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e also vital for improving the patient’s health after discharge and include education regarding proper inhaler technique, and avoidance of second-hand smoke (and other respiratory irritants). Patient education regarding the ability to recognize the symptoms of an exacerbation should be emphasized.

PULMONARY REHABILITATION

Pulmonary rehabilitation is an important part of outpatient COPD care after an admission for AECOPD, and should be considered at the time of discharge for all patients with chronic lung disease with the goal of alleviating symptoms and optimizing functional capacity. Evidence supports that entering pulmonary rehabilitation within 10 days of hospital discharge is safe. Furthermore, patients enrolled in early pulmonary rehabilitation experienced improved exercise tolerance and health status at 3 months. Beyond functional capacity, pulmonary rehabilitation programs often focus on establishing social support and care networks that are most appropriate for the patient and can have quality- of-life benefits beyond physical improvements.

PRACTICE POINT

Evidence supports that entering pulmonary rehabilitation within 10 days of hospital discharge is safe, and patients enrolled in early pulmonary rehabilitation experience improved exercise tolerance and health status at 3 months.

SURGICAL TREATMENT OPTIONS AND TRANSPLANT EVALUATION

Surgical treatment options for COPD include lung volume reduction surgery (LVRS), bullectomy, lung transplantation and investigational approaches. LVRS involves bilateral removal of 25% to 30% of total lung volume. The National Emphysema Treatment Trial, published in 2003, demonstrated that LVRS improved exercise capacity but not survival among all patients with severe emphysema. This trial did, however, identify subgroups that had a survival advantage. The best candidates for LVRS are patients with predominantly upper-lobe disease and a low exercise capacity after pulmonary rehabilitation. Bullectomy has not been well studied in randomized trials, but it may be considered for patients with at least one-third of the thorax occupied by bullae.

For patients with advanced disease another therapy to consider is lung transplantation. Lung transplant referral is indicated for younger patients with COPD that have progressive symptoms despite maximal medical therapy, including smoking cessation. Lung transplant for COPD has been shown to improve quality of life, but effect on mortality has not been clearly demonstrated and is more controversial. For further analysis of trials addressing treatment strategies in COPD, please refer to the key references (Table 232-10).

TABLE 232-10 Evidence-based Medicine: Key References for Chronic Obstructive Pulmonary Disease

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Reference Methodology Results Limitations Bottom Line Calverely P, et al. N Engl J Med. 2007;356:775- 789. TORCH trial

Randomized, double-blind, placebo- controlled trial of placebo vs salmeterol alone vs fluticasone alone vs salmeterol plus fluticasone inhaled twice daily for 3 y. 6112 patients were active or former smokers with diagnosis of COPD, FEV1 < 60% predicted and no significant bronchodilator response

Comparing combination therapy to placebo, there was nonstatistically significant reduction in mortality (OR, 0.825; CI 0.681- 1.002). Compared to placebo, combination therapy reduced exacerbations. There were higher levels of pneumonia in both groups receiving fluticasone when compared to placebo

There was a large drop-out rate (as might be expected in a COPD trial with a placebo arm)

There is insufficient data to suggest that inhaled corticosteroids decrease mortality in patients with COPD, but addition of inhaled corticosteroid may reduce exacerbations for patients on LABAs that have recurrent exacerbations. For monotherapy in COPD, LABA should be used rather than an ICS

Taskin DP, et al. N Engl J Med. 2008;359:1543- 1554. UPLIFT

Randomized, double-blind, placebo- controlled trial of tiotroprium vs placebo to decrease decline in FEV1 over time (before and after bronchodilation) in 5993 patients

There was no significant difference in decline in FEV1 over time in the tiotroprium group as compared to placebo. Tiotroprium did lead to increases in FEV1 (but not change over time), improved quality-of-life scores, and fewer exacerbations

There was a large drop-out rate and short- acting inhaled anticholinergics were stopped in all patients

Tiotroprium may be prescribed to alleviate symptoms of COPD, but should not be expected to alter progression of disease

Anthonisen NR. JAMA.

Randomized, placebo- controlled trial

Participants in both smoking cessation

There was predictably low adherence to

Smoking cessation counseling can

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1994;272:1497- 1505. Lung Health study

comparing no intervention to smoking cessation counseling plus placebo to smoking cessation counseling plus inhaled short- acting anticholinergics in 5887 patients

groups experienced smaller declines in FEV1 over time. Responses to short-acting anticholinergics were not cumulative over time

prescribed inhalers

lead to declines in rates of smoking, and FEV1 decline was mitigated amongst patients who received counseling, and the effect was strongest in those who did abstain

Bronchard L, et al. N Engl J Med. 1995;333:817- 822.

Prospective randomized trial comparing use of NIPPV vs standard care for treating 85 patients admitted to ICU with COPD exacerbation

NIPPV significantly decreased rate of endotracheal intubation, hospital LOS, and in-hospital mortality

Large percentage of patients admitted to ICU with COPD exacerbation were excluded, limiting population of patients to which data can be applied

For selected patients with acute exacerbations of COPD, application of NIPPV can prevent need for endotracheal intubation and speed recovery

NETT Research Group. N Engl J Med. 2003;348:2059- 2073. NETT trial

Randomized trial of 1218 patients with severe emphysema to receive lung volume reduction surgery vs continued medical care. Overall mortality and maximal exercise capacity were compared as primary outcomes

In entire study group, there was no difference in overall mortality. Surgery group had significantly higher percentage of patients who improved maximal exercise capacity when compared to nonsurgery group. In subgroup analysis, patients with mostly upper- lobe disease and low exercise

No difference in mortality overall. Caution must be used when results of subgroup analysis are applied

Lung volume reduction surgery may be indicated for specific group of patients who have predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation. Risks and benefits must be weighed against options of doing nothing vs lung transplant. Patients with FEV1 ≤ 20%

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capacity after pulmonary rehabilitation, there was a mortality benefit from surgery. Amongst subgroup of nonupper-lobe emphysema and high exercise capacity, mortality was higher in surgery group. Interim analysis identified group of patients with high risk of surgical death

predicted and either homogenous emphysema or DLCO ≤ 20% predicted are at high risk of death from lung- volume reduction surgery

Leuppi JD. JAMA. 2013;309:2223- 2231. REDUCE trial

Randomized, noninferiority trial comparing use of 5 d vs 14 d of corticosteroids in 314 patients with COPD exacerbation

No significant difference in rates of re- exacerbation at 6 mo between treatment arms (37.2% in the short term treatment group vs 38.4% in the long-term treatment group)

The study used an absolute difference of 15% to show noninferiority which may miss smaller treatment differences between treatment arms

To reduce the overall exposure to steroids, limit treatment to a total of 5 d of prednisone for acute exacerbations of COPD

COPD, chronic obstructive pulmonary disease; DLCO, diffusing capacity of the lung for carbon monoxide; FEV1, forced expiratory volume in 1 s; ICS, inhaled corticosteroid; ICU, intensive care unit; LABA, long-acting beta-agonist; NIPPV, noninvasive positive pressure ventilation; OR, odds ratio.

TRANSITIONS OF CARE

Patients transitioning from inpatient to outpatient care, whether for an AECOPD or for patients with underlying COPD admitted for other reasons, have many educational and therapeutic needs. Education needs include smoking cessation, inhaler technique and mobility prescriptions. For patients that might still have pain issues or decreased mobility, education regarding incentive spirometry is imperative. Follow-up care should be arranged with a primary care physician, a pulmonary specialist or both. For discharges after an AECOPD, follow-up should be arranged at discharge for the patient to be seen within 2 weeks of discharge or sooner if requiring significant changes to their care regimen. Recent

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literature has suggested implementing a “COPD care bundle” prior to discharge. This includes specialist notification of patient admissions, smoking cessation assistance, referral to pulmonary rehab, educational literature and proper inhaler teaching. Preliminary data have shown a significant reduction in readmissions for AECOPD following these steps.

DISPARITIES IN HEALTH CARE

COPD has long been considered a disease of white, male smokers. Data, however, show that the epidemic is increasing most rapidly for women and African Americans. For over a decade, more women have died of COPD than men annually. The death rate is increasing more rapidly for African Americans as well. To some degree, these changes represent changes in the demographics of cigarette smoking over decades. However, some data suggest that women and African Americans may actually be more susceptible to chronic lung disease when compared to white men. In general, women have smaller caliber central airways than similarly sized men and African Americans have smaller trunk/leg ratios than whites. These differences may explain more clinically significant airflow limitation after exposure to cigarettes or other respiratory toxins. Possible differences in specific genes, proteases, and/or cytokines might also explain some differences in response to exposures.

OUTCOMES TO MONITOR

There are many possible outcomes to monitor and measure regarding quality of care for patients admitted with an AECOPD or for patients with COPD treated in the hospital for other issues. The percentage of patients provided with smoking cessation counseling would be appropriate for either group, as would vaccination rates.

For patients treated for an AECOPD, tracking the number of patients referred for pulmonary rehabilitation is another option, as is the short-term readmission rate. Lastly, the percentage of patients with severe COPD that are referred to hospice and/or palliative services could be monitored.

COSTS AND RESOURCE UTILIZATION

While only smoking cessation and supplemental oxygen have been proven to have an impact on chronic COPD mortality, there are many other modalities that may improve quality of life and possibly decrease health care costs for patients with COPD.

Smoking cessation programs, health-maintenance caseworkers for patients with COPD and pulmonary rehabilitation programs each offer ways in which large institutions might decrease overall costs for the care of a population of COPD patients. Vaccinations have been shown to have significant cost-savings as well.

Another area of focus for resource utilization is goals of care and end-of-life discussions. A 2006 study found that COPD patients in the last 6 months of life were more likely to be admitted to an ICU and have longer length of stay when compared to patients in the last 6 months of life with lung cancer. Total health care costs were $4000 more per patient during this time frame. Improved communication (preferably before admission, but also possibly at the time of admission) regarding goals of care and realistic expectations could prove to decrease these costs while hopefully improving quality of life for terminal patients and their families.

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SUGGESTED READINGS Almagro P, Balbo E, Ochoa de Echaguen A, et al. Mortality after hospitalization for COPD.

Chest. 2002;121:1441-1448. Barnes P. Cellular and molecular mechanisms of chronic obstructive pulmonary disease.

Clin Chest Med. 2014;35:71-86. Bronchard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations

of chronic obstructive pulmonary disease. N Engl J Med. 1995;333:817-822.

Celli BR, MacNee W, Augusti A, et al. ATS/ERS TASK FORCE. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2015. Available at: http://www.goldcopd.com. Accessed March 30, 2015.

Hopkinson NS, Englebretsen C, Cooley N, et al. Designing and implementing a COPD discharge care bundle. Thorax. 2012;67(1):90-92.

Nathan SD. Lung transplantation: disease-specific considerations for referral. Chest. 2005;127:1006-1016.

Ram FSF, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004:Issue 3. Art. No.: CD004104.

Rigotti NA, Clair C, Munafo MR, et al. Interventions for smoking cessation in hospitalized patients. Cochrane Database Syst Rev. 2012;Issue 5. Art. No.: CD001837.

Salpeter SS, Ormiston T, Salpeter E, et al. Cardioselective beta blockers for chronic obstructive pulmonary disease (Cochrane Review). Cochrane Database Syst Rev. 2005(1);Issue 4. Art. No.:CD003566.

Seemungal TA, Donaldson GC, Bhowmik A, et al. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161:1608-1613.

Walters JAE, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014;Issue 12. Art. No.: CD006897.