The Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) has released its 2017 report. The executive summary highlights the “most significant” changes:
- The assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations
- For each of the groups A to D, escalation strategies for pharmacological treatments are proposed
- The concept of de-escalation of therapy is introduced in the treatment assessment scheme
- Nonpharmacologic therapies are comprehensively presented
- The importance of comorbid conditions in managing COPD is reviewed
The remainder of the report explains and expands upon these five shifts in strategy for the management of COPD. When implementing the refined GOLD strategy, here are 3 tactics to consider:
Drive the management of COPD patients with standardized assessment protocols
Immediately out of the chute the refined GOLD assessment recommends “escalation strategies” and “de-escalation of therapy” be implemented based on the patient assessment grouping ABCD and ongoing treatment regimen. According to Stoller, the effective use of protocols…“adjust the duration of therapy to assure that patients continue to receive therapy as long as needed but that therapy is curtailed or eliminated when a change in the patient’s clinical status (ie, improvement) permits”1 Stoller also noted that studies have shown that protocols demonstrate “a higher rate of concordance with a gold standard respiratory care plan”2.
Perform an individualized patient discharge assessment and post discharge follow-up
Under the subheading Prevention and Maintenance Therapy the report emphasizes: “Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices.” Daily integration of the newly “refined” ABCD assessment criteria with an algorithmic assessment protocol designed to tailor the patient’s care plan to their unique needs and situation is paramount to an effective discharge plan of care and guiding follow up post discharge.
Work with home health care and other clinical agencies to prevent acute exacerbation
The GOLD report stresses: “the goal for treatment of exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events.” Prevention of AECOPD is key both for decreasing readmission, with all its concomitant risks, as well as staying the patient’s disease progression. Evidentially, this can best be effected by the management of the patient at home: “Routine follow-up of patients with COPD is essential. Symptoms, exacerbations, and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop. To adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen.
Symptoms that indicate worsening or development of another comorbid condition should be evaluated and treated.” Collaboration by respiratory therapy beyond the confines of the hospital, with the visiting nurse, PT, OT, social worker and others is imperative for the wellbeing of the COPD patient.
To the one lucky enough to catch hold of a Leprechaun the familiar Irish legend promises the chance that the wily green imp will lead him to the pot-o-gold buried somewhere at the rainbow’s end. In similar fashion the clever integration of the refined GOLD strategies into a far reaching clinical paradigm holds for our COPD patients, the promise of improved quality of life and fewer return trips to hospital. Hmm, there may be treasure at the end of this rainbow after all?