Severity of airflow limitation, co-morbidities and management of chronic obstructive pulmonary disease patients acutely admitted to hospital

Abstract

Objective To assess the disease spectrum, severity of airflow limitation, admission pattern, co-morbidities, and management of patients admitted for acute exacerbations of chronic obstructive pulmonary disease. Design Case series.Setting An acute regional hospital in Hong Kong.Patients Adult subjects admitted during January 2010 to December 2010 with the principal discharge diagnosis of chronic obstructive pulmonary disease. ResultsIn all, the records of 253 patients with physician-diagnosed chronic obstructive pulmonary disease were analysed. The majority were old (mean age, 78 years). The median number of admissions per patient for this condition in 2010 was two. About two thirds (64%) had had spirometry at least once. Mean forced expiratory volume in one second predicted was 55%. Almost 90% had moderate-to-very severe airflow limitation by spirometry. Overall, long-acting bronchodilators (beta agonists and/or antimuscarinics) were being prescribed for only 21% of the patients. ConclusionMost of the patients admitted to hospital for acute exacerbations of chronic obstructive pulmonary disease were old, had multiple co-morbidities, and the majority had moderate-to-severe airflow limitation by spirometry. Almost half of them (around 46%) had two or more admissions in 2010. Adherence to the latest treatment guidelines seemed inadequate, there being a low prescription rate of long-acting bronchodilators. Chronic obstructive pulmonary disease patients warranting emergency admissions are at risk of future exacerbations and mortality. Management by a designated multidisciplinary team is recommended. Severity of airflow limitation, co-morbidities and management of chronic obstructive pulmonary disease patients acutely admitted to hospital O R I G I N A L A R T I C L E LH Au HS Chan 區力行 陳學深New knowledge added by this study • Almost 90% of chronic obstructive pulmonary disease (COPD) subjects with spirometry performed had moderate-to-very severe disease when hospital admission ensued. • About half of these patients had two or more admissions in 1 year.• Despite the severity of their illness, long-acting bronchodilators were underused by these Hong Kong COPD patients.• Long-term oxygen therapy and non-invasive ventilation (acute and long term) were used by significant numbers of patients with severe-to-very severe disease. Implications for clinical practice or policy• As many COPD patients warranting hospital admissions were already at high risk, preferably they should be managed by a multidisciplinary team in a designated respiratory or COPD ward.• Patients with a clinical diagnosis of COPD should have confirmatory spirometry.• Patients with moderate-to-severe COPD disease warrant planned interventions (including use of long-acting bronchodilators) to reduce future exacerbations and hospital admissions.• COPD patients with hypercapnic respiratory failure are at risk of mortality, and if feasible, should be managed by trained staff in a dedicated team.

Adherence to a COPD treatment guideline among patients in Hong Kong

“… 16 Scattered reports on the prevalence of COPD comorbidities in HK have been published, but data from large-scale studies are lacking. 17 , 18 …”

Risk factors of chronic obstructive pulmonary disease exacerbations

“…The relationship between COPD exacerbation and the degree of airflow limitation was demonstrated by several studies …”

“…64 A study developed in Hong Kong showed that 77% of hospital admissions were for patients with COPD with moderate to severe airflow limitation. 65 Montes de Oca et al revealed an increased number of medical visits directly correlated with the airflow obstruction severity and dyspnea, 66 while Foda showed that an increased airway obstruction determined a more severe AECOPD. 67…”

“…A study developed in Hong Kong showed that 77% of hospital admissions were for patients with COPD with moderate to severe airflow limitation …”

“…The relationship between COPD exacerbation and the degree of airflow limitation was demonstrated by several studies. [63][64][65][66][67] A recent 3-year study published in the Netherlands, which included 795 COPD patients with a lower FEV 1 % predicted was associated with a higher risk of hospital admission for a severe AECOPD with an HR of 2.0 (95% CI 1.4-2.5) for patients treated with tiotropium respectively an HR of 2.04 (95% CI 1.43-2.50) for ICS treated patients. Furthermore, a lower FEV 1 % predicted at baseline was associated with a higher mortality risk.…”