COPD flare-ups: how to end the ‘gross overuse’ of antibiotics

Earlier and better patient education is needed to promote self-management

As they struggle to breathe, patients battling a flare-up of chronic obstructive pulmonary disease (COPD) would once have been routinely advised to reach for the antibiotics.

But now the National Institute for Health and Care Excellence (NICE) is urging healthcare professionals to consider the risks of antimicrobial resistance, and take other factors into account before deciding whether antibiotics are the best course of action. ‘Evidence shows there are limited benefits of using antibiotics for managing acute exacerbations of COPD,’ says Paul Chrisp, director of the centre for guidelines at NICE.

Consultant respiratory nurse, Jane Scullion, of University Hospitals of Leicester NHS Trust says: ‘There’s a place for antibiotics, but we have grossly over-used them.’

She welcomes the NICE recommendations, detailed in its updated clinical guidelines on diagnosing and managing COPD, and on antimicrobial prescribing for people with acute COPD exacerbations, which were published in December.

Inappropriate use of rescue packs

‘Increasingly, people are starting to realise that antibiotics have become the default position because they’re at hand,’ says Ms Scullion.

Many patients diagnosed with COPD are given a ‘rescue pack’, which contains small quantities of antibiotic and steroid tablets that they can administer themselves, if they’re experiencing a flare-up of symptoms. ‘The idea is that patients can quickly treat infections at home, avoiding becoming ill over the weekend or during holidays,’ she explains. 

COPD – what it is and how it affects patients

Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties. It includes emphysema and chronic bronchitis.

It mainly affects middle-aged and older people. According to NICE, around three million people in the UK are affected, two million of whom are undiagnosed. It causes 115,000 admissions to hospital every year.

Symptoms include increased breathlessness, especially when people are active, a persistent cough with phlegm, frequent chest infections and wheezing. Breathing problems tend to get gradually worse over time, limiting everyday activities, although treatment can help to keep the condition under control. Patients may experience exacerbations, when symptoms become more severe.

Smoking is the main cause, thought to be responsible for around nine in every ten cases, although some are caused by long-term exposure to fumes or dust, or the result of a rare genetic problem.

Alongside ensuring prompt treatment, the packs can help reduce the strain on over-stretched general practices and emergency departments. ‘But when we’ve looked at what’s happening in practice, some patients are using them once or even twice a month. We’ve been horrified to find as many as 24 uses a year,’ says Ms Scullion.

‘We’ve muddied the waters about what a true exacerbation is and we don’t have a good up-to-date definition’

Jane Scullion, consultant respiratory nurse

Some patients find it difficult to distinguish between an exacerbation and what she describes as an ‘off-day’. ‘People can panic when their symptoms worsen,’ says Ms Scullion. ‘They get breathless, cough more and produce more sputum. But it may be simply because they were more active than usual the day before.’

Spectrum of exacerbation

Exacerbations vary from severe, where the individual is in danger of death and needs urgent hospital treatment, to mild, where they may just need rest. But many patients are confused by the terminology. ‘We’ve muddied the waters by not being clear about what a true exacerbation is,’ says Ms Scullion. ‘And we don’t have a good up-to-date definition.’

For consultant respiratory nurse Joanne King, who leads on COPD for the Association of Respiratory Nurse Specialists (ARNS), educating patients is key. ‘There is definitely a place for standby antibiotics, with research supporting this approach,’ says Ms King, who works at Frimley Health NHS Foundation Trust. ‘But where we may have gone wrong is they’ve been handed out, without the education to back it up. If patients understand their disease and how to treat it, what to expect and how it might or might not progress – all those things around education – then they will do better, taking ownership of their condition.’

Being able to self-manage is also crucial, she argues, not least because COPD is so specific to the individual and can vary day-to-day. ‘We can’t be with patients all the time, so self-management is a massive issue,’ says Ms King. ‘But I’m not sure we spend enough time making sure patients have a good plan that’s individual to them, and not just printed off the internet.

'If we’re going to make the patient the expert, we need to invest time at the beginning'

Joanne King, consultant respiratory nurse

‘What’s becoming increasingly clear is that we need to move away from one-size-fits-all. On the whole, the issues I see around COPD progression go back to the patient’s own understanding and whether someone has sat down and explained what COPD is, and how it might react,’ Ms King says.

This customised approach would also lead to much more targeted antibiotic use, she believes, with patients more likely to feel confident about waiting for a day or two, than immediately starting medication because they fear they have an infection that will quickly get worse.

Specialist nurse support at the point of diagnosis

She believes around 80% of patients are currently cared for in primary care, with many never seeing a specialist nurse. ‘We only ever see those who are in difficulties or whose symptoms are severe,’ says Ms King.

Looking ahead, she would like to change the way newly diagnosed patients are managed. ‘I’d like to see us look at doing things differently, taking some lessons from those who care for patients with other long-term conditions, such as diabetes,’ she says.

‘At diagnosis is the time we need to start education. What information are patients given then? And is it enough? If we’re going to make the patient the expert, we need to invest time at the beginning.’

For those patients who are having repeated and regular exacerbations, she recommends having sputum samples analysed. ‘I don’t think we send them regularly enough,’ says Ms King. Clear and unambiguous guidance is vital, using language that patients understand, she argues.

‘We need much clearer guidelines and a rounded education,’ says Ms King. ‘If patients do take antibiotics, they should be reviewed on the penultimate day. I see patients who say they felt better on days six and seven, but then worse again on day eight – it’s clear they never got over the initial infection.’

Another difficulty is poor practice in relation to how both patients and healthcare staff use inhalers. ‘I would say that around 90% of patients don’t know how to use an inhaler properly and healthcare professionals are just as bad,’ says Ms King. ‘If we don’t know how to use them ourselves, how on earth can we help patients? It’s a huge problem.’

• RELATED: Correct use of inhalers is our responsibility

She believes it is a skill that needs to be checked constantly. ‘Unfortunately, it’s not something you teach once and it becomes lifelong, like riding a bike,’ says Ms King. ‘People get into bad habits easily, forgetting how to do it properly. I can’t tell you how many times I’ve heard patients say, ‘no one’s ever told me that before’, with some saying they’ve never been taught any techniques and just read the instructions.’

Click here for RCNi Learning modules on COPD

Find out more

• NICE guidance on the diagnosis and management of COPD 
• NICE guidance on antimicrobial prescribing for acute exacerbations in COPD
• Association of Respiratory Nurse Specialists

Lynne Pearce is a health journalist