Can we reduce the risk of readmission for a patient with an exacerbation of COPD?

INHALERS

Inhaler therapy is recommended based on COPD severity according to GOLD classification, and appropriate inhaler therapy with proper inhaler technique reduces the number of COPD exacerbations and hospitalizations.⁶

Long-acting beta-agonists and anticholinergics reduce the risk of COPD exacerbation and hospitalization and so are preferred over short-acting formulations except for patients in GOLD group A, ie, those who have few symptoms and are at low risk of exacerbations.⁶

Long-term treatment with inhaled corticosteroids with long-acting bronchodilators is recommended for patients at high risk of exacerbations (ie, those with two or more exacerbations in the previous year or a forced expiratory volume in 1 second [FEV₁] less than 50% of predicted).⁶

OXYGEN THERAPY

Two older randomized controlled trials, the Nocturnal Oxygen Therapy Trial and the Medical Research Council study, reviewed by Stoller et al,¹² provided clear evidence that oxygen therapy reduces the death rate and improves quality of life in COPD patients who have chronic resting hypoxemia (room air Pao₂ ≤ 55 mm Hg, or ≤ 59 mm Hg with signs of right-sided heart strain or polycythemia).

PULMONARY REHABILITATION

Pulmonary rehabilitation likely reduces hospital admissions by improving exercise capacity.¹³ A systematic review of six trials in 230 patients found that respiratory rehabilitation after an acute COPD exacerbation reduced the risk of COPD hospital admission (RR 0.26, 95% CI 0.12–0.54) and the risk of death (RR 0.45, 95% CI 0.22–0.91).¹³

OTHER INTERVENTIONS

Home noninvasive ventilator support reduced hospital and intensive care unit readmissions in select patients recurrently hospitalized for acidotic exacerbations of COPD in one small study.¹⁴

Long-term antibiotic therapy. Although there is evidence that azithromycin, taken daily for 1 year, decreases the frequency of COPD exacerbations,¹⁵ concern persists that this approach promotes antibiotic resistance, and the GOLD guidelines do not recommend routinely using antibiotics in patients with clinically stable COPD.⁶

Roflumilast. According to the GOLD guidelines, the phosphodiesterase-4 inhibitor roflumilast (Daliresp) may be useful in reducing exacerbations in patients who have an FEV₁ less than 50% of predicted, chronic bronchitis, and frequent exacerbations.⁶

Referral. Patients who have severe recurrent COPD exacerbations despite appropriate therapy will likely benefit from referral to a pulmonary specialist for other options such as theophylline, lung-reduction surgery, and lung transplantation.

PATIENT EDUCATION AND OUTPATIENT COPD PROGRAMS

There is growing evidence that outpatient programs that provide education and medical support significantly reduce the rate of hospitalizations for COPD.^16–18 Patient education includes symptom monitoring, early recognition of an exacerbation, appropriate use of inhalers and nebulizers, and advice on smoking cessation.¹⁶

On the other hand, a Veterans Administration randomized controlled trial was stopped early because of a higher rate of death in the group that underwent a comprehensive care-management program of COPD education, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management.¹⁹

Further study is needed to investigate the cost-effectiveness and safety of COPD management programs and whether to adopt such programs on a systematic level.

In conclusion, COPD patients require a comprehensive approach based on studied interventions. This may be achieved through systematic methods that allow each patient to benefit from all possible interventions appropriate for him or her. Hospitalization of COPD patients provides an excellent opportunity to implement this comprehensive approach.