Chronic obstructive pulmonary disease (COPD) is a condition which is associated with symptoms of breathlessness, cough and sputum (National Institute for Health and Care Excellence (NICE), 2019a). For many people who have been diagnosed with COPD, there is also a risk of experiencing an exacerbation of their symptoms which will require additional acute treatment to supplement their usual therapy. In the spirit of supporting self-management, people living with COPD (PLWCOPD) may be advised to keep a ‘rescue pack’ of oral corticosteroids and antibiotics to start if they develop symptoms of an exacerbation. In this article, the rationale for offering rescue packs will be considered, along with recommendations relating to the management of acute exacerbations of COPD (AECOPD) and the use of rescue packs.
By the end of this article, the reader will be able to:
- Recognise how exacerbations of COPD present
- Consider current recommendations about managing acute exacerbations of COPD and relate these recommendations to the use of rescue packs
- Implement guideline-based advice on education and self-management for PLWCOPD during exacerbations
- Determine the role of education for self-management in AECOPD
- Reflect on how exacerbations might inform the long-term management of COPD.
The definition and presentation of an acute exacerbation of COPD
AECOPD are defined as an acute worsening of the respiratory symptoms associated with COPD, including cough, breathlessness and sputum production and which require additional therapy (NICE, 2019a; Ritchie and Wedzicha, 2020; Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2021: 31). Exacerbations are often caused by viral infections, most often the common cold, but also bacterial infections or environmental pollutants, and they confer a significant burden on PLWCOPD, their carers and healthcare resources (GOLD, 2021: 7). In a pathophysiological sense, AECOPD are linked to increased levels of inflammation, hyperinflation and gas trapping (GOLD, 2021: 15).
GOLD states that around 80% of AECOPD are managed outside of the hospital setting, meaning that primary care and PLWCOPD themselves will be responsible for timely diagnosis and effective treatment, which may prevent worsening symptoms and the need for hospital admission. In general, severe exacerbations will need hospital admission, whereas mild and moderate exacerbations are unlikely to require this. In the latest guidance from GOLD (2021: 116), it is said that AECOPD can be managed outside of the hospital setting if there is no evidence of respiratory failure, for example:
- The patient's respiratory rate is comfortably between 20–30 breaths per minute
- There is no accessory muscle use
- No deterioration in the person's mental state
- Any initial hypoxia has responded to supplemental oxygen to maintain saturations between 88–92%
- There is no evidence of hypercapnia or any red flags which might increase the suspicion of a concurrent condition being the cause of the symptoms. This is important as PLWCOPD are high risk for comorbidities such as cardiovascular disease or heart failure, and symptoms may overlap, indicating that careful, holistic assessment is needed.
Management of acute exacerbations
There are two key guidelines used to inform the diagnosis and management of COPD in the UK: GOLD (2021) and NICE (2019a). These guidelines offer different advice on how to manage acute exacerbations. In essence, the approach taken to the management of acute exacerbations will also inform the contents of the rescue packs offered to PLWCOPD for them to start if they have symptoms which indicate a likely exacerbation.
According to the GOLD guidelines, the management of an acute exacerbation will depend on the severity. For a mild exacerbation, the advice is to offer extra short-acting beta2 agonists with or without short-acting muscarinic therapy, using 1–2 puffs every hour for 2–3 doses then every 2–4 hours based on response; however, adding a SAMA via inhaler is not part of UK and NHS guidance but is more likely in other healthcare systems. If a nebuliser is used, GOLD recommends air-driven not O2 to avoid risk of increasing partial pressure of carbon dioxide (PaCO2).
In the case of a moderate exacerbation, antibiotics and oral corticosteroids should be given based on the individual presentation, along with supplementary short-acting bronchodilators. GOLD supports the use of prednisolone 40 mg for 5 days, based on the REDuction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) study findings (Leuppi et al, 2013). NICE recommends a lower dose of 30 mg for five days (NICE, 2019a: 45). Although a longer course can be given, GOLD states that oral corticosteroids should not be given for longer than 7 days, as longer courses increase the risk of pneumonia and have been linked to higher levels of mortality (GOLD, 2021: 113). For many people who have an AECOPD, breathlessness is a key feature, and oral corticosteroids have been shown to improve lung function, increase oxygenation and result in a shorter recovery time and in-patient stay. However, oral corticosteroids have potential side effects, and every case should be considered independently, weighing up the potential advantages and disadvantages. Some studies have suggested that they may be less effective in people with low eosinophil counts, for example (Sivapalan et al, 2021).
Antibiotics are recommended for people with increased sputum purulence and the risk–benefit ratio is better if people experiencing an exacerbation also have at least one other symptom out of dyspnoea and/or increased sputum volume. According to the Anthonisen criteria, the presence of increased sputum purulence has been linked to a greater likelihood of a bacterial infection (Anthonisen et al, 1987). When antibiotics are prescribed for these people, they have been shown to result in an improved recovery, reduced risk of early relapse and/or treatment failure and hospital stays are shorter (Wilson and Macklin-Doherty, 2012). GOLD also recommends that courses of antibiotics should last for 5–7 days.
NICE recommends that the decision to prescribe antibiotics for AECOPD should be based on individual assessment of the severity of symptoms, and, like GOLD, specifies sputum colour changes and increases in volume or thickness as a key indicator (NICE, 2018). NICE also suggests that the decision to prescribe antibiotics should be based on previous exacerbation history, and the risk of antimicrobial resistance with repeated courses of antibiotics (NICE, 2018). These elements indicate that a holistic clinical assessment is essential when deciding whether or not to prescribe antibiotics, which could be an argument against prescribing ‘just in case’ medication for AECOPD via rescue packs.
Of note, neither GOLD nor NICE recommend routinely sending sputum samples for culture, with GOLD advising that it can take too long to get the results and, even when the results are available, they are not always reliable. Conversely, GOLD does include advice to consider C-reactive protein (CRP) testing as a way of identifying those most likely to benefit from an antibiotic and some practices are now able to access CRP testing for people having AECOPDs.
The choice of antibiotics should be based on local formularies, which reflect sensitivity and resistance patterns in that area. However, NICE does give some recommendations as to the usual antibiotics which may be helpful (amoxicillin, doxycycline and clarithromycin), but in all cases NICE advises that a 5-day course should suffice (NICE, 2018).
Severe exacerbations will usually be managed in the hospital setting and NICE also has a list of factors which support hospital care over community-based care (NICE, 2019a).
Education and support for self-management
Both NICE and GOLD underline the importance of ensuring that people with COPD are supported to self-manage effectively and that any education should include advice on how to recognise and treat an exacerbation. PLWCOPD and their carers, where indicated, should be aware of how to recognise the symptoms of an AECOPD as opposed to the day-to-day changes they might normally experience with their symptoms. They should also be aware of important red flags which might suggest an alternative diagnosis, such as haemoptysis, weight loss (both associated with lung cancer), or frothy sputum and orthopnoea, which are symptoms of heart failure.
In the case of both oral corticosteroids and antibiotics, consideration and explanation of possible side effects should be included as part of the education process. Education for self-management is key and problems may occur if this is omitted when supplying rescue packs, especially if they are made available as a repeat prescription to be ordered at the patient's behest. The risks associated with oral corticosteroids (and in particular, the overuse of these drugs) include osteoporosis, adrenal suppression and steroid-induced diabetes. They can also cause steroid myopathy, which will actually make COPD symptoms worse (Manson et al, 2009). The inappropriate use of antibiotics is also one of the key drivers of antibiotic resistance.
Clinician and patient perspectives on the use of rescue packs
A Cochrane review of self-management interventions concluded that interventions, which included an action plan for worsening COPD symptoms, improved health-related quality of life and reduced the number of people who needed one or more hospital admissions. However, there was also a very small but significant increase in respiratory-related deaths for people using self-management interventions, albeit the quality of this evidence was poor (Lenferink et al, 2017). It should be noted that rescue packs on repeat prescription are not recommended.
Therefore, not all clinicians are comfortable with offering rescue packs for self-management of AECOPD. Davies at al (2014) found that clinicians did not feel it appropriate to offer self-treatment rescue packs to all patients routinely without careful consideration of patient understanding of their illness and their capacity for self-management. This seems to be a reasonable position, not least as people with COPD often have, or are at risk of, other significant conditions. For example, decompensated heart failure may present with similar symptoms to an AECOPD and essential treatment may be delayed while the PLWCOPD treats their symptoms incorrectly. Laue et al (2016) found that fear of overlooking severe comorbidity and of further deteriorating symptoms was a key feature of the clinician's management decisions. However, in this study, the clinicians recognised the importance of taking a holistic overview of the situation and that the patients' own judgment was crucial to decision making in uncertain situations. A recommendation of this study was that greater collaboration between clinicians across primary and secondary care and with the patient and their social network could support better monitoring and prompt intervention for AECOPD.
Another study looking at the patients' perspective showed that they consider self-treatment of exacerbations with antibiotics and/or oral corticosteroids as a valuable intervention. A key aspect that supported effective self-management was having their concerns regarding the medications' adverse effects addressed. The study also identified the fact that clinicians need to factor in the patients' understanding of and preferences for self-treatment as a means of health care. The recommendation was that clinicians should consider these perspectives and work collaboratively when offering PLWCOPD the option to self-treat AECOPD (Laue et al, 2017).
Exacerbations and the long-term management of COPD
Exacerbations offer an opportunity to review the long-term management of COPD to ensure that interventions are in place to minimise the risk of future exacerbations. AECOPD are associated with permanent loss of lung function and an increased risk of mortality, so it is important to review and reflect on whether the patient is optimally managed. Symptoms of an AECOPD usually last between 7–10 days but recovery may take several weeks, with one in five people not fully recovered to their pre-exacerbation state after 8 weeks (Seemungal et al, 2000).
GOLD recommends that the patient who has experienced an AECOPD should be reviewed within 1 month, and again within 3 months, although many PLWCOPD will be reviewed sooner than this in practice. The review should include assessment of inhaler technique, adherence, suitability for and attendance at a pulmonary rehabilitation programme, vaccination status and provision of smoking cessation support. It is also the time to review pharmacological therapies. Every patient who has had an AECOPD should be on long-acting bronchodilators as a minimum, as long-acting B2 agonists (LABAs) can reduce exacerbation rates and long-acting muscarinic antagonists (LAMAs) may have an even greater effect (GOLD, 2021: 51). NICE recommends the pragmatic approach of combining the two (LAMA/LABA) to reduce exacerbation rates, minimise the risk of hospitalisation and optimise symptoms control (NICE, 2019b). For some people there will need to be careful consideration of whether the risk–benefit ratio of giving an inhaled corticosteroid (ICS) with the long-acting B2 agonist is favourable. People who are at higher risk of further exacerbations may respond well to ICS therapy, but this may also increase pneumonia risk (GOLD, 2021: 55). In some people with a history of frequent or severe exacerbations, triple therapy (ICS/LAMA/LABA) may be required (GOLD, 2021: 56).
For frequent exacerbators who have been on maximal inhaled therapy, consideration should be given to the use of prophylactic antibiotics such as azithromycin or erythromycin (GOLD, 2021: 57), although local guidance should be sought as to whether this is a primary or secondary care intervention.
Mucolytics may also help to reduce exacerbation rates and improve quality of life (GOLD, 2021: 57). Once daily, effervescent options are now available, which may be more acceptable to patients.
Conclusion
Exacerbations of COPD are associated with reduced quality of life, loss of lung function and a higher risk of dying. People living with COPD and their carers should be offered support to self-manage if they are happy to do so. Patient education should include advice on how to recognise exacerbations and when and how to treat them, with information about the effects and side-effects of any medication. They should also be made aware of atypical symptoms that require clinical assessment. Every exacerbation is an opportunity for the clinician to review the ongoing care of that individual in order to assess for opportunities to reduce future risk. This may be via pharmacological and non-pharmacological interventions.
KEY POINTS:
- Mild and moderate exacerbations of COPD can be managed by the patient at home
- In moderate exacerbations, oral corticosteroids and/or antibiotics may be indicated
- Rescue packs should include these drugs, with antibiotic choices aligned to local formularies
- Patient education is an essential part of supporting people to manage exacerbations with rescue packs
- Post-exacerbation follow up offers an opportunity to review ongoing management and reduce future exacerbation risk
CPD REFLECTIVE PRACTICE:
- How might exacerbations inform the long-term management of COPD in your patients?
- When might rescue packs be useful for those with COPD?
- How do you review patients after an exacerbation?
- How will this article change your clinical practice?