Hospitalists know the obvious things to do for a patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation—optimizing medications, potentially prescribing antibiotics or steroids, and maybe referring to rehab—but there may be additional steps to take to achieve the best patient outcomes.
Beyond usual care, hospitalists should be mindful of correctly diagnosing COPD patients, identifying cardiovascular risks, and enabling self-management, experts say.
A study published by the International Journal of COPD in October 2017 found plenty of room for improvement within hospital-based care of this population, particularly in the realms of patient education and self-management advice. Smoking cessation interventions were provided to only 47% of patients who currently smoked, and a recommendation or referral to rehab was made in 24% of the cases. Other interventions, such as assessment of inhaler technique, were implemented for fewer than 20% of patients.
Diagnosis and risk assessment
Before education and even treatment can start, the first box to check is making sure the patient is indeed having a COPD exacerbation.
“Many times the patient has a history of COPD and they come in with shortness of breath, sometimes hypoxia, and the initial or knee-jerk reaction would be, ‘Oh, they are having a COPD exacerbation. Let's continue treating for that with with nebulized bronchodilators, steroids, and continue what the ED has started,’” said ACP Member Satyen Nichani, MBBS, a hospitalist at the University of Michigan in Ann Arbor.
He encourages hospitalists not to anchor on the diagnosis that the ED has made. “Go back and get a history, see whether this actually is a COPD exacerbation, or if there are alternative diagnoses that need to be considered, such as acute pulmonary embolism, heart failure, pneumonia, or something else. Not every patient with COPD admitted with shortness of breath has a COPD exacerbation,” he said.
Narrowing down the cause of or contributing factors to a patient's symptoms can sometimes be complicated by viral infections, fluid or volume status, cardiac comorbidities, or even aspiration, added Denitza Blagev, MD, a pulmonologist at Intermountain Healthcare in Salt Lake City, Utah.
Patients with respiratory problems are at high risk for aspiration, she said. “They have a hard time holding their breath long enough to swallow, especially as they start to decompensate.” So make sure to pay attention to whether they are coughing or choking while eating or if they have trouble swallowing, and take standard acid reflux and aspiration precautions, especially if their respiratory status is worsening, Dr. Blagev advised.
In addition to looking carefully at the lungs, it may be helpful to focus more closely on COPD patients' hearts. An observational study, published by the Journal of General Internal Medicine in June, found that after an acute COPD exacerbation, both 30-day and one-year incidences of ED visits and hospitalizations for acute cardiovascular events were heightened.
Smoking is the common risk factor for both lung and heart disease, explained Roger Goldstein, MD, a professor of medicine at the University of Toronto and head of respiratory services at West Park Healthcare Centre. “You can more or less assume that there's going to be some heart disease in most patients with lung disease . . . The hospitalist needs to be mindful for possible cardiac consequences, by which I mean arrhythmias or heart failure or aggravated angina,” he said.
Dr. Blagev said she often sees patients whose “COPD would be really well treated but I might not be paying attention to their cardiovascular disease, and on the flipside, I have cardiovascular colleagues who have patients who are long-time smokers who are really meticulous about managing their cardiovascular problems and might not be tuned into the COPD. Both really do affect each other.”
Thus, it is critical to assess COPD patients' cardiac health when they first are examined so that any problems can potentially be treated, Dr. Blagev said. For example, if a COPD patient also has symptoms of heart failure, such as edema, then it may be appropriate for a hospitalist to order an echocardiogram. “Or they may have had one, so attention to it and finding and eliciting that history may be important,” said Dr. Blagev.
Hospitalization may also be an underappreciated opportunity to educate COPD patients. A small study, published by CHEST in June, found that a brief educational program delivered during a COPD exacerbation was feasible for a subset of patients and improved their disease-specific knowledge.
“It's been shown now that individuals in hospital, even though they can be quite unwell, are able to retain information,” said Dr. Goldstein, who was a coauthor on the paper. “Therefore, it is a teaching opportunity in terms of . . . how to self-manage, how to recognize an exacerbation, and of course things like smoking cessation.”
Instead of waiting for an outpatient physician to teach patients, hospitalists should recognize that the earlier education is given, the better, he stressed. “A particularly vulnerable time is right after hospital discharge where patients have a greatly reduced exercise tolerance and they still don't feel well,” according to Dr. Goldstein. Without interventions, particularly pulmonary rehabilitation and smoking cessation, “it could take a couple of months before they regain their level of function, so intervening in that period of time shortens the period of disability,” he said.
Dr. Blagev envisions hospital-based teaching modules or pamphlets for COPD patients similar to what new parents are given after a baby is born. “Models like that of education would be helpful, where during the hospitalization we're continually educating from day one,” she said. Such education could cover smoking cessation, inhaler use, self-management, and indicators of when to seek medical care, she suggested.
The challenge is not overwhelming patients with information, the experts noted. Dr. Blagev commonly sees attempts to squeeze in all education at discharge. “People have more than one medical problem, they have a lot of medications—and often we're trying to cram in this really quick overview of a lot of different things that people just aren't able to process,” she said.
The solution may be to choose the top one or two interventions that would be the most significant for an individual patient and focus on them, recommended Dr. Nichani.
Compared with outpatient physicians, hospitalists “have access to the patient for as long as necessary,” he said. “I can actually sit at a patient's bedside for a good 30 minutes or even an hour discussing what is the thing that is going to make the biggest impact on their health.” Hospitalists can also recruit the assistance of a smoking cessation specialist, dietitian, or respiratory therapist to work with the patient, Dr. Nichani observed. “Sometimes it's simple things like using the inhalers appropriately and making sure they are using a spacer.”
Hospitalists should also take the time to get into patients' social and environmental histories. “Sometimes it is helpful to know like if they are living in a basement or damp environments that may expose them to fungi [or] whether they can afford their medications,” Dr. Nichani said. “Sometimes our patients are embarrassed, and unless you ask them, they may not volunteer such information.”
Optimizing COPD care also involves tackling the transition of care. “We find that many of the problems occur in times of transition,” Dr. Goldstein said.
Patients can be confused by differing advice from multiple clinicians or even variations from a single clinician. “They may get different recommendations, or at worst, there may be sort of polite disputes as to what one person has said. You want to get rid of all of that. The patient wants a point person to talk to and consistent management by the team,” said Dr. Goldstein.
Both Drs. Goldstein and Blagev discussed the importance of patients having a health coach or navigator, who should collaborate with the treating hospitalist.
“The key there is going to be close coordination so that when the patient leaves the hospital, everyone—the patient, the hospitalist, and their primary care physician—are crystal clear on what the medications that are new are, and what the medications that are just for the short term are . . . so that when the patient shows up in the primary care office, ideally within a short period of time from discharge, it can be really clear what they need to be on, what should be continued, and what happened in the hospital,” said Dr. Blagev.
Dr. Nichani said his institution sends all COPD patients to a bridge clinic for subspecialist care and education after discharge.
“Patients who are hospitalized with COPD exacerbation are at high risk for readmission for recurrent exacerbations, as well as a higher mortality in the first year, and so it's important that they have that close check-in after discharge,” he said, adding that the bridge clinic has been especially effective for patients facing socioeconomic obstacles to outpatient care.
The clinic provides patients with systematic evaluation by a pulmonologist and team, including testing and treatment that builds upon the educational and therapeutic interventions begun in the hospital, Dr. Nichani explained. For example, pulmonary function testing may be performed to evaluate and sometimes even confirm the patient's diagnosis and disease severity.
Dr. Blagev urged hospitalists to constantly be thinking about the overall care of the patient. “Often by the time [patients] are feeling better and we're discharging them, we're not that clear on what kind of controller inhalers or what controller therapy they should be on in order to prevent them from relapsing after they finish the acute course,” she said. “As a system, we're trying to figure out how to coordinate care better, to where we're not just paying attention to the 12 hours that we cover the patient and then kind of lose the big picture of what it takes to maintain health for this patient and keep them out of the hospital long-term.”