COPD and the ER

Definition of COPD

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The condition comprises pathological changes in four different compartments of the lungs (central airways, peripheral airways, lung parenchyma and pulmonary vasculature) which are variably present in individuals with the disease. The pathogenesis of the disease is multifactorial, involving inflammatory changes in the lung in response to exposure to noxious particles or gases, that leads to remodelling and thickening of the airway wall as well as destruction of alveoli and enlargement of airspaces with the net result of airflow obstruction, air trapping and hyperinflation. These physiological changes result in the cardinal symptoms of COPD, namely shortness of breath, cough, wheeze and chronic sputum production. Cigarette smoking is the leading environmental risk factor for the development of the disease, with 50% of smokers effected in their lifetime, though genetics, occupational and environmental exposures can cause and contribute to disease progression.

Impact of COPD on Patients

COPD is a major cause of morbidity and mortality worldwide and is currently the 4th leading cause of death in the world but is projected to be the 3rd by 2020. More than 3 million people died from the condition in 2012, 6% of all documented deaths worldwide. COPD is also a major cause of chronic morbidity as many people suffer symptomatically for many years. As well as the obvious respiratory symptoms there are a range of extra pulmonary complications of COPD and its treatments such as skeletal muscle dysfunction, lean mass depletion, osteoporosis and Osteopenia that add to the burden of morbidity for patients.

Impact of COPD on Society

COPD rates are projected to increase in the coming decades because of continued exposure to COPD risk factors and aging of the population. As a result the huge economic burden of treating the condition will continue to increase also. In the European Union, the total direct costs of respiratory disease are estimated to be about 6% of the total healthcare budget, with COPD accounting for 65% (38.6 billion Euros) of this. The largest contributor to this cost is hospitalization. International studies of trends in COPD related hospitalization indicate that although the average length of stay has decreased since 1972, admissions per 1000 persons per year have increased in all age groups in that time period. Hospitalization related costs in COPD patients are much higher than in Non- COPD cohorts ($5,409 vs $3511 according to The National Medical Expendidture Study in the US). The total cost of COPD hospitalisations in Ireland was over €70million in 2014 with an average hospital length of stay of 9.5 days per person. Avoiding hospitalization in COPD patients therefore should be a priority of all government led healthcare providers. Unfortunately, Ireland is struggling to keep COPD patients out of hospital. A recent OECD report showed that Ireland had the highest hospitalisation rates for COPD of all OECD countries with an average admission rate of 394.9 per 100,000 people. This is obviously a concerning finding at a time when heath care costs and hospital waiting lists are escalating and the media is rife with stories of overcrowded and chaotic Emergency departments throughout the country. 

Better Management: Better Outcomes

So, how can Ireland decrease its rates of hospitalization for COPD patients while at the same time ensuring patient safety and treatment efficacy? The answer is multifaceted and is the responsibility of heath care providers, government policy and patients themselves. There are a number of pharmacological and non-pharmacological interventions proven to decrease hospital admissions in COPD cohorts. From a pharmacological perspective correct use of and adherence to inhaled bronchodilators and steroids has been proven in large clinical trials (FLAME, UPLIFT, TORCH) to reduce rates of COPD exacerbation by up to 25% with the upshot of reduced hospital admission rates. The role of inhaled corticosteroids in maintenance therapy is an area of active research and may be of benefit to some cohorts of COPD patients more than others, particularly those with raised Eosinophil counts. Adherence rates to inhaler regimes are depressingly low however. According to WHO estimates, only 50% of patients receiving long term pharmacotherapy for chronic diseases are adherent to treatment with adherence rates in COPD varying widely from 22-78%. One of the most important factors that influence adherence to inhaled medications is the level of education patients receive about the condition itself as well as the medication and the delivery devices. Poor doctor patient communication is also proven to decrease adherence rate. It is therefore incumbent on health care providers both in primary care and hospital medicine to provide education and training on inhaler technique and compliance to patients when they commence on inhaler regimes. Older patients with cognitive issues or patients with comorbidities that restrict their movements (such as Rheumatoid arthritis) may be particularly vulnerable to adherence problems and many simply can use some types of inhalers that require manipulation of devices. Particular attention needs to be paid to these individuals which highlights the importance of good communication and a good working relationship between the health care provider and the patient. Other important pharmacological interventions include yearly influenza vaccine which has been proven to reduce the need for inpatient care in patients with COPD and the judicious use of antibiotics and oral steroids in the community for patients who are experiencing exacerbations.  

The Vicious Cycle of Repeated Exacerbation

COPD patients often relapse at home and require repeated inpatient treatments. 90 Day readmission rates are as high as 35% and frequent readmissions are a predictor of increased mortality. Increased age, Low FEV1%, elevated dyspnoea scores and frequency of exacerbations are predictors of readmission that can guide physicians when discharge planning and arranging follow up for COPD patients while in hospital. COPD outreach schemes are vitally important tools that can provide a “hospital at home” to ensure that recently discharged patients are followed up in the community by respiratory services. Patients are generally followed for up to 6 weeks with multiple home visits and are provided with access to services such as physiotherapy when needed. This service can reduce readmission rates and provides patients with the reassurance that they can access care and expertise at home should they require it. 

More Than Just Drugs

While there is clearly a role for pharmacotherapy in prevention of exacerbation and hospitalization, non-pharmacological therapies are just as important, none more so than smoking cessation. Smoking cessation has established benefits on the rate of decline of lung function, chronic symptoms and the development of comorbidities. In addition beneficial effects of stopping smoking on exacerbation frequency and hospitalization have been described. Again education on how to stop smoking and access to cessation services for information and guidance plays an important role in this process that many patients find extremely challenging. Pulmonary rehabilitation is a multi-disciplinary strategy to optimise symptom control, physical capacity and health related quality of life through a mix of exercise programmes and education that usually lasts between 4 and 6 weeks and has been shown to limit the psychological impact of the disease and to prevent exacerbations and complications. These programmes are widely available throughout the country and provide consistently good results. However, uptake of the programmes by the public is poor, through lack of time, transportation issues and often fear or lack of confidence to attend. 

Investing in Community Care

The OECD report that placed Ireland at the top of the list for COPD hospital admission also stated that countries that had noted a reduction in their hospital admissions in that time period had improved the access to and the quality of their primary care services. This is of paramount importance if Ireland is going to effectively reduce the number of hospital admissions from COPD in the coming years. Primary care facilities need to be equipped with the facilities and trained staff to manage mild to moderate COPD exacerbations in the community. This includes access to spirometry to aid diagnosis as well as nursing care and education for patients. With that there should be support available from respiratory services in hospitals to GPs in the community, including streamlined referral criteria for severe cases and cases failing therapy in the Community. Only through a collaborative and supportive approach between primary care and hospital services can we hope to reduce the number of COPD patients coming through the doors of the ER.