COPD

COPD needs ‘zero tolerance’ approach to exacerbations: expert


Respiratory physicians should adopt a zero tolerance approach to COPD exacerbations and poor care in order to drive progress and improve outcomes for patients, a UK conference has heard.

“Our current paradigm in COPD care, that is to say tolerating exacerbations and escalating to treatment only once events occur rather than taking a more proactive primary prevention approach, may be doing some of our patients a disservice,” Professor John Hurst, a Professor of Respiratory Medicine at University College London, told delegates at the British Thoracic Society (BTS) Winter 2021 meeting.

Describing the urgent need for a change in thinking, Professor Hurst pointed to a national audit in 2019 that highlighted “significant challenges to the delivery of evidence based care for COPD, and variation across the country in care delivery and outcomes,” which are still true today.

Key challenges include the absence of spirometry confirmation in a majority of patients admitted to hospital and treated for COPD exacerbation, “stubbornly high readmission rates” and the absence of clinical leadership in some trusts to drive improvements to the quality of COPD care.

He also highlighted the need for better access to specialist care, as seen with a host of other conditions such as acute coronary syndromes. “Seeing a COPD specialist from the multi-professional team early on in admission is associated with reduced in-patient mortality, and yet, that isn’t routine.” Also, “assessment and application of non-invasive ventilation requires specialist skill, so why are we still accepting a situation where our COPD patients are admitted through the general take?”

With regard to COPD exacerbations, Professor Hurst advocates a different approach in which high risk time periods are targeted for prevention rather than ‘merely’ those patients who are deemed high risk because of prior history of exacerbations. 

“There’s a high risk period for a second exacerbation in the period immediately following complete recovery of the first. We don’t understand the mechanism yet, perhaps an initial viral infection is predisposing to secondary bacterial ones, but we know that more than a quarter of community treated exacerbations that fully recover will be associated with a second event within eight weeks of recovery, and that’s significantly higher than would be expected by chance,” he said.

Also, the longer-term rhythm of exacerbations shows a trend of acceleration, so the time periods between hospitalised exacerbations reduces with each one, which “highlights the crucial need to intervene and optimise exacerbation prevention after first hospitalisation”.

According to Professor Hurst, the idea of failure to optimise care is “all too common” within COPD. “Patients must have a number of significant events prior to escalation to more effective therapy. Would we expect cardiologists to wait for two or three MI’s before full deployment of treatment?”

This is particularly pertinent given that early exacerbations are known to be linked with significant consequences; “in absolute terms, the permanent loss of function from an exacerbation is greater in mild COPD compared to severe disease,” and exacerbations are also associated with excess CV risk. 

“One of the problems here is that we still too often use treatment in response to disease severity, rather than the equally if not more important concept of disease activity. We need to be more worried about those with milder disease that’s active than those with severe disease that might be considered burned out,” he told delegates.

“Most of our current disease measures look at disease severity, such as FEV1. We need to move beyond that. We need to think laterally, about exacerbations, or about inflammation…Of course the thorny questions of how to identify early active COPD and how to intervene remain so we’re not there yet, but this has to be the ambition”.

In the meantime, he said there are practical steps respiratory physicians can take to maximise the quality of care and move towards reducing the burden of future severe disease, such as active case finding and smoking cessation, optimising COPD preventive interventions – particularly after hospital exacerbations, and auditing services to drive quality improvement and outcomes for patients.

“No more nihilistic tolerance in COPD – it’s time for zero tolerance of COPD exacerbations and poor care,” Professor Hurst stressed.

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