Management of Exacerbations

The majority of exacerbations are handled at home by the patient or the primary care team, with ~50% of exacerbations unreported to clinicians [19]. Moderate-to-severe COPD patients with frequent exacerbations have a faster decline in lung function and are more often admitted to hospital with longer lengths of stay [20].

Symptoms and not lung function worsen significantly before an exacerbation, with dyspnoea or colds characterising the more severe (see Exacerbation: definition evaluation and treatment). Therefore, patients with COPD should be made more aware of the symptoms of an exacerbation and encouraged to report these early to clinicians [21]. Conversely, physicians should make use of the experience of the individual patient and ask for early signs of an exacerbation and initiate a plan of care.

Since oral steroids seem especially useful for the first 72 h [22], these should be initiated at first signs of an exacerbation. If corticosteroids are initiated, short courses [23] are recommended (fig. 1). Antibiotics may be initiated in patients with altered sputum characteristics, but level I patients with increased quantities of nonpurulent sputum improve without antibiotic therapy [24] (see Exacerbation sections).

Programmes that include social and medical support for early planned discharge may reduce hospital stay and do not result in an increased readmission rate [25-27]. Patients are more likely to prefer domiciliary care over inpatient care [28], leading to greater patient satisfaction [29].

Planned monitoring of the patient after discharge is an integral component to the rehabilitation approach and promotes the ability of the patient and family to move toward self-management [30].

It is important that long-term care for chronic relapsing diseases be delivered by a team of professionals with the "expert patient" at the centre; such an approach is likely to maintain the patient’s quality of life [31].