How to Recognize Signs of COPD Exacerbations for Early Intervention

Dr. Turck:   

Welcome to Clinician’s Roundtable on ReachMD. I'm Dr. Charles Turck, and joining me to discuss how we can recognize exacerbations in patients with chronic obstructive pulmonary disease, or COPD for short, is Ms. Jonnie Korinko, who's a registered respiratory therapist and the Manager of Public and Professional Education at the COPD Foundation. Jonnie, thanks for being here today.  

Jonnie:  

Thank you so much for having me.  

Dr. Turck:  

So if we start with some background, Jonnie, would you tell us about the frequency of exacerbations among patients with COPD?  

Jonnie:  

Absolutely. So with COPD, it can actually range just depending on how severe that person's lung disease has progressed. So it's estimated that about up to 50 percent of people who are living with COPD are going to have an exacerbation each year. That chance increases as a person’s FEV1 continues to progress. So there we have this subgroup of our COPD patients that have an average of 2 and a half, even 3 exacerbations each year, and each time they have an exacerbation, they're likely to get worse, number one, and number two, they're likely to have more exacerbations in the future. And so the more exacerbation someone has, the worse their quality of life is. Their lung function continues to decline even after that. And the other thing we have to think about is it's not just COPD that can impact someone's flare-ups or exacerbations. Comorbidities—not all of them, but many of them—can impact exacerbations as well. For example, if someone has asthma and COPD, they're much more likely to have really severe respiratory complications and respiratory symptoms. And then you have people with cardiovascular disease who are more likely to have a harder time with oxygenation. They might have more shortness of breath, and they're going to have a worse quality of life, absolutely, as well.  

Dr. Turck:  

So with all that in mind, how are we doing in terms of recognizing COPD flare-ups in our patients?  

Jonnie:   

Well, we kind of have to look at it twofold. We as healthcare providers have to be able to recognize it, and we're working on trying to have a set of criteria, right? So there is some debate amongst some medical professionals on what exactly the definition of a flare-up is. But we try to have a set criteria that we can give our patients to say, “Hey, if you see this, you need to seek attention. You need to make an appointment or come to the emergency department,” whatever the case may be. But really, we also have a big burden on educating our patients so that they know what is their normal. You know? So if they know what they can normally do or what their baseline is, then when they're feeling worse than their baseline and when they're having those increasing symptoms, they need to be able to identify that they're having an exacerbation. There's a lot of patient education going toward that right now, but we know that self-reported exacerbations are, unfortunately, underreported.  

Dr. Turck:   

You know, you began to talk a little bit earlier about how a COPD exacerbation increases the likelihood of additional future exacerbations. Are there any other reasons it's important that we recognize and treat these exacerbations as early as possible?  

Jonnie:   

Absolutely. So patients who don't report their COPD exacerbations right away tend to have a poor quality of life. So not only are they going to take longer to be able to recover from that exacerbation, but in the long run, it's going to lead to poor lung function and therefore more exacerbations in the future. And this is going to increase the total cost of their medical care and increase the cost of medications typically for that patient. Also, things that we don't think of a lot are the indirect costs of COPD exacerbation. So any days missed from work, either from themselves or from any family members who have to take off work to help take care of them. So the earlier that we're able to identify, recognize, and treat these exacerbations, the more quickly our patients can recover, the lower cost burden to our patients, and the better quality of life that they can have.  

Dr. Turck:   

For those just tuning in, you're listening to Clinician’s Roundtable on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Ms. Jonnie Korinko, who's a registered respiratory therapist, about COPD exacerbations.  

So given the importance of early recognition and intervention, Jonnie, let's turn our attention to how we might optimize our approach. First, what are some common triggers that we should be aware of?  

Jonnie:   

COPD exacerbations are usually triggered by either a viral or some sort of bacterial infection. So it's really common to see acute exacerbation of COPD when we see increases in other viral infections, like the flu or RSV. But there are some people who are really sensitive to other biological factors and environmental factors as well. For example, exposure to different particulate matter. So when the weather is really bad, it can increase particulates in the environment that could really be irritating to some people. Also, what some people don't think of is common household irritants that can really irritate some people that can send them into an exacerbation. I've had patients that went and did a really deep spring cleaning and breathing in those cleaning products that are meant to break down biological material were really irritating to them. So overexerting yourself and different environmental factors can also increase the likelihood of an exacerbation.  

Dr. Turck:  

And would you review for us how COPD exacerbations typically present?  

Jonnie:  

Yeah. So we have a few what we call cardinal symptoms. So that would be someone having increased dyspnea or shortness of breath, increased sputum purulence, and increased volume of their sputum. So they're going to be short of breath and have a lot of really thick white sputum. And they might have one to all three of those cardinal symptoms. But if they only have one or two, it'll typically be in combination with either an upper respiratory infection, a fever where there's not another cause of that fever, an increase in either cough or wheezing, and they might even have an increase in their heart rate or their respiratory rate just because they are struggling to combat this COPD exacerbation.   

Other things we might see would be a worsened exercise tolerance. So someone who normally is able to walk down to the mailbox to get their own mail might have difficulty doing that when that's normal for them. They might have more fluid retention, and they might be more fatigued than usual. And if we see a patient who is more lethargic or is more confused than normal, then that's a pretty severe sign. We would want to make sure that they got medical treatment right away.  

Dr. Turck:  

And lastly, Jonnie, would you tell us what proactive prevention and monitoring looks like and how it can impact a patient's long-term health?  

Jonnie:  

Absolutely. So the first thing is if you know of something that is a trigger for your patients or for your family member, try to be proactive about preventing any exacerbation. So smoking cessation—if you have someone who we know is a current smoker or who is still kind of struggling with trying to quit, giving them that support with smoking cessation therapy. And this can include pharmacologic treatment as well. Some people do need that if they have that nicotine addiction. Also, vaccinations based on local guidelines. So our annual flu vaccination, COVID-19—this is considered a high-risk population—pneumococcal vaccination, pertussis, shingles, and RSV. All of those are really important to making sure that our patients don't have an increase in COPD symptoms.   

Also, something that people don't think of as much would be keeping your patients physically active. So if we're preventing deconditioning, then we're helping our patients with their quality of life and their ability to maintain that normal respiratory work. And then also pulmonary rehabilitation. So if we have a patient who is either symptomatic—so they're experiencing symptoms and might not be having a lot of exacerbations yet, but they're experiencing pretty symptomatic work of breathing or breathlessness—or we have someone who we've identified to be what we call a frequent exacerbator—so they’re someone who comes into the hospital, or they're having two to three exacerbations every year—those are patients that we want to pretty early on get into a pulmonary rehab program. Pulmonary rehab is absolutely excellent at helping teach our patients to self-monitor. So they are able to then identify what their normal is and then identify when, “OK, I'm not feeling like this is my normal. I need to call my doctor, or I need to start taking this rescue path of corticosteroids that they prescribed to me,” or whatever the case may be. But it's really important that they’re not only following the advice of their physician, but they're also being proactive about trying to prevent any acute infections and prevent any deconditioning.  

Dr. Turck:  

Well, given the potential impact on our patient’s lives, I want to thank my guest, Ms. Jonnie Korinko, for joining me to discuss these essential strategies for recognizing COPD exacerbations. Jonnie, it was great having you on the program today.  

Jonnie:  

Thank you so much. I have loved being here.