7- Point Discharge Protocol for AECOPD: Time to Inculcate in Practice

A recent consensus & expert recommendations published in the Primary Care Respiratory Medicine journal has revealed insightful facts.

In-hospital mortality for ECOPD varies between 2.5% and 25%, while 25-55% of survivors face readmission.

A 7-point evidence-based discharge protocol can significantly lower mortality and reduce rehospitalization rates for acute exacerbations of COPD(ECOPD) if effectively implemented.

This discharge protocol has been created by an Expert Working Group of nine Indian pulmonologists who reviewed 457 studies on AECOPD, debated key findings, and developed a 7-point discharge protocol to help physicians reduce mortality and readmissions in COPD patients.

Let’s have a look at the 7-point care strategies that a doctor should know:

1) Enhance Awareness and Seriousness of ECOPD

The 2-year mortality of ECOPD is higher than acute myocardial infarction (AMI), yet ECOPD is not taken seriously. Just like we recognize the urgency of a heart attack, the experts suggest calling COPD exacerbations "Lung Attacks" to emphasize the severity of these episodes and encourage early medical intervention.

2) Identifying patients at risk for future exacerbations

A history of previous exacerbation has been shown to be the strongest predictor of future exacerbations. Doctors could focus on predicting future flare-ups using other predictors such as presence of comorbid conditions, worsening of ambient air quality and use of inappropriate pharmacotherapy and poor compliance and adherence to inhaled medications.

3) Optimizing pharmacologic treatment of COPD

The protocol suggests the use of long-acting bronchodilators and triple therapy for severe cases. However, choosing the right inhaler or opting for home nebulization is equally important for effective drug delivery. Nebulized treatment provides an alternative for COPD patients, eliminating the need for inspiratory flow, dexterity, or hand-breath coordination. Evidence suggests its efficacy is comparable to pMDIs and DPIs when used correctly.

When to Consider Home Nebulization?

• Elderly patients or those with arthritis, cognitive impairment, or poor inhaler coordination.
• Patients who are inadequately controlled on DPIs or MDIs need high doses of drugs.
• Acute exacerbations of asthma or COPD requiring hospitalization

4) Identifying and treating comorbidities

As per a national registry study of over 82,000 COPD patients, 82% got readmitted over 5 years after an index hospitalization for ECOPD, and among these 59% were for non-respiratory cause. The new protocol recommends routine screening and treatment for heart disease, diabetes, kidney disease, and mental health- ensuring a holistic approach to patient care.

5) Preventing bacterial and viral infections

Infections are a leading cause of COPD flare-ups. This protocol emphasizes vaccinations against influenza, pneumonia, and COVID-19, as well as using long-term antibiotics like macrolides for those at higher risk when indicated

6) Pulmonary rehabilitation

Early rehabilitation is critical. Patients could be encouraged to start exercise programs—even simple home-based routines like yoga—to improve their lung function and prevent future hospital visits.

7) Palliative care

Palliative care is an important component in the treatment of patients with severe COPD and has been shown to not only reduce the odds of 30-day readmission by up to 50%, but also reduce the odds of heart failure by 73%. Open and effective palliative care conversations between patients and healthcare professionals must be encouraged.

These 7-point care protocols, if implemented successfully will have a significant impact on reducing mortality and future risk of rehospitalization in ECOPD cases.

CAT: COPD Assessment Test (CAT) score, LIVE: Laboratory-based Intermountain Validated Exacerbation, pMDIs: Pressurized Metered-Dose Inhalers, DPI: Dry Powder Inhalers

Reference:

• Salvi S, Ghorpade D, Nair S, Pinto L, Singh AK, Venugopal K, Dhar R, Talwar D, Koul P, Prabhudesai P. A 7-point evidence-based care discharge protocol for patients hospitalized for exacerbation of COPD: consensus strategy and expert recommendation. NPJ Prim Care Respir Med. 2024 Dec 20;34(1):44. doi: 10.1038/s41533-024-00378-7. PMID: 39706845; PMCID: PMC11662074.