D3.2 Exacerbation prevention

Detailed discussion of the management of exacerbations is found in section X.

Committee Commentary: COPD Exacerbation Terminology

In patient education and for effective patient-clinician partnerships, the words we use as clinicians’ matter. This is particularly important when discussing COPD exacerbations. COPD exacerbations are common and have deleterious impacts on patients at the time of the event, on their recovery and on their future risk (McDonald 2019). Unfortunately, exacerbations of COPD are frequently under-reported and untreated (Calderazzo 2019, Jones 2014). It has been proposed that patients and clinicians do not recognise the need for urgent treatment of these events or their impact on future outcomes (Holverda 2020, Bafadhel 2020, Jones 2019). For example COPD mortality risk at one year following a hospitalisation for an acute exacerbation is approximately 25% (García-Sanz 2017, Ho 2014), which is greater than the mortality risk of someone hospitalised for an acute myocardial infarction (McDonald 2019, Halpin 2008).

Patients in part may not understand the impact of exacerbations due to language clinicians use to describe these events (Holverda 2020, Bafadhel 2020). Terms such as ‘exacerbations’ and ‘flare ups’ trivialise these events in asthma and may do the same in COPD (Holverda 2020, Bafadhel 2020, Jones 2019, Pavord 2018). Furthermore, most patients do not understand the term exacerbation. In a qualitative study of 125 people with moderate to severe COPD <2% understood what the term ‘exacerbation’ actually meant (Kessler 2006). This is a similar concern in asthma (Jones 2019).

There are calls for the abandonment of the terms exacerbations and flare ups and to replace these with terms such as attack, lung attack or COPD crisis (Holverda 2020, Bafadhel 2020, Jones 2019, Pavord 2018, Fitzgerald 2011).  We recognise that it is important to agree on the most appropriate person-centred language to improve response to COPD exacerbations and suggest that this is an area for future collaborative work among the respiratory community and patients.

 

For severe exacerbations there is evidence for the use of bronchodilators, antibiotics, systemic cortic

osteroids and supplemental oxygen (if patients are hypoxaemic). Selected patients may benefit from early intervention with these agents according to a predetermined plan developed by a GP or respiratory specialist. Some patients can be instructed to start using a “crisis medication pack” while awaiting medical review. They may also be instructed to contact a particular member of the multidisciplinary care team as part of their overall care plan.

Controlled trials are required to document the efficacy of self-management plans in patients with stable COPD, but, drawing on the success of asthma action plans, education of patients with COPD in self-management is recommended. Written plans are usually required to complement such interventions (see examples at https://lungfoundation.com.au/resources/?user_category=32&search=copd%20action%20plan).

A randomised controlled trial of 577 subjects with mild COPD, obtained from UK primary care COPD registers of 71 general practices evaluated a telephone health coaching programme which included the provision of a pedometer, written educational documents, diary, inhaler use education and encouragement of medication adherence (Jolly 2018). Most potential subjects did not respond to an invitation to participate. While there was no benefit on the primary outcome of quality of life as measured by the St George Respiratory Questionnaire (SGRQ), nor the secondary outcomes of anxiety and depression, other secondary outcomes of self-reported physical activity and inhaler usage did improve [evidence level II].