Description

Chronic obstructive pulmonary disease is very common disease. Twenty five percent of all medical admissions are due to respiratory problems and over half of these are due to COPD.

An acute exacerbation of COPD includes symptoms of increased dyspnoea, sputum purulence, wheeze, chest tightness and fluid retention. Treatment includes bronchodilators, antibiotics, corticosteroids and admission to hospital.

There have been 4 studies aimed at treating patients with exacerbations of COPD at home rather than in hospital. In each case patients were either referred by general practitioners or accident and emergency staff or identified after admission on the medical ward by a respiratory nurse. These patients were fully assessed to determine severity of exacerbation and criteria for admission or continued hospital care included impaired level of consciousness, acute changes on radiograph, presence of acidosis, social problems or concomitant medical conditions. Suitable patients were discharged home with arrangements for regular visits by a respiratory nurse and a treatment package including nebulised bronchodilators, antibiotics and corticosteroids. In the study at Glasgow Royal Infirmary⁹ 80% of patients referred by general practitioners were treated
at home, of which 12% later required admission. In the randomised controlled study performed in Edinburgh¹⁰, 184 patients were randomised 2:1 to home support or standard hospital admission. Seven percent of those treated at home required admission later but there was no significant difference in the readmission rate in the 8 week follow-up period. The second study from Glasgow¹¹ randomised 81 patients to early discharge or continued hospital care. The length of stay was reduced from 6.1 days to 3.2 days. In Liverpool¹², patients were randomised in accident and emergency to homecare or hospital care and there was no significant difference in the readmission rates or mortality.

Patients referred to hospital with mild to moderate exacerbations of COPD can be managed safely and effectively at home with the support of a respiratory nurse and a treatment package, if other significant medical problems are excluded and home circumstances are appropriate. In a district general hospital it is likely that 60-80 patients per year would be suitable for home-care. If length of stay were reduced from 6 to 3 days in these patients 180 bed days could be saved, which would have significant impact on boarding of medical patients and cancelled elective admissions.