Managing Acute Exacerbations of COPD: A Scorecard

As readers of the Journal know all too well, the long-term course of COPD is punctuated, characterized really, by acute exacerbations (AECOPD) that occur about once a year on average, mainly in the more severe stages, GOLD stages III and IV. These events cause a great deal of morbidity that may persist for weeks or months (1). They also cause not inconsiderable mortality, and probably a stepwise decline in lung function and health status with each event. They are also expensive, such that managed care and health insurance companies are as eager as the medical profession to reduce their number and severity. Over the last decade, studies have shown that most of our maintenance COPD therapies can achieve reductions in the frequency of AECOPDs, each by very roughly 15–30%. These facts need to be more widely known and exploited. Just as important as preventing the acute exacerbation is managing it when it occurs. The former mayor of New York City, Ed Koch, used to go regularly into the Manhattan streets and randomly ask the citizenry “How’m I doin’?” Whether to follow his excellent example or not, New York City’s pulmonologists have adopted his practice (if not his methodology) by asking themselves the same question. In the excellent and fascinating report by Yip and colleagues in this issue of the Journal (2) we get some of the answers. The study was large, covering more than 1,600 exacerbations in 5 New York City hospitals that serve essentially all segments of the urban population and continued through 2 full seasonal cycles so that, apart from the demographic only being representative of a big metropolis, the management practices they identified are probably fairly representative of the U.S. nation if not other developed countries. There is a lot to learn so, dispensing with finger-pointing, let me draw up a scorecard of those aspects of AECOPD management that, in my opinion, and in this demographic, were being