HOW EFFECTIVE IS THE MANAGEMENT OF COPD

BACKGROUND : Although the GOLD guidelines have raised the level of awareness of COPD in physicians, there are still several lacunae in the implementation of these evidence based guidelines into actual clinical practice

AIM : The Rationale was to review the management of COPD patients at our tertiary care urban teaching hospital several years after introduction of GOLD guidelines.

METHODS : Retrospective analysis of medical records of our patients admitted over one year period with the diagnosis of COPD from June 2005 to July 2006

RESULTS : There were 150 subjects with a discharge diagnosis of COPD mean age 64.5 yrs; there were 114(76%) males and 36(24%) females . Diagnosis of COPD was missed on admission in emergency department in 20 patients (13%). 125 patients (85% ) were treated with steroids, nebulized therapy, antibiotics & oxygen supplementation, although only 60% fulfilled the GOLD criteria for acute exacerbation. Thus 25% of patients (n=62) were wrongly labelled as acute exacerbation of COPD. 200 patients (86%) had normal chest x-rays. 114 patients (76%) were current or ex-smokers. Smoking history was not obtained in 10% (n=25)of cases. Arterial blood gases were done in 110 patients (73%) follow-up ABGs were done in only 30% of cases (n=45 ). 37 patients (25% ) required ICU care & 15 (10%) required non invasive ventilation. Average LOS in ICU was 3.2 days and in the hospital was 8.4 days. Upon discharge, smoking cessation counselling was offered in only15 cases(10%) & only 1% were referred for chest physio & pulmonary rehabilitation programme. Inhaled long acting Beta-2 agonists &/or inhaled long acting anti cholinergic agent (tiotropium) was prescribed in only 90 patients (60%); advice on annual influenza vaccination was offered in only 67 patients (45%).

CONCLUSIONS : Despite the availability of GOLD guidelines for several years
(a) physicians at our center have problems in accurately diagnosing COPD exacerbation (b) Over diagnosis is not uncommon (c) smoking history was not elicited in all patients (d) serial monitoring by ABGs was not uniformly done (e) Patient education & counseling by discharge physicians was inappropriate & lacked commitment