Building toolkits for COPD exacerbations: lessons from the past and present
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
In the nineteenth century it was recognised that acute attacks of chronic bronchitis were harmful. One hundred and forty years later, it is clearer than ever that exacerbations of Chronic Obstructive Pulmonary Disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over twenty-five years ago.
An ECOPD is “an acute worsening of respiratory symptoms that results in additional therapy”. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care. Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over thirty years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.
LAY SUMMARY: Patients with Chronic Obstructive Pulmonary Disease frequently experience acute flares of symptoms (termed “exacerbations”) which are associated with death, readmission to hospital, worsening lung damage and an increased need for social care. The therapies we use to treat exacerbations have limited effect and have not changed in over 25 years. We discuss how our understanding of exacerbations has developed over time, and what steps are needed to improve health outcomes for patients.
An ECOPD is “an acute worsening of respiratory symptoms that results in additional therapy”. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care. Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over thirty years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.
LAY SUMMARY: Patients with Chronic Obstructive Pulmonary Disease frequently experience acute flares of symptoms (termed “exacerbations”) which are associated with death, readmission to hospital, worsening lung damage and an increased need for social care. The therapies we use to treat exacerbations have limited effect and have not changed in over 25 years. We discuss how our understanding of exacerbations has developed over time, and what steps are needed to improve health outcomes for patients.
Date Issued
2019-08-14
Date Acceptance
2019-05-06
Citation
Thorax, 2019, 74 (9)
ISSN
1468-3296
Publisher
BMJ Publishing Group
Journal / Book Title
Thorax
Volume
74
Issue
9
Copyright Statement
© 2019 Author(s) (or their
employer(s)). Re-use
permitted under CC BY (https://creativecommons.org/licenses/by/4.0/).
Published by BMJ.
employer(s)). Re-use
permitted under CC BY (https://creativecommons.org/licenses/by/4.0/).
Published by BMJ.
Subjects
copd exacerbations
emphysema
innate immunity
Respiratory System
1103 Clinical Sciences
Publication Status
Published
Date Publish Online
2019-07-03