COPD as a Life-Limiting Illness: Implications for Advanced Practice Nurses

Donna M. Goodridge, RN, PhD

Topics in Advanced Practice Nursing eJournal. 2006;6(4)

Acute Exacerbations of COPD

While people with COPD tend to live in an unremitting state of compromised health, periodic exacerbations become increasingly frequent as the disease progresses. Acute exacerbations of COPD (AECOPD) are the most common cause of physician visits, hospital admissions, and death among patients with COPD, and they lead to decreased quality of life and accelerated decline in lung function.^[12] Increased sputum volume, increased sputum purulence, and increased dyspnea define this syndrome.^[23]

AECOPD often necessitates emergency room visits, with exacerbations occurring as often as 4 times a year.^[24] In fact, respiratory admissions accounted for 25% of all acute medical emergency admissions in 1 study from the United Kingdom, with AECOPD accounting for half of these admissions.^[25]

Although COPD is characterized by a protracted course, death typically results from sudden complications such as infection, cardiovascular events such as dysrhythmias, or acute respiratory failure.^{[26,27,28,29]} Mortality data are known to underestimate COPD as a cause of death because it is more likely to be cited as a contributory rather than an underlying cause of death.^[17] Table 3 describes a profile of COPD patients at risk for death from acute respiratory failure.^[12]

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Abstract
The Burden of COPD
Assessment of COPD Severity
Acute Exacerbations of COPD
Living With Advanced COPD
Advance Care Planning
Healthcare Resources and Service Utilization
Promoting Excellent Care for People With Severe COPD
References

Table 1. GOLD Spirometric Classification of COPD Severity
Stage	Severity	Spirometry
Stage I	Mild	FEV₁/FVC < 0.70
Stage I	Mild	FEV₁ ≥ 80% predicted
Stage II	Moderate	FEV₁/FVC < 0.70
Stage II	Moderate	50% ≤ FEV1 < 80% predicted
Stage III	Severe	FEV₁/FVC < 0.70
Stage III	Severe	30% ≤ FEV₁ < 50% predicted
Stage IV	Very severe	FEV₁/FVC < 0.70
Stage IV	Very severe	FEV₁ < 30% predicted or FEV₁ < 50% predicted plus chronic respiratory failure

COPD = chronic obstructive pulmonary disease; FEV₁ = forced expiratory volume in 1 second; FVC = forced vital capacity
Used with permission from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease, 2006. Available at www.goldcopd.org.

Table 2. The BODE Index
Variable	Points	On	BODE	Index
	0	1	2	3
FEV₁ (% of predicted)	≥ 65	50-64	36-49	≤ 35
Distance walked in 6 minutes (m)	≥ 350	250-349	150-249	≤ 149
MMRC dyspnea scale	0-1	2	3	4
Body mass index	> 21	< 21

FEV₁ = forced expiratory volume in 1 second; MMRC = Modified Medical Research Council.
Celli BR, Cote CG, Marin JM et al. (2004) The body-mass index, airflow obstruction, dyspnea and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012. Copyright 2004 Massachusetts Medical Society. All rights reserved.

Table 3. Profile of COPD Patients at Risk for Death From Acute Respiratory Failure
Severe airflow obstruction (FEV₁, 40% predicted) Poor functional status (MRC dyspnea scale 4-5) Poor nutritional status (BMI < 19 kg/m²) Older age Recurrent acute exacerbations of COPD (especially requiring hospitalization and mechanical ventilation) Chronic comorbidities (depression, congestive heart failure)

BMI = body mass index; COPD = chronic obstructive pulmonary disease; FEV₁ = forced expiratory volume in 1 second; MRC = Medical Research Council.

Table 4. Components of Palliative and End-of-Life Care for Patients With Cardiopulmonary Disease
Component	Interventions and Activities
Support for patient and family	Advance care planning
	Maintaining and supporting the patient's dignity, including cultural and spiritual needs
	Emotional support for the family, including bereavement services
Care of the patient	Relief of distressing symptoms
	Management of the dying process, including withdrawal of life-sustaining treatment
	Referral to appropriate hospital and community resources
	Quality palliative and end-of-life care in all treatment settings, including institution and home
Responsibility of the professional caregiver	Assurance of professional education and competence in quality palliative and end-of-life care
	Support and counseling to address professional caregiver grieving
	Development of institutional, professional, and regulatory policies to ensure quality palliative and end-of-life care

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