Evidence-based approach to acute exacerbations of COPD

Abstract

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and it accounts for approximately 500,000 hospitalizations for exacerbations each year. New definitions of acute COPD exacerbation have been suggested, but the one used by Anthonisen et al. is still widely accepted. It requires the presence of one or more of the following findings: increase in sputum purulence, increase in sputum volume, and worsening of dyspnea. Patients with COPD typically present with acute decompensation of their disease one to three times a year, and 3% to 16% of these will require hospital admission. Hospital mortality of these admissions ranges from 3% to 10% in severe COPD patients, and it is much higher for patients requiring ICU admission. The etiology of the exacerbations is mainly infectious (up to 80%). Other conditions such as heart failure, pulmonary embolism, nonpulmonary infections, and pneumothorax can mimic an acute exacerbation or possibly act as "triggers." Baseline chest radiography and arterial blood gas analysis during an exacerbation are recommended. Oxygen administration through a venturi mask seems to be appropriate and safe, and the oxygen saturation should be kept just above 90%. Either a short acting beta 2-agonist or an anticholinergic is the preferred bronchodilator agent. The choice between the two depends largely on potential undesirable side effects and the patient's coexistent conditions. Adding a second bronchodilator to the first one does not seem to offer much benefit. The evidence suggests similar benefit of MDIs when compared with nebulized treatment for bronchodilator delivery. If MDIs are to be used, spacer devices are recommended. Steroids do improve several outcomes during an acute COPD exacerbation, and a 10- to 14-day course seems appropriate. Antibiotic use has been shown to be beneficial, especially for patients with severe exacerbation. Changes in bacteria strains have been documented during exacerbations, and newer generations of antibiotics might offer a better response rate. There is no role for mucolytic agents or chest physiotherapy in the acute exacerbation setting. Noninvasive positive pressure ventilation might benefit a group of patients with rapid decline in respiratory function and gas exchange. It has the potential to decrease the need for intubation and invasive mechanical ventilation and possibly decrease in-hospital mortality.

Pharmacoeconomics of the management of acute exacerbations of chronic obstructive pulmonary disease

“…COPD patients typically suffer from one to four exacerbations per year, with the frequency of exacerbations increasing with the severity and duration of COPD [5]. Exacerbations also worsen the natural history of COPD [4].…”

“…The time horizon of these studies was limited to an exacerbation episode. Therefore, these studies did not consider the fact that patients may suffer from multiple exacerbations during 1 year [5] and did not investigate the possible impact of various antibiotics on time between exacerbation episodes.…”

“…Exacerbations lead to poor functional status and quality of life [4]. An in-patient mortality rate of exacerbations of 10%, rising to 40% in 1 year, has been reported [5]. The economic burden imposed by exacerbations is substantial.…”

“…Almost 620,000 patients with an exacerbation were hospitalised in the US in 2002, making exacerbations one of the top 10 causes of hospitalisation among adults [6]. The literature indicates that 3 -16% of exacerbations gave rise to a hospital admission in the second half of the 1990s [5]. In addition, 50% of hospitalised patients need to be re-admitted to hospital at least once in the next 6 months [7].…”

Der kritisch kranke COPD-PatientExpertentreffen Luftschlösser

“…Eine eindeutige bronchodilatative Überlegenheit zwischen kurzwirksamen â 2 -Mimetika und Ipratropiumbromid ließ sich in Studien bisher nicht nachweisen. Allerdings wirken beide Substanzen additiv, weswegen bei der COPD-Exazerbation die kombinierte Gabe empfohlen ist [13,14]. [15].…”