Preventing Hospital Readmission for COPD Exacerbation

An exacerbation of COPD means a worsening of symptoms including more shortness of breath, increased coughing, and possible coughing up more mucus, especially if the color is yellow or green. If the exacerbation is severe, it may require hospitalization for treatment.  Starting in October 2014, hospitals in the United States have been judged on their ability to reduce 30-day, all-cause unplanned readmissions for COPD after an initial hospitalization for a COPD exacerbation. The U.S. Centers for Medicare and Medicaid Services (CMS) will penalize hospitals for what they consider excessive admissions. In a 2015 editorial in the Journal of COPD Foundation (volume 2; pages 4 – 7), Dr Sidney Braman of the Icahn School of Medicine at Mount Sinai in New York City commented on strategies for preventing hospital readmissions for those with COPD.
Dr. Sidney Braman, Professor of Medicine

Dr. Sidney Braman, Professor of Medicine

  This information directly applies to someone who has COPD because everyone wants to stay out of the hospital unless it is necessary. Dr. Braman outlined four elements of medical care:
  1. COPD guideline-directed treatment protocols for Emergency Department visits and hospitalized patients
  2. patient/caregiver education on smoking cessation, inhaler use and an Action Plan for an exacerbation
  3. patient assessment of oxygen needs, medical conditions other than COPD, goals of care, and breathing tests
  4. a follow-up plan that includes a phone call at 48-72 hours after discharge, a visit within 7-10 days with a health care provider, participation in pulmonary rehabilitation when available, and appropriate use of community home care services.
An Action Plan is important so that you know what to do if you experience more  breathing difficulty. Here are four steps of an Action Plan that you can consider and discuss with your doctor. Step 1. If your have more shortness of breath: >use pulse-lips breathing >try to relax >use your rescue inhaler. For most, this will be albuterol aerosol from an inhaler. Alternatively, albuterol can be inhaled as a solution from a nebulizer. Other rescue medications are ipratropium (Atrovent) and albuterol and ipratropium combination (Combivent) inhaled as a mist or a solution from a nebulizer. Step 2. If you cough up yellow or green mucus, then most likely you have a bacterial chest infection. You should contact your doctor to ask about an antibiotic. White-gray mucus suggests either inflammation or a viral infection. Remember, we do not have effective antibiotics for most viruses that cause a chest infection (bronchitis or pneumonia). Step 3. If your breathing is much worse and the rescue medication is not helping enough, you should contact your doctor to ask about prednisone. This medication fights inflammation which develops in your breathing tubes when a chest infection occurs. Step 4. If your breathing difficulty becomes quite severe, you need to go to the nearest Emergency Department. Either have someone drive you there or call 911 for an ambulance.

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.