Community care assessment of exacerbations of chronic obstructive pulmonary disease

Abstract

The aim of this study was to develop a clinical algorithm to assess chronic obstructive pulmonary disease exacerbation severity in a community setting. An important aspect of community management of exacerbations is assessing patient safety. Although researchers have investigated risk factors for rapid deterioration, there is a lack of evidence validating clinical measures of exacerbation severity. This was a prospective, community-based cohort study of patients enrolled in the Melbourne Longitudinal Chronic Obstructive Pulmonary Disease Cohort. The outreach team collected data on symptom severity at baseline and exacerbation onset using the Medical Research Council Dyspnoea Scale, St George Quality-of-Life Questionnaire and Symptom Severity Index. Ninety-two patients were monitored from 2003 to 2005. There were 148 exacerbations: 121 (82%) were treated at home and 27 (17·5%) required hospitalization. An ordinal logistic regression model demonstrated that a combination of chronic obstructive pulmonary disease severity with dyspnoea and wheeze severity at exacerbation onset could differentiate severe from milder episodes [(OR 7·69, 95%CI: 3·9-11·5, P < 0·01), area under the receiver operating characteristics curve 0·75 (95%CI: 0·65-0·86)]. The majority of chronic obstructive pulmonary disease exacerbations can be safely managed in a community setting, but clinical assessment alone may not be sufficient to identify all patients who will develop complications such as respiratory failure. Further research is needed to validate clinical assessment and decision-making algorithms for community-management of chronic obstructive pulmonary disease exacerbations.