By Rachel Pugh
Management of chronic obstructive pulmonary disease (COPD) has not changed significantly for more than 20 years, but significant benefits could be achieved by the consistent use of simple procedures contained in the National COPD Audit programme.
Dr John Hurst, professor of respiratory medicine, at University College London gave this message and demonstrated the potential for quality improvement by highlighting the 20 per cent increase in people seeing a respiratory specialist within 24 hours of admission for an exacerbation, since the National Audit began its continuous data collection in February 2017.
here has also been a 30 per cent increase in patients being discharged from hospital with a ‘discharge bundle’ which includes access to smoking cessation, a follow-up plan and pulmonary rehabilitation.
Dr Hurst said: “This is really basic stuff. COPD management is not about doing complicated things. It’s about doing simple things, doing them every time and getting them right.”
National COPD Audit data reveals the following depressing patient picture:
- Four per cent in-hospital mortality of those admitted with an exacerbation
- Three per cent died after discharge from hospital with exacerbation of COPD
- Twenty-five per cent are re-admitted to hospital within 30 days of discharge.
Mortality figures for COPD are similar to those for myocardial infarction (MI), but MI figures have halved over recent decades, whereas those for COPD have remained static.
He asked why a patient admitted with an MI can expect to be seen by a specialist within minutes, whereas the same access to a respiratory specialist for a COPD exacerbation is uncommon.
Another gap in COPD management revealed by the national audit is the need for spirometry as less than half of patients admitted for a COPD exacerbation have the data to back their admission. Dr Hurst said: “How can we be expected to diagnose COPD, if we do not have the evidence that they have it in the first place?”
The National COPD Audit programme started continuous data collection 1 February 2017 and its first report published April 2018 looked at 36,431 hospital admissions in a year. It allows individual teams to track their progress against national standards.
Having published no guidelines on COPD since 2010, NICE has recently published three — on the use of oral corticosteroids (under consultation), on antibiotics and the last one dealing disease management1.
Taken together, clinicians can be sure of being NICE compliant if they are using:
- Five days of amoxicillin/doxycycline/clarithromycin.
- Up to 7 days of corticosteroids and considering a safe stop.
Problems exist in defining exacerbations as everyone ending up in hospital is classed as severe. Dr Hurst emphasised the need for greater analysis of the underlying disease and for greater consideration of the role of comorbidities, which are more frequent and numerous in COPD patients and can influence the course of the disease and treatment.
Dr Hurst called for a redefinition of triple therapy for COPD (currently accepted as being inhaled corticosteroids, long-acting beta agonist and long-acting muscarinics) to be replaced by the most cost-effective version: vaccination, pulmonary rehabilitation and smoking cessation.
Advances in COPD have begun. The IMPACT study has shown that triple therapy with fluticasone furoate, umeclidinium, and vilanterol results in a lower rate of moderate or severe COPD exacerbations than fluticasone furoate–vilanterol or umeclidinium–vilanterol.
Urgent research is required on exacerbations. Dr Hurst has led the establishment of the survey with the British Lung Foundation for clinicians, COPD sufferers and carers at https://www.blf.org.uk/support-for-you/copd/survey .