COPD Flare-ups: Not Everyone Recovers

Consequences Of COPD Flare-ups: Some Improve, Others Do Not   

Background: COPD flare-ups are worsening of symptoms and are usually due to a chest infection (bronchitis or pneumonia) or inhaling something bad (like an irritant) in the air. The medical word for a COPD flare-up is an exacerbation. Previous studies have shown that recovery for COPD flare-ups is quite variable. Some individuals are back to normal in a few weeks, while others seem to never get back to their baseline. Study: Drs. Murray and Leidy who work at Evidera (a company that provides consulting and research services) analyzed the results of two 12-week studies evaluating a new medication (called a neutrophil elastase inhibitor) for those with COPD. All subjects completed a daily electronic dairy each evening for 2 weeks before being started on a medication or placebo and then for 12 more weeks. The 14 items in the dairy is called EXACT. Changes in the daily EXACT score were used to measure Recovery or Worsening compared with values before starting the medication. In some subjects, there was not enough time to assess recovery or worsening because the flare-up occurred close to the end of the study. These were called “Censored” by the authors and were not analyzed. The study was published in the February 2018 issue of the Journal of the COPD Foundation (volume 5, pages 27-37). doi: Results: Of the 1,346 subjects, 31% had a flare-up during the 12 week period. 260 subjects recovered, while 80 experienced persistent worsening.
Recovery and persistent worsening in the those with COPD flare-ups

EXACT scores in those with a COPD flare-up at 0 days. This is noted by the two peaks. Those who recovered are noted by the solid line. Those who had persistent worsening are shown by the dashed line above the solid line.

Both groups were similar at the start of the study. The persistent worsening group had more breathlessness and chest symptoms compared with the recovery group. Conclusions: The authors concluded that some patients have difficulty recovering from COPD flare-ups leading to worse health status and shortness of breath without any change in breathing tests (lung function). My Comments: In my practice it is common to see individuals for are frustrated with shortness of breath and/or cough that persist after a chest infection or flare-up. It is important to figure out why this happens. 1. In some, there may be persistent inflammation in the lungs, and then a course of prednisone should be prescribed. 2. In others, there may be weakness and deconditioning (“out of shape”) because of prolonged inactivity during the illness. For this problem, starting or re-starting an exercise program is crucial. The best approach is with a pulmonary rehabilitation program. 3. Another possible reason is psychological as anxiety or depression can make everything seem much worse. For this problem, referral to a psychologist or counselor should be considered along with possible medications for either anxiety or depression. 4. It is also important to make sure that the cause for breathing difficulty is not due to another medical problem such as a heart condition. Appropriate testing is the first step to evaluate for this possibility.

Donald A. Mahler, M.D. is Emeritus Professor of Medicine at Geisel School of Medicine at Dartmouth in Hanover, New Hampshire. He works as a pulmonary physician at Valley Regional Hospital in Claremont, NH, where he is Director of Respiratory Services.