Independent Nurse: Clinical - Respiratory - Tackling COPD exacerbations in primary care.(Corticosteroids have an important place in exacerbation management)

COPD exacerbations can be traumatic for patients. Dr David Lynes and Sue Cross outline options for their prevention and management.

Exacerbations are distressing and disruptive for patients with COPD,1 and are associated with a worsening prognosis. They are significant events in the natural history of the disease and severe exacerbations account for a significant portion of the total costs of caring for these patients.2

A retrospective audit of 1,400 admissions for exacerbations showed that 34 per cent of patients were re-admitted and 14 per cent had died within three months.3 Early discharge and other schemes mean that many patients who would have been hospitalised in the past are now treated at home.

Preventing exacerbations

The most common causes of acute exacerbation are bacterial or viral infection, although the cause may be unidentifiable in up to 30 per cent of cases.4 It is important to consider alternative diagnoses such as pneumothorax, pulmonary embolus, or worsening of pre-existing heart failure.

New treatments and advances in our understanding of existing pharmacotherapy mean we can reduce exacerbation rates by as much as 40 per cent.

Further gains may be possible but there is a lack of evidence to support the use of a range of combination therapies.

Long-acting bronchodilators have been shown to reduce exacerbation frequency when compared with short-acting bronchodilators or placebo. Inhaled corticosteroids can also reduce exacerbations if used in the right patients. Both are recommended for exacerbation prevention in UK guidelines (see table).

Trials have shown that inhaled corticosteroids do not affect exacerbation rates in …