Lung Disease

Pearls of Wisdom: Acute Exacerbation of COPD

Bob, a 62-year-old man, is admitted to the hospital for an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). Despite his COPD diagnosis several years ago, Bob has continued to smoke.

What is the mortality rate within the next 2 years in patients presenting with this scenario?

A. Less than 10%
B. 25% to 35%
C. 36% to 49%
D. 50% to 60%

What is the correct answer?
(Answer and discussion on next page)

 

Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Answer: 36% to 49%

Patients with COPD have several important agendas to which clinicians must attend. Despite experiencing serious consequences of smoking, persons with COPD frequently continue to smoke. Perhaps this is why some clinicians take a fairly nihilistic attitude toward COPD. Yet several noteworthy aspects of COPD bear reminding.

In contrast to most of the other top 10 causes of death in the United States (eg, myocardial infarction [MI], stroke), mortality rates for COPD are rising. The explanations for this are not entirely clear, except perhaps that our success in rescuing MI and stroke patients from the precipice of disaster allows another opportunity to be assailed by COPD.

COPD: Survival vs Exacerbation Frequency

survival

Because AE-COPD episodes are so commonplace among patients with COPD, it is easy to become complacent about these exacerbations. However, COPD patients know that—in contrast to asthma, where during quiescent periods, lung function may be essentially normal or near normal—after each AE-COPD episode, there is a decrease in pulmonary function that is not regained.1 So COPD patients may become resigned to the fact that each AE-COPD episode means another progressive decline in respiratory function.

It is important that we not only strive to treat AE-COPD aggressively, but also aim to prevent these exacerbations. This is because AE-COPD episodes are not just "bumps in the road of COPD" but are associated with a compelling mortality burden.

COPD: Survival vs Exacerbation Severity

survival 2

Some authors have reported that the mortality in the 2 years after a hospital admission for COPD may reach as high as 49%.2 Survival in COPD, as related to exacerbations, is linearly linked not only to the frequency of exacerbations, but also to the severity of exacerbations.2

The survival picture for patients admitted to the intensive care unit due to the severity of AE-COPD is even worse: As many as 25% of these patients die in the hospital.1 Fortunately, clinicians have several tools (in addition to smoking cessation) with which to reduce exacerbation frequency: bronchodilators (both β-agonists and anticholinergics), inhaled corticosteroids, and the PDE4 inhibitor roflumilast.

Percent Change in Age-Adjusted US Death Rates

age adjusted

Data collected from 1965 to 1998 show a 163% increase in age-adjusted US death rates related to COPD. This large figure is startling and is compounded by the percent decreases seen across the board for other causes of death during this time. Coronary heart disease rates fell 59%, stroke rates fell 64%, and other cardiovascular disease-related deaths fell 35%. All other causes of age-adjusted US death rates declined by 7%.

What’s the “Take Home”?

AE-COPD is costly to the patient in terms of further loss of pulmonary function and overall survival. Clinicians should be vigilant to provide risk reduction for AE-COPD through pharmacotherapy and smoking cessation.

References:

  1. Hanania NA, Sharafkhaneh A. COPD. In: Bope ET, Kellerman RD, eds. Conn’s Current Therapy 2012. Philadelphia, PA: Elsevier; 2012:343-348.
  2. Soler-Cataluña JJ, Martínez-García MÁ, Román Sánchez P,  Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60(11):925-931.
  3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD – 2001. Bethesda, MD: Global Initiative for Chronic Obstructive Lung Disease; 2001.