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Smoking cessation, vaccination, maximizing inhaled therapy critical to reduce COPD readmission

Josalyn Cho

ORLANDO, Fla. – COPD is one of the most common conditions associated with hospital readmission, and many of these may be preventable, according to a presentation here at Hospital Medicine 2018.

Clinicians should be aware that the severity of some patients’ COPD may make readmission necessary, according to Josalyn Cho, MD, assistant professor of medicine of medicine at Massachusetts General Hospital and Harvard Medical School.

“Data show 20% of patients won’t recover full lung function up to 8 weeks after their exacerbation, so it may be that part of readmission may be that the patient’s disease is still not well-controlled and they may still may not have returned to baseline and it is appropriate for them to be back in the hospital,” she said.

This underscores the need to focus on strategies that address preventable readmissions, she said.

Before discharge, all patients with COPD should receive smoking cessation counseling, with even brief interventions having been shown to have significant impact, Cho said. Influenza and community-acquired pneumonia significantly increase the risk of an acute exacerbation of COPD, and these patients are at increased risk for more severe illness, so vaccinations should be strongly recommended for all patients.

Patient education is another critical step to ensure they understand the nature of their disease and the risk factors that can precipitate acute exacerbations, as well as their medication regimen and how to use an inhaler properly, she added.

“Self-management ... has been shown to decrease hospitalizations and emergency department visits,” Cho said.

Referral to pulmonary rehabilitation should be considered, although there are no good data to guide how soon after discharge this should begin, Cho said. Follow-up within 30 days should be arranged and has been shown to be beneficial.

Establishing an appropriate medical regimen after discharge is also important to reduce the risk of exacerbations and readmission.

“One thing that we find in our patients that we could do better is optimizing medications for the treatment of COPD once the patient is an outpatient,” Cho said. “That’s critical because there are a lot of good data that show that optimal medical management of outpatients with COPD reduces exacerbations.”

Among patients with moderate disease — those who have had two or more exacerbations and at least one hospitalization for COPD — who do not have significant symptoms, initial therapy should be a long-acting muscarinic antagonist (LAMA), which have been shown to be superior to the long-acting beta₂-agonists (LABA) in preventing exacerbations, Cho said. For patients who do not respond, combined LABA/LAMA is recommended. Because of the increased risk of pneumonia with inhaled corticosteroids (ICS), a combination of ICS with an LABA would be considered a second-line option.

For patients with more severe symptoms and functional limitations, combined LAMA/LABA is recommended because it offers better outcomes than monotherapy or adding ICS, Cho said. ICS may be considered in patients with concomitant asthma or elevated blood eosinophils.

If exacerbations continue, ICS may be added to LABA and LAMA, she said, and if this is still not sufficient, a pulmonologist should be consulted. Roflumilast may be added in patients with an FEV₁ of 50% or less and chronic bronchitis, but some patients have difficulty with the gastrointestinal side effects. For former smokers, a macrolide may be added to the regimen.

Long-term oxygen therapy should also be considered because it has been shown to increase survival with severe chronic resting arterial hypoxemia, Cho said. Noninvasive ventilation can also be considered because there is some evidence that it may reduce readmission, particularly among patients with daytime hypercapnia.

Data do not support strategies such as telehealth, hospital-at-home and integrated care at this time, Cho said.

Reference:

Cho J. Just Keep Breathing: COPD Guidelines and Update. Presented at: The Meeting of Doctors; Dec. 6-9, 2015; Atlanta.

Disclosure: Cho reports no relevant financial disclosures.