMedGoogle Scholar
• 14 Aaron S D, Vandemheen K L, Hebert P et al.. Outpatient oral prednisone after emergency treatment of chronic obstructive pulmonary disease.  N Engl J Med. 2003;  348 2618-2625
  CrossrefPubMedGoogle Scholar
• 15 Davies L, Angus R M, Calverley P M. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial.  Lancet. 1999;  354 456-460
  CrossrefPubMedGoogle Scholar
• 16 Niewoehner D E, Erbland M L, Deupree R H Department of Veterans Affairs Cooperative Study Group et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease.  N Engl J Med. 1999;  340 1941-1947
  CrossrefPubMedGoogle Scholar
• 17 Wongsurakiat P, Maranetra K N, Wasi C, Kositanont U, Dejsomritrutai W, Charoenratanakul S. Acute respiratory illness in patients with COPD and the effectiveness of influenza vaccination: a randomized controlled study.  Chest. 2004;  125 2011-2020
  CrossrefPubMedGoogle Scholar
• 18 Nichol K L, Baken L, Nelson A. Relation between influenza vaccination and outpatient visits, hospitalization, and mortality in elderly persons with chronic lung disease.  Ann Intern Med. 1999;  130 397-403
  PubMedGoogle Scholar
• 19 Fine M J, Smith M A, Carson C A et al.. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials.  Arch Intern Med. 1994;  154 2666-2677
  PubMedGoogle Scholar
• 20 Wong A W, Gan W Q, Burns J, Sin D D, van Eeden S F. Acute exacerbation of chronic obstructive pulmonary disease: influence of social factors in determining length of hospital stay and readmission rates.  Can Respir J. 2008;  15 361-364
  CrossrefPubMedGoogle Scholar
• 21 Anderson H R, Spix C, Medina S et al.. Air pollution and daily admissions for chronic obstructive pulmonary disease in 6 European cities: results from the APHEA project.  Eur Respir J. 1997;  10 1064-1071
  CrossrefPubMedGoogle Scholar
• 22 Kosatsky T, Dufresne J, Richard L et al.. Heat awareness and response among Montreal residents with chronic cardiac and pulmonary disease.  Can J Public Health. 2009;  100 237-240
  PubMedGoogle Scholar
• 23 Anthonisen N R, Connett J E, Murray R P. Smoking and lung function of Lung Health Study participants after 11 years.  Am J Respir Crit Care Med. 2002;  166 675-679
  CrossrefPubMedGoogle Scholar
• 24 Kessler R, Faller M, Fourgaut G, Mennecier B, Weitzenblum E. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1999;  159 158-164
  CrossrefPubMedGoogle Scholar
• 25 Garcia-Aymerich J, Monsó E, Marrades R M EFRAM Investigators et al. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study.  Am J Respir Crit Care Med. 2001;  164 1002-1007
  CrossrefPubMedGoogle Scholar
• 26 Nocturnal Oxygen Therapy Trial Group . Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial.  Ann Intern Med. 1980;  93 391-398
  PubMedGoogle Scholar
• 27 Report of the Medical Research Council Working Party . Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema.  Lancet. 1981;  1 681-686
  PubMedGoogle Scholar
• 28 Aaron S D, Vandemheen K L, Fergusson D Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium et al. Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial.  Ann Intern Med. 2007;  146 545-555
  CrossrefPubMedGoogle Scholar
• 29 Calverley P M, Anderson J A, Celli B TORCH investigators et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease.  N Engl J Med. 2007;  356 775-789
  CrossrefPubMedGoogle Scholar
• 30 Tashkin D P, Celli B, Senn S UPLIFT Study Investigators et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease.  N Engl J Med. 2008;  359 1543-1554
  CrossrefPubMedGoogle Scholar
• 31 Wedzicha J A, Calverley P M, Seemungal T A, Hagan G, Ansari Z, Stockley R A. INSPIRE Investigators . The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide.  Am J Respir Crit Care Med. 2008;  177 19-26
  CrossrefPubMedGoogle Scholar
• 32 Welte T, Miravitlles M, Hernandez P et al.. Efficacy and tolerability of budesonide/formoterol added to tiotropium in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2009;  180 741-750
  CrossrefPubMedGoogle Scholar
• 33 Bourbeau J, Sebaldt R J, Day A et al.. Practice patterns in the management of chronic obstructive pulmonary disease in primary practice: the CAGE study.  Can Respir J. 2008;  15 13-19
  PubMedGoogle Scholar
• 34 Lacasse Y, Wong E, Guyatt G H, King D, Cook D J, Goldstein R S. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease.  Lancet. 1996;  348 1115-1119
  CrossrefPubMedGoogle Scholar
• 35 Ries A L, Bauldoff G S, Carlin B W et al.. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines.  Chest. 2007;  131(5 Suppl) 4S-42S
  CrossrefPubMedGoogle Scholar
• 36 Puhan M A, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality—a systematic review.  Respir Res. 2005;  6 54
  CrossrefPubMedGoogle Scholar
• 37 Behnke M, Taube C, Kirsten D, Lehnigk B, Jörres R A, Magnussen H. Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.  Respir Med. 2000;  94 1184-1191
  CrossrefPubMedGoogle Scholar
• 38 Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó J M. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study.  Thorax. 2006;  61 772-778
  CrossrefPubMedGoogle Scholar
• 39 Bourbeau J, van der Palen J. Promoting effective self-management programmes to improve COPD.  Eur Respir J. 2009;  33 461-463
  CrossrefPubMedGoogle Scholar
• 40 Gonseth J, Guallar-Castillón P, Banegas J R, Rodríguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports.  Eur Heart J. 2004;  25 1570-1595
  CrossrefPubMedGoogle Scholar
• 41 Gibson P G, Powell H, Coughlan J et al.. Self-management education and regular practitioner review for adults with asthma.  Cochrane Database Syst Rev. 2003;  (1) CD001117
  PubMedGoogle Scholar
• 42 Effing T, Monninkhof E M, van der Valk P D et al.. Self-management education for patients with chronic obstructive pulmonary disease.  Cochrane Database Syst Rev. 2007;  (4) CD002990
  PubMedGoogle Scholar
• 43 Adams S G, Smith P K, Allan P F, Anzueto A, Pugh J A, Cornell J E. Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management.  Arch Intern Med. 2007;  167 551-561
  CrossrefPubMedGoogle Scholar
• 44 Bourbeau J, Julien M, Maltais F Chronic Obstructive Pulmonary Disease axis of the Respiratory Network Fonds de la Recherche en Santé du Québec et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.  Arch Intern Med. 2003;  163 585-591
  CrossrefPubMedGoogle Scholar
• 45 Gadoury M A, Schwartzman K, Rouleau M Chronic Obstructive Pulmonary Disease axis of the Respiratory Health Network, Fonds de la recherche en santé du Québec (FRSQ) et al. Self-management reduces both short- and long-term hospitalisation in COPD.  Eur Respir J. 2005;  26 853-857
  CrossrefPubMedGoogle Scholar
• 46 Rea H, McAuley S, Stewart A, Lamont C, Roseman P, Didsbury P. A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease.  Intern Med J. 2004;  34 608-614
  CrossrefPubMedGoogle Scholar
• 47 Casas A, Troosters T, Garcia-Aymerich J members of the CHRONIC Project et al. Integrated care prevents hospitalisations for exacerbations in COPD patients.  Eur Respir J. 2006;  28 123-130
  CrossrefPubMedGoogle Scholar
• 48 Weingarten S R, Henning J M, Badamgarav E et al.. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports.  BMJ. 2002;  325 925-928
  CrossrefPubMedGoogle Scholar
• 49 Bourbeau J, Nault D, Dang-Tan T. Self-management and behaviour modification in COPD.  Patient Educ Couns. 2004;  52 271-277
  CrossrefPubMedGoogle Scholar
• 50 Glasgow R E, Funnell M M, Bonomi A E, Davis C, Beckham V, Wagner E H. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams.  Ann Behav Med. 2002;  24 80-87
  CrossrefPubMedGoogle Scholar
• 51 Hernandez P, Balter M, Bourbeau J, Hodder R. Living with chronic obstructive pulmonary disease: a survey of patients' knowledge and attitudes.  Respir Med. 2009;  103 1004-1012
  CrossrefPubMedGoogle Scholar
• 52 Wilkinson T M, Donaldson G C, Hurst J R, Seemungal T A, Wedzicha J A. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2004;  169 1298-1303
  CrossrefPubMedGoogle Scholar
• 53 Bischoff E, Hamd D, Benedetti A et al.. Effects of a written action plan on COPD exacerbation recovery. Paper presented at: European Respiratory Society Annual Congress October 6, 2008 Berlin, Germany;
  PubMedGoogle Scholar
• 54 Sedeno M F, Nault D, Hamd D H, Bourbeau J. A self-management education program including an action plan for acute COPD exacerbations.  COPD. 2009;  6 352-358
  CrossrefPubMedGoogle Scholar
• 55 Turnock A C, Walters E H, Walters J A, Wood-Baker R. Action plans for chronic obstructive pulmonary disease.  Cochrane Database Syst Rev. 2005;  (4) CD005074
  PubMedGoogle Scholar

Jean BourbeauM.D. 

Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute

3650 St.-Urbain Street, K 1.32, Montréal, Québec H2X 2P4 Canada

Email: jean.bourbeau@mcgill.ca