Caring for adult patients with acute exacerbations of asthma or COPD in general practice

In the project, patients in primary care with excerbations of asthma or COPD have been described, as well as the treatments given during exacerbations. In one study data was collected from 100 patients hospitalized due to asthma or COPD exacerbations in two Norwegian hospitals. Treatment outside hospital was more often attempted when the first consultation was with their regular GP compared to those who first consulted out of hour services. Hospital admission was often arranged after consultation by phone, without the patient being clinically examined. In another part of the project,380 patients diagnosed with asthma or COPD were followed over a period of one year. 47% experienced one or more exacerbations leading to a doctor visit or self-administered treatment with antibiotics or oral corticosteroids. Approximately half of 95 patients who visited their GP were given antibiotics or oral corticosteroids. Chest findings, increased CRP value and decreased oxygen saturation were more strongly associated with antibiotic treatment than were airway symptoms. International guidelines recommend a strong emphasize on purulence. We have arranged focus group discussions with GPs and pulmonologists from 6 European countries and Hong Kong. These showed varying views on how to manage COPD exacerbations. Multimorbidity was regarded to be challenging, and good knowledge of the patients was regarded crucial. Patients may be offered self-treatment with antibiotics or oral corticosteroids if they know their disease well and have been properly educated. GPs may lack time for such communication. In depth interviews with Norwegian COPD patients about their views on self-treatment of exacerbations and access to primary care, it has been shown that patients appreciate the possibility of self-treatment but still want easy access to a doctor.

Improved guidelines for assessing and treating asthma and COPD exacerbations in primary care are needed. Exacerbations of COPD, often difficult to distinguish from those of asthma, are defined as ?an event in the natural course of the disease characterize d by a change in the patient?s baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication?. They are frequently treated with antibiotics and oral corticosteroids. Today?s symptom based criteria for giving antibiotics are subjective, and adding a biomarker like C-reactive protein (CRP) to the criteria has been suggested. Tests informing about the severity of exacerbations, like spirometry, pulse oximetry, and CRP-te st, are available in primary care, but we do not know their current of potential role. Asthma and COPD patients are often supplied with antibiotics and oral corticosteroids for use during exacerbations, ensuring prompt treatment, but probably also leading to over treatment and delayed doctor visits. Care of asthma/COPD exacerbations in general practice will be investigated through four studies. In Study 1, 380 general practice patients with asthma/COPD will be followed for a year, and examined by their GP with a set of tests: spirometry, pulse oximetry, and CRP-test. during exacerbations. The predictive value of the tests for medical treatment and referral to hospital will be assessed, as well as for the clinical course. In study 2, in-depth interviews wi ll be carried out with COPD patients, about access to health care, self-treatment, and emotional barriers in help-seeking. In Study 3, focus group discussions will be done with GPs and pulmonologists from 6 European countries on assessment and medical tre atment of patients with asthma/COPD exacerbations. In study 4, patients hospitalized due to asthma/COPD exacerbations will answer a questionnaire on self-treatment and contact with primary care prior to admittance.