chronic obstructive pulmonary disease (COPD) is the medical name for chronic bronchitis. It is almost always a disease of the over-40s, and the patient usually has a history of smoking. Some occupations increase the risk of COPD.
Lung volumes decrease steadily in smokers, but they will have been smoking 20 cigarettes a day for 20 years or more before respiratory symptoms develop.
A cough producing sputum and progressive shortening of breath reflect the obstruction of air-flow into the lungs and impairment of oxygen and carbon dioxide exchange.
Patients with moderate to severe COPD get recurrent chest infections and notice that exertion brings on shortness of breath.
Unlike asthma, where the airway narrowing is reversible, the ability to reopen the airways using medication is usually more limited in chronic bronchitis.
COPD is the most common respiratory cause for acute hospital admission in middle-aged and older people. It is one of the main contributors to the pressure on hospital beds during winter months.
The Republic: Timmy is a 76year-old from Co Kerry who developed COPD in 1984. He had worked for most of his life on the railways in the UK, cleaning the inside of steam engines. A life-long smoker, he lives alone. For the first 10 years of the disease he gained some benefit from inhalers and oral medication. Then he became increasingly house-bound with breathing difficulties. Two years ago his GP started provision of oxygen at home.
Every year he needs several admissions to Tralee General Hospital for acute breathing problems brought on by infection. However, his GP has beds in the local community hospital; Timmy preferred it when he could be admitted there and treated by his own doctor.
On April 11th, 2000, he developed an acute exacerbation of COPD and had to be admitted to the general hospital because there were no beds in the local community unit.
However, 10 days later he was transferred back to the community hospital where he spent the next three weeks being actively treated with medication, oxygen and physiotherapy. He went home on May 15th.
The availability of the community hospital and willingness of his GP to look after him there meant that he spent only 10 days from a hospital stay of a month in an acute, high-tech environment. This was more acceptable to Timmy and represented a huge saving in the cost of treating him, £320 versus £80 per day.
Northern Ireland: Gerard is a 48-year-old unemployed man from south Belfast. He is married with two children and is unable to work because of moderately severe chronic obstructive pulmonary disease. A long-term smoker, he suffers from regular exacerbations of his condition.
On Saturday, December 2nd, 2000, he was admitted to the City Hospital, Belfast, with worsening shortness of breath, a temperature and chest pain. After an ECG, X-ray and blood tests, he was started on intravenous antibiotics and oxygen.
Gerard was seen in the hospital the following Monday by nurses from the community Rapid Response Team. Run by the Eastern Board of the South & East Belfast Trust, the team consists of seven nurses and four nursing auxiliaries whose task is to manage patients at home. The team agreed a care plan for Gerard with the physicians in the hospital's chest unit and arranged to bring him home later in the week. Once home, he continued to receive steroid treatment, intravenous antibiotics , "Nebulised medication" inhalers delivered by a face mask four times a day and chest physiotherapy.
The Rapid Response Team visited Gerard three times a day for two weeks and were available to him and his family on a 24-hour call-out basis. The nurses gradually weaned him off medication. When the team discontinued its care, Gerard was in a stable condition and back on his regular medication. Because of the Rapid Response Team's availability, Gerard spent less than a third of his illness in hospital.
Comparison: The ability to manage acute flare-ups of chronic illnesses away from the acute hospital sector must be a key goal of a modern health service. The availability of local community hospitals beds in the Republic is largely confined to rural areas. Ironically, this model of care was a feature of our health service until 25 years ago; it remains an integral part of rural health services in Canada and the US.
The concept of the Rapid Response Team is an excellent one which needs to be replicated throughout the health services, North and South. It is cost-effective: the Belfast team is run on a budget of £80,000 sterling a year. This compares to a cost of £250 sterling per day for an acute hospital bed in the NHS.
In the Republic, it costs £80 to £90 per day to stay in a community hospital, compared to a daily cost of £320 in an acute hospital.
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