Published in the June 2007 issue of Today’s Hospitalist.
Because chronic obstructive pulmonary disease (COPD) is neither curable nor reversible, hospitalists treating inpatients with exacerbations need to help those patients live with their illness as well as they can. That often means embracing approaches to prevent all-too-common relapses.
According to Kevin R. Flaherty, MD, a pulmonologist and assistant professor of internal medicine at the University of Michigan in Ann Arbor, the proper use of antibiotics, steroids and other treatments such as noninvasive ventilation can help "interrupt the vicious circle of recurrent infection and increased lung damage" that leads to frequent relapse.
"We want to extend the disease-free interval," Dr. Flaherty said, "so patients are coming back only once a year, not coming back every three months."
Speaking at the Spring 2007 Hospitalist CME Series meeting in Cambridge, Mass., he proposed a strategy to first treat the exacerbation, focusing on quick resolution of patient symptoms, then prevent relapses.
At the same time, he urged hospitalists encountering patients with a COPD exacerbation to keep two key factors in mind. First, many of these patients have serious and multiple comorbidities, including heart disease, pneumonia and pulmonary embolism. And two, studies have shown that as many as one-quarter of the people said to have COPD instead were experiencing heart failure.
"Even though they’re admitted from the ER with a COPD exacerbation, when you assume their care, keep your differential diagnosis broad," Dr. Flaherty advised. Paying attention to all of a patient’s problems can reduce the already high likelihood that a COPD patient will have repeat hospitalizations.
The role of antibiotics
While hospital admissions for COPD exacerbations may seem very common, Dr. Flaherty said the situation is actually worse than doctors think.
The amount of undiagnosed COPD is surprisingly high, he pointed out. Researchers testing participants with spirometry have found that nearly 7% of the U.S. population has abnormal lung function, with nearly two-thirds of those cases going undiagnosed. Hospitalists, as a result, need to remain highly suspicious of COPD when they treat patients with any impaired lung function.
"As common as we think this disease is, it’s actually more common," Dr. Flaherty said. And by all signs, COPD in this country is getting worse.
While mortality rates for coronary disease and stroke have shown improvement, death rates for COPD in the U.S. have increased since 1965. On average, a patient hospitalized for a COPD acute exacerbation will stay in the hospital for nine days.
And while 90% of COPD patients survive that experience to be discharged, mortality over the following few months is extremely high. "If you happen to be sick enough to be admitted to the ICU, your six-month mortality is about 40%," Dr. Flaherty pointed out. For patients who are intubated, that figure approaches 50%.
In most cases, the etiology of a COPD exacerbation is infectious, half being viral and half being bacterial, Dr. Flaherty said. (Between 10% and 20% of COPD exacerbations have no identifiable cause.)
"That’s important because as we start to think about the role of antibiotics, we need to pinpoint which incidents are caused by bacteria to determine which patients need antibiotic therapy," he explained. Several studies over the last decade, he pointed out, have shown that while many patients’ symptoms may not respond to antibiotic therapy at all, sicker patients do respond.
In particular, he said, patients sick enough to require intubation "should be treated with antibiotics." Other COPD patients who benefit from antibiotics include those with poor baseline lung function.
And hospitalists deciding to use antibiotic therapy should also consider sputum color: Purulent sputum that is green is an indication for antibiotics, Dr. Flaherty said.
Which antibiotic to choose?
Studies have shown that the most common pathogen seen in COPD exacerbations is H. influenzae. Others include M. catarrhalis, pneumococcus and, in more severe cases, pseudomonas.
Unfortunately, Dr. Flaherty explained, "there are no good studies looking at whether our antibiotic choices really make much of a difference." One study published in 2000 found that more patients who were treated with amoxicillin relapsed than those treated with other antibiotics. That may be due to the fact that one-third of H. influenzae are beta-lactamase positive. (See "Treating COPD exacerbations: Which antibiotic should you choose?" at left.)
And while "inadequate" antibiotics are the No. 1 reason COPD patients do poorly after treatment, there are other factors associated with poor outcomes: the severity of the patient’s lung disease; a history of cardiopulmonary diagnosis, pneumonia and sinusitis; whether the patient needs home oxygen and is on maintenance steroids; and the frequency of exacerbations.
The bottom line, said Dr. Flaherty: "More mild disease, less risk of failure." When choosing antibiotics for a patient with an exacerbation, he said, hospitalists need to put all that information “patient characteristics, symptom severity and etiology “together.
Steroids: more is not better
The other class of medications commonly used for patients with COPD exacerbations is steroids. Evidence from a number of studies suggests that steroids can help accelerate the improvement of symptoms.
More is not better, however, Dr. Flaherty said. Studies show that "a moderate dose in moderate duration" works better than either placebo or high-dose, longer-term regimens. Moreover, he said, inexpensive oral prednisone seems to work "faster and a little bit better" than high-dose inhaled steroids. There have not been, he pointed out, any studies comparing IV and oral steroids.
Nor is there a standard recommended way to dose steroids for these patients, said Dr. Flaherty. For patients who can take the drug orally, he orders a 40 mg to 60 mg dose once a day for the first few days, tapering to 30 mg for the next few days, then to 20 mg for a few days, stopping steroid treatment at between 10 and 14 days. (For patients who can’t take drugs PO, he administers methylprednisolone 60 mg to 80 mg IV every eight hours, tapering as tolerated and/or switching to PO medication when able.)
Try noninvasive ventilation
Dr. Flaherty also highlighted the need to try noninvasive positive pressure ventilation, including CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure). "If you can break the bronchospasm and get on top of the disease over a matter of hours," he said, "you can avoid intubating the patient." For a starting level, he uses 10 inspiratory, 5 expiratory.
Despite the technique’s very real benefits, however, noninvasive positive pressure ventilation comes with some downsides. "This is not something that’s very comfortable, and it’s very labor intensive," he pointed out. If the patient and your staff don’t buy into its use, "it’s never going to work."
And some COPD patients are not good candidates for noninvasive ventilation because of comorbidities, such as sepsis, arrhythmias, cardiovascular collapse or severe pneumonia. Other contraindications include respiratory arrest; cardiovascular instability; decreased mental status or somnolence; copious secretions and the risk of aspiration; burns; recent facial, gastric or esophageal surgery; or extreme obesity.
"If patients have a huge chest wall," said Dr. Flaherty, "oftentimes you just can’t get enough pressure to make this work comfortably."
Some studies have shown a high failure rate for noninvasive ventilation compared to conventional ventilation. But when those data were studied more closely, the therapy appeared to have significant benefit for mild or moderate hypercarbic COPD exacerbation. Moreover, said Dr. Flaherty, it seems to cause fewer complications, such as ventilator-associated pneumonia or sepsis.
The lessons learned from the studies, he pointed out, are that noninvasive ventilation should be tried only during the early course of the disease, and that success will come in the first few hours. If, after four hours, pH and COÂ² levels worsen, noninvasive ventilation is likely to fail.
"Give it a good try," he recommended, "but if you don’t turn it around quickly, move on."
Using discharge for prevention
Because preventing exacerbations needs to be at the top of hospitalists’ agendas, Dr. Flaherty said that physicians should make sure they’re not discharging patients too soon. Hospitalists also need to discharge patients with medications that may help prevent future flare-ups.
Options include tiotropium (an anticholinergic), salmeterol (a long-acting beta-agonist) and inhaled steroids. That last therapy may seem counter-intuitive, he pointed out, because inhaled steroids should not be used as first-line agents to treat COPD exacerbations.
And given their side effects, including skin bruising and oral candidiasis, inhaled steroids are not for everyone. "But they are agents that you would want to add on for patients with frequent exacerbations," he said. "We may be able to impact the COPD mortality curve by aggressively treating this disease."
Supervised pulmonary rehabilitation programs “more than just exercise “have also been shown to help people get back on their feet and decrease subsequent hospitalizations. As a result, Dr. Flaherty said, hospitalists should recommend such programs to their COPD patients.
Another proven way to reduce the chance of relapse and re-admission: Spend time (one study considered three hours) educating patients about their disease and medications. That study, published in the June 20, 1992, The Lancet, found that patients given that level of education while hospitalized, Dr. Flaherty said, "went on to have significantly fewer admissions and intubations in the following year."
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
Smoking cessation: Taking advantage of the teachable moment
When it comes to preventing COPD exacerbations in their patients, hospitalists need to push another proven technique: smoking cessation.
According to Kevin R. Flaherty, MD, a pulmonologist and assistant
professor of internal medicine at the University of Michigan in Ann Arbor, COPD in the U.S. is largely due to cigarette smoking. Patients who continue to smoke have more relapses and worse disease progression.
We all lose lung function over time," said Dr. Flaherty, "but if you smoke and you’re susceptible to cigarette smoke, you lose lung function much faster." In patients who quit smoking, on the other hand, their decline in lung function reverts to that of someone who never smoked.
Because hospitalized patients are often more motivated than ever to quit smoking, counseling them is essential. Such counseling should be an integral part of treatment because patients who continue smoking are susceptible to more infections, suffer worse inflammation and end up with much more extensive lung damage.