Chapter 27: Chronic Obstructive Pulmonary Disease

Content Update

July 30, 2019

Using C-Reactive Protein (CRP) Testing to Guide Antibiotic Use for COPD Exacerbations: Almost half of COPD patients experience one or more acute exacerbations of symptoms each year. Acute exacerbations are triggered by a variety of causes, including upper respiratory tract infections in 70% to 80% of cases. Most patients who present with acute worsening of COPD symptoms are treated with antibiotics, but antibiotic overuse contributes to antimicrobial resistance and increases the risk of adverse effects. Researchers in the United Kingdom used C-reactive protein (CRP) testing as a biomarker to assess acute COPD exacerbations and to guide antibiotic prescribing. The results suggest that using the results of point-of-care CRP tests could significantly reduce the number of antibiotics prescribed without adversely impacting COPD symptoms or hospitalization rates.

Patient Care Process for the Management of Chronic Obstructive Pulmonary Disease (COPD)

Collect

• Patient characteristics (e.g., age, gender)

• History of present illness including history of COPD exacerbations in last 12 months and management (e.g., home, PCP visit, ED or hospitalization)

• Patient history (past medical, family, social—environmental exposures, tobacco use, exercise tolerance and capacity)

• Current medications including immunizations (e.g., influenza, pneumococcus) and any prior pulmonary medication use

• Objective data (see Tables 27-5, 27-6, 27-7)

  • Symptom scores using validated questionnaire (e.g., CAT, mMRC)

  • Current and previous spirometry/pulmonary function tests (e.g. FEV1)

Assess

• Severity of symptoms (e.g., "more symptoms" or "less symptoms" based on questionnaires, Table 27-6)

• Risk of future exacerbation (e.g., high risk or low risk)

• Degree of airflow limitation (e.g., GOLD spirometry group, Table 27-5)

• Patient category based on GOLD Combined Assessment (e.g., Category ABCD, Table 27-7)

• Readiness to quit, if current tobacco use (see Tables 27-10, 27-11, 27-12)

• Appropriateness and effectiveness of current pulmonary medication regimen

• Ability to administer/participate with inhaled therapies (e.g., dexterity, vision, coordination)

• Ability to pay for medications (e.g., insurance, formulary considerations, self-pay)

Plan^*

• Patient-specific goals of therapy (see Table 27-9)

• Drug therapy regimen including specific medication, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Tables 27-13, 27-14)

• Oxygen therapy, if severe airflow limitation

• Monitoring parameters including efficacy (e.g., symptoms, exacerbations), safety (medication-specific adverse effects), and timeframe

• Patient education (e.g., purpose of medications, administration technique, recognition of exacerbations)

• Referrals to other providers when appropriate (e.g., physician, pulmonary rehabilitation)

Implement^*

• Provide patient education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up

Follow-up: Monitor and Evaluate

• Determine goal attainment (e.g., symptoms, exacerbations, complications)

• Presence of treatment-related adverse effects

• Patient adherence to treatment plan using multiple sources of information