Gloria Fann

Acute Pulmonary Exacerbations Present Inherent Clinical Challenges, For Now

By Gloria Fann, M.D.
Gloria Fann

The chronic, progressive presentation of COPD, symptom overlap, and nature of patient self-reporting make it hard to identify exacerbations. We need more specific guidelines around, as well as tools for, assessing a patient’s progression from day to day. AI-supported diagnostic systems represent a potential breakthrough technology that could help us overcome significant knowledge gaps.

Pulmonary exacerbation is a serious clinical scenario that can lead to significant morbidity and mortality. Recent estimates place the one-year mortality rate for a COPD exacerbation at 28%. Patients suffering from an exacerbation experience inflammation in the lungs, which causes an increase in mucus production and remodeling on a cellular level, further impacting lung function later on. Given the condition’s serious nature, suspicion warrants urgent intervention.

Unfortunately, many exacerbations fly under the proverbial radar due to limitations in how we detect and characterize the condition. Although emerging technology may offer us new and intriguing ways to close these care gaps.

What is an Exacerbation?

We use the term “exacerbation” to refer to an acute respiratory event marked by sudden worsening of a patient’s core symptoms. The term can be used in relation to any pulmonary disease state, but most often, we use it to refer to chronic obstructive pulmonary disease (COPD) or asthma. To make this distinction, we must account for the day-to-day variations with each patient’s symptoms and determine that the worsening is significant enough to warrant a change in treatment strategy. An increase in frequency or severity of cough, increased sputum production or discoloration, or shortness of breath can all serve as key indicators.

Bacterial or viral syndromes are a primary contributor to respiratory disease exacerbation, and environmental pollutants can also serve as triggers. Sometimes these triggers can come and go without triggering an exacerbation; other times, they activate the spiral of physiologic changes needed for exacerbation to occur.

When an exacerbation is identified, treatment can proceed based on the severity of manifestation and the patient’s personal history. Steroids and supportive care are first line in most instances, but in particularly severe cases, intubation or oxygen may be necessary. In the event of a moderate to severe infection requiring hospitalization, current guidelines also recommend antibiotics. Cigarette smokers are advised to stop smoking, as tobacco inhalation represents a primary risk factor for COPD development and progression. Individuals with severe presentation with prior exacerbations may require triple therapy consisting of inhaled corticosteroids, long-acting muscarinic antagonists, and long-acting beta agonists. Those with less severe presentation may use one or two of these agents rather than all three.

Complex Presentation Creates Difficult Decisions

In a perfect world, we would have fully objective, data-driven means to identify an exacerbation. In reality, clinicians must use their experience, knowledge, and best judgment to determine if a patient’s respiratory condition is worsening beyond an acceptable baseline. This is a challenging endeavor, as a “normal” baseline can vary significantly from patient to patient. It’s usually easy enough to spot aberrant breathing in a healthy, physically conditioned patient, but a patient that is out of shape may experience shortness of breath walking up stairs. Symptom overlap can also be a factor: shortness of breath, for instance, can be associated with anything from a common cold to an acute cardiac event.

Additionally, for some patients, respiratory decline is a slow, gradual descent that takes place over years to decades, making sudden worsening harder to demarcate. COPD, specifically, is a chronic and progressive disease, and COPD patients reach a point where they forget what normal, healthy breathing feels like. These patients may avoid reporting acute worsening or particularly severe episodes that they perceive as normal.

The chronic, progressive presentation of COPD, symptom overlap, and nature of patient self-reporting make it hard to identify exacerbations with total certainty. This creates an unfortunate strain on care providers, who are now tasked with addressing a potentially serious condition with limited, sometimes unreliable information. As with any intensive intervention, modalities such as triple therapy increase the risk of intolerable or adverse side effects, making diagnostic nuance as important as it is challenging.

Care Limitations Compound the Problem

Today, individuals with chronic respiratory conditions often bear the burden of symptom reporting, including aggravated breathing, wheezing, and changes in sputum production or color. This means that patients typically need to interpret their own symptoms and be capable of identifying what’s considered normative. This wouldn’t be as serious an issue if they were able to follow up with a clinician every two weeks or once a month. However, given that most patients see their specialist every three to six months, chances are an exacerbation won’t be identified until weeks or even months after it emerges unless the exacerbation is severe enough for the patient to present to an emergency department or hospital. This mismatch between symptom identification and standard care protocols leaves a lot on the proverbial table in terms of optimizing treatment and preventing serious adverse outcomes at a population level.

Given the considerable challenges associated with identifying and delineating the condition, it is estimated that more than half of all exacerbation events go unreported. This is especially true for milder cases, where symptom presentation is subtle and may be attributed to general health, lifestyle, allergies, and other factors.

The Work Ahead: Optimizing Treatment Strategies

In the future, treatment strategies should evolve to mitigate these diagnostic challenges as much as possible. First, we need more specific guidelines around, as well as tools for, assessing a patient’s progression from day to day. It was only relatively recently that we received standardized questionnaires and other diagnostic tools to help assess a patient’s day to day reality. While these questionnaires are certainly helpful, they are ultimately still rooted in patient self-reporting, which is inherently subjective in our imperfect world.

Conversely, tools that provide objective measurements represent a crucial step forward, as these tools can help us deliver superior care in the short term and develop evidence-based guidelines in the long term. Although the concept is still new, AI-supported diagnostic systems represent a potential breakthrough technology. In theory, they could help us overcome significant knowledge gaps in several ways: first, by providing objective data filtered through an established normative baseline; second, by collecting data during sleep, a time when the patient isn’t aware of, let alone managing symptoms; and third, by compiling data from large-scale patient populations to inform evidence-based standards of care.

However, as with any new technology, adoption and implementation will undoubtedly take time. Today, we must continue to learn, interpret the information currently available to us, and tap real-world clinical experience to make the best clinical judgments possible.

For individuals living with pulmonary conditions, optimizing the available tools to manage their condition will also improve outcomes.  Such tools might include symptom tracking, working with their healthcare providers to improve their health habits, and leveraging health coaches and self-management programs.  Increasing accessibility and improving usability of these tools offer additional opportunities for further innovation and may help to remove barriers to effective self-management.

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Gloria Fann