Key Point:

Among patients who visit the ED for a COPD exacerbation, one in five will have a relapse event within two weeks of ED discharge.

BOSTON—In the United States, more than one million patients visit the emergency department (ED) each year because of acute exacerbations of chronic obstructive pulmonary disease (COPD). Many of these patients are treated in the ED and sent home. Researchers studied the relapse rate of COPD patients presenting to the ED and found that one in five had a relapse of symptoms within two weeks of their visit.[1]

This finding comes from a prospective cohort study conducted by the Emergency Medicine Network—a large collaboration of EDs with an interest in respiratory emergencies and public health. The total population included 140 patients with a diagnosis of COPD, emphysema, or chronic bronchitis who were discharged directly home from the ED. The patients were contacted two weeks later to determine whether they had had any urgent care visits for COPD or changes in medication use.

RELAPSE RATE HIGHER THAN EXPECTED

At follow-up, 21% of the study group (30 of 140 patients) reported a relapse of COPD symptoms. Relapses occurred throughout the follow-up period; the likelihood of experiencing such an event could not be predicted from baseline demographic characteristics.

Physical findings and patient history were a bit more helpful. Patients who suffered relapses had had higher respiratory rates at ED admission than did the other patients; however, there were no differences between the two groups in oxygen saturation or peak expiratory flow (when measured). The likelihood of relapse was also associated with the number of urgent care or ED visits for COPD within the past year. Interestingly, all patients rated their subjective symptoms as moderate to severe, but the frequency and severity of symptoms were unrelated to relapse. Self-perceived activity limitation, however, was strongly associated with relapse risk.

The authors noted that in the late 1980s, the relapse rate for COPD was 28%—and it has not improved much since then. One reason for this lack of improvement, said study author Carlos Camargo, MD, DrPH, an Associate Professor of Medicine and Epidemiology at Harvard University, is the underutilization of available medications that can improve COPD symptoms, albeit modestly. “More importantly,” he stressed, “is the lack of a medication that dramatically improves this chronic disease. Although inhaled corticosteroids have some beneficial effect on COPD, this disease does not yet have a breakthrough treatment equivalent to what inhaled corticosteroids did for asthma.

“Most patients need additional education about their disease,” Dr. Camargo observed. “If they can get that as outpatients, great. If the education is more effectively delivered during a brief inpatient visit, that too, is fine.”

While the results of the present study may not be applicable to the entire COPD population, the authors pointed out that they will be useful for the many patients who visit the ED for their COPD care.

—Gale Jurasek

Reference
1. Kim S, Emerman CL, Cydulka RK, et al, for the MARC Investigators. Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation. Chest. 2004;125:473-481.

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