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Building toolkits for COPD exacerbations: Lessons from the past and present

Building toolkits for COPD exacerbations: Lessons from the past and present
Building toolkits for COPD exacerbations: Lessons from the past and present

In the nineteenth century, it was recognised that acute attacks of chronic bronchitis were harmful. 140 years later, it is clearer than ever that exacerbations of chronic obstructive pulmonary disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over 25 years ago. An ECOPD is 'an acute worsening of respiratory symptoms that results in additional therapy'. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care (POC). Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over 30 years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.

copd exacerbations, emphysema, innate immunity
0040-6376
Sapey, Elizabeth
7e4891fd-1941-4b33-9cc6-e2c2acaa20c9
Bafadhel, Mona
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Bolton, Charlotte Emma
df4a70b2-faf9-4306-8089-cf36adc303d1
Wilkinson, Thomas
8c55ebbb-e547-445c-95a1-c8bed02dd652
Hurst, John R.
37c4256e-b20f-4df0-ada0-cf3cbd59ecdf
Quint, Jennifer K.
22800655-8987-4464-8385-7f08860c92f9
Sapey, Elizabeth
7e4891fd-1941-4b33-9cc6-e2c2acaa20c9
Bafadhel, Mona
2b47e6b0-24d0-4cd1-9b2c-51b4894564f2
Bolton, Charlotte Emma
df4a70b2-faf9-4306-8089-cf36adc303d1
Wilkinson, Thomas
8c55ebbb-e547-445c-95a1-c8bed02dd652
Hurst, John R.
37c4256e-b20f-4df0-ada0-cf3cbd59ecdf
Quint, Jennifer K.
22800655-8987-4464-8385-7f08860c92f9

Sapey, Elizabeth, Bafadhel, Mona, Bolton, Charlotte Emma, Wilkinson, Thomas, Hurst, John R. and Quint, Jennifer K. (2019) Building toolkits for COPD exacerbations: Lessons from the past and present. Thorax. (doi:10.1136/thoraxjnl-2018-213035).

Record type: Review

Abstract

In the nineteenth century, it was recognised that acute attacks of chronic bronchitis were harmful. 140 years later, it is clearer than ever that exacerbations of chronic obstructive pulmonary disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over 25 years ago. An ECOPD is 'an acute worsening of respiratory symptoms that results in additional therapy'. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care (POC). Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over 30 years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.

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More information

Accepted/In Press date: 5 May 2019
e-pub ahead of print date: 3 July 2019
Keywords: copd exacerbations, emphysema, innate immunity

Identifiers

Local EPrints ID: 432857
URI: http://eprints.soton.ac.uk/id/eprint/432857
ISSN: 0040-6376
PURE UUID: 876da71a-b384-4469-b7e4-d034cf11eb6e

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Date deposited: 31 Jul 2019 16:30
Last modified: 25 Nov 2021 19:50

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Contributors

Author: Elizabeth Sapey
Author: Mona Bafadhel
Author: Charlotte Emma Bolton
Author: John R. Hurst
Author: Jennifer K. Quint

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