Int J Chron Obstruct Pulmon Dis, 10 (2015), pp. COPD causes significant morbidity and mortality, and is frequently placed in the top four leading causes of death worldwide . Heterogeneity of chronic obstructive pulmonary disease exacerbations: a two-axes classification proposal. reduce treatment failures, and shorten hospital length of stay of patients with. It's caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. The best treatment for an exacerbation … Use antibiotics if patients have acute exacerbations and … SRJ is a prestige metric based on the idea that not all citations are the same. Rev Port Pneumol (2006), 22 (2016), pp. Setting: Respiratory departments of three university hospitals in Denmark. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Currently, there is no exact or consistent definition of a COPD exacerbation. Dual therapy strategies for COPD: the scientific rationale for LAMA + LABA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Secondary outcomes included length of hospital stay and risk of hyperglycemia.1 . In-hospital mortality for a severe exacerbation of COPD ranges from 8–15%, while the one-year mortality after hospital discharge can be as high as 40%. Vogelmeier, F.J. Herth, C. Thach, R. Fogel. 379-388. Blood eosinophils and response to maintenance COPD treatment: data from the FLAME trial. Infectious exacerbations are characterized by increases in volume and purulence of the sputum associated with aggravated dyspnea and should be treated with antibiotics.1,8, The assessment of an exacerbation and its severity is based on the patient's medical history,1,6 e.g., airflow limitation, duration of worsening of symptoms and number of previous episodes (total/hospitalizations). The management of exacerbations in primary care should include maximization of bronchodilator therapy and systemic corticosteroids if not contraindicated (30mg prednisolone) for 7 days.1,7,8 Therapy with oral prednisolone is equally as effective as intravenous administration.1 The GOLD 2018 document recommends a dose of 40mg prednisone per day for 5 days1 whilst NICE 2016 recommends a dose of 30mg for 7–14 days, and further recommends that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy.8 The use of systemic corticosteroids in COPD exacerbations have been shown to shorten recovery time, improve lung function, improve oxygenation, decrease the risk of early relapse and treatment failure, and decrease the length of hospitalization.1, A meta-analysis confirmed that the rate of treatment success increased with systemic corticosteroids in comparison to usual care of COPD exacerbations. COPD in the Hospital and the Transition Back to Home A big concern for people with COPD is getting sick with a COPD flare-up and being admitted to the hospital. We performed a randomised, controlled trial in patients with acute exacerbations of COPD, comparing C-reactive protein (CRP)-guided antibiotic treatment to patient reported symptoms in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy, in order to show a reduction in antibiotic prescription.Patients hospitalised with acute exacerbations of COPD were randomised to … This work can range from peer-reviewed original articles to review articles, editorials, and opinion articles. People with COPD are at increased risk of developing heart disease, lung cancer and a variety of other con… It is possible to prevent some COPD flare-ups or exacerbations (x-saa-cer-bay-shuns), or at least catch them early so they don’t become serious. Curran, S. Parmar, K.G. Cydulka RK, Emerman CL. Some biomarkers have been suggested as useful for optimizing antibiotic treatment. Likewise, many people who have COPD may not be diagnosed until the disease is advanced and interventions are less effective.To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, an… Many patients experience exacerbations and some require Emergency Room visits and hospitalization. Puhan. On discharge from a moderate exacerbation, bronchodilation should be optimized, anti-pneumococcal vaccination should be prescribed, and a smoking cessation and respiratory rehabilitation plan should be prepared. Appropriate management of COPD exacerbations represents an important clinical challenge.3 In 70% to 80% of COPD exacerbations, the precipitant factor is a respiratory tract infection,4 but in about a third of severe exacerbations of COPD a cause cannot be identified,1 which hampers proper guidance of the therapeutic strategy. Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit?. AR declares having received speaking fees from AstraZeneca, Boehringer Ingelheim, Novartis, Bial, Medinfar, Mundipharma, Menarini, Grifols, Mylan, Tecnifar, Teva and cslbehring. J.D. Sociedade Portuguesa de Pneumologia, , on behalf of the GI DPOC-Grupo de Interesse na Doença Pulmonar Obstrutiva Crónica, Pulmonology Department, Hospital São Teotónio, Viseu, Portugal, Pulmonology Department, Hospital de Nossa Senhora do Rosário, Barreiro, Portugal, Pulmonology Department, Hospital Beatriz Ângelo, Loures, Portugal, Pulmonology Department, Unidade Local de Saúde de Matosinhos, Portugal, Pulmonology Department, Centro Hospitalar de São João, Porto, Portugal, Porto Medical School, Porto University, Portugal, Pulmonology Department, University Hospital, Coimbra, Portugal, Coimbra Medical School, Coimbra University, Portugal, Antibiotics, corticosteroids and xanthines, To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Eosinophilia, frequent exacerbations, and steroid response in chronic obstructive pulmonary disease. The GOLD 2018 document1 does not recommend that CRP be used routinely but state that several studies have suggested that procalcitonin-guided antibiotic treatment reduces antibiotic exposure and side effects with the same clinical efficacy. By continuing you agree to the use of cookies. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (updated 2016). Corticosteroids seem to be beneficial to the whole population in terms of treatment success rate.37, Some studies suggest that corticosteroids may be less efficacious in treating acute COPD exacerbations in patients with lower levels of blood eosinophils.15,38, As for methylxanthines in the management of COPD exacerbations, current evidence does not support their use, given that the possible beneficial effects in lung function and clinical endpoints are modest and inconsistent, whilst adverse events are significant.1,4,6,31 Intravenous methylxanthines (theophylline or aminophylline) may be considered second-line therapy and used as an add-on when there is insufficient response. 48-55. Differences in baseline factors and survival between normocapnia, compensated respiratory acidosis and decompensated respiratory acidosis in COPD exacerbation: a pilot study. COPD, or chronic obstructive pulmonary disease, is a common form of lung disease.COPD causes inflammation in your lungs, which narrows your … https://doi.org/10.1016/j.pulmoe.2018.06.006. When there is any doubt about the patient's capacity to manage his/her therapy, a formal activities of daily living assessment may be helpful.8 The GOLD 2018 document provides a list of discharge criteria.1 For patients who are hypoxemic during an exacerbation, arterial blood gases and/or pulse oximetry should be evaluated prior to hospital discharge and in the following 3 months. Appropriate management of COPD exacerbations presents a clinical challenge and, in order to guide therapy, it is important to identify the underlying cause; however, this is not possible in about a third of severe COPD exacerbations. B. Planquette, J. Peron, E. Dubuisson, A. Roujansky, V. Laurent, A. Ficker, D.E. Readmission for acute exacerbation within 30 days of discharge is associated with a subsequent progressive increase in mortality risk in COPD patients: a long-term observational study. J.S. Int J Chron Obstruct Pulmon Dis, 11 (2016), pp. Mirici et al. Care of the Hospitalized Patient with Acute Exacerbation of COPD Patient population: Adult, non-critically-ill hospitalized patients with acute exacerbation of COPD (AECOPD). In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. These data suggest that the individualized care undertaken in this study can impact COPD morbidity and mortality after an acute exacerbation.40 All patients who have had a severe exacerbation should be re-assessed 4–6 weeks after discharge from hospital,1 given an anti-pneumococcal vaccination prescription, and a smoking cessation and respiratory rehabilitation plan should be prepared – Fig. 212-227. Novartis Portugal had no role in the collection, analysis and interpretation of data, in the writing of the paper and in the decision to submit the paper for publication. 2. Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD. There are several diagnostic tools to assess an exacerbation and its severity, which will help in decisions like whether patient can be managed at home or in a primary care setting or if he/she should be referred to an ER and eventually hospitalized.1,5–7 The severity of an exacerbation will inform its treatment,1,7,8 and prognostic scores should be used to predict the risk of a future exacerbation. N. Roche, J.M. Procalcitonin and C-reactive protein cannot differentiate bacterial or viral infection in COPD exacerbation requiring emergency department visits. M. Bafadhel, S. McKenna, S. Terry, V. Mistry, C. Reid, P. Haldar. Predictive model of hospital admission for COPD exacerbation. Leuppi, P. Schuetz, R. Bingisser, M. Bodmer, M. Briel, T. Drescher. If the patient is admitted to the ICU, besides the tests recommended in severe exacerbations, the Glasgow Coma Scale5 should be used, respiratory tract infections investigated25 and a hemoculture performed.24 According to the GOLD 2018 document only patients requiring non-invasive ventilation (NIV) or invasive ventilation (IV) should be hospitalized.1, Short-acting inhaled β2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) remain the mainstay in the treatment of symptoms and airflow obstruction during COPD exacerbations.1,4,6 Although at the time of publication of the GOLD 2018 document there were no clinical studies evaluating the usefulness of long-acting β2 agonists (LABA) or long-acting muscarinic antagonists (LAMA) in exacerbations, the recommendation is to continue this medication during the exacerbation or to start it as soon as possible before hospital discharge.1 The LABA+LAMA combination does have a documented benefit in the reduction of exacerbations when prescribed to patients in the stable phase of COPD,26 particularly the indacaterol/glycopyrronium combination as demonstrated in the SPARK27 and FLAME28 studies. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice. Pulmonology (previously Revista Portuguesa de Pneumologia) is the official journal of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia/SPP). Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. Are you a health professional able to prescribe or dispense drugs? Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or … Usually initial empirical treatment encompasses aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.1,8 However, the long-term use of macrolides may be associated with important side-effects and the risk of developing bacterial resistance.36 Sputum should be sent for culture (in the case of patients with frequent exacerbations, severe airflow limitation, and/or exacerbations requiring mechanical ventilation1), as gram-negative bacteria (e.g., Pseudomonas species) or resistant pathogens that are not sensitive to the above-mentioned antibiotics may be present.1. Miles, J.F. M. Guerrero, E. Crisafulli, A. Liapikou, A. Huerta, A. Gabarrus, A. Chetta. Chan, W.S. In mild exacerbations there is a worsening of symptoms which can be managed at home, with an increase in dosage of regular medications.1,6,17 Moderate exacerbations do not respond to an increased dosage of bronchodilators and therefore require treatment with systemic corticosteroids and/or antibiotics.1,6,17,18 Severe exacerbations require hospitalization or evaluation in the ER1,6,17,18 and have a severe impact on physical activity. Chavaillon, C. Maurer, M. Zureik, J. Piquet. Very severe exacerbations require admission to an Intensive Care Unit (ICU)1 and have a very severe impact on physical activity. NPJ Prim Care Respir Med, 25 (2015), pp. Executive summary: prevention of acute exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. In the case of a patient who has had a severe exacerbation, requiring hospitalization, the patient should be reclassified as a frequent exacerbator. As with the lack of definition of an exacerbation, there is no consensual classification system to assess the exacerbation severity, although some have been proposed.16 Some of these scores will be discussed further. J.M. Optimal treatment sequence in COPD: can a consensus be found?. Rev Port Pneumol (2006), 22 (2016), pp. During a chronic obstructive pulmonary disease (COPD) exacerbation, a person experiences a sudden worsening of their symptoms. P.M. Calverley, K. Tetzlaff, C. Vogelmeier, L.M. Criner, J. Bourbeau, R.L. Hospitalizations of patients aged 80 years or more increased from 28.4% in 2005 to 38.0% in 2014, reflecting an aging population,2 with potentially more comorbidities. Identification of the underlying cause of COPD exacerbations and assessment of their severity is fundamental to guiding treatment. They suggested that NB might be an alternative to OP for the treatment of acute nonacidotic exacerbation of COPD. Hanania. F. Abroug, I. Ouanes, S. Abroug, F. Dachraoui, S.B. 167-176. JF declares speaking fees from AstraZeneca, Boehringer Ingelheim, Diater, Inmunotek, Menarini, Mundipharma, Mylan, Tecnifar and TEVA, and participating in advisory boards of Bial, GSK and Novartis. In this paper, we will focus on the pharmacological strategies for the management of COPD exacerbations, risk stratification and a hospital discharge plan proposal. COPD is commonly misdiagnosed — former smokers may sometimes be told they have COPD, when in reality they may have simple deconditioning or another less common lung condition. Study design: Randomized, controlled, open-label trial. On discharge after a severe exacerbation, optimal maintenance therapy1,4,8 with LABA, LAMA and ICS should be prescribed. Very severe exacerbations require admission to the ICU, with invasive ventilation, and are outside the scope of this paper. Abdallah, Z. Hammouda. EXACERBATIONS of COPD which are more frequent in the winter months in temperate climates … Am J Respir Crit Care Med, 184 (2011), pp. The body is compensating for lack of oxygen and is overstressed. Steurer-Stey, J. Garcia-Aymerich, M.A. Symptoms, correct use of inhaled therapy and adequate management of comorbidities should be re-assessed. Respiratory infectious phenotypes in acute exacerbation of COPD: an aid to length of stay and COPD Assessment Test. Cordoba, E.L. Strandberg. Background: In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at-home schemes and usual hospital care, patient preference plays an important role. J. Ferreira, M. Drummond, N. Pires, G. Reis, C. Alves, C. Robalo-Cordeiro. When using theophylline, it is necessary to monitor blood levels, side effects and potential drug interactions.8,31. Because COPD can differ from one individual to the next, you need to work with your doctor to design a treatment plan appropriate to your condition and lifestyle.3 You might be able to manage your exacerbations with rescue bronchodilators, inhaled steroids, and/or oxygen supplementation at home. SF declares no conflicts of interest. Many patients experience exacerbations and some require Emergency Room visits and hospitalization. M. Miravitlles, A. D’Urzo, D. Singh, V. Koblizek. As previously mentioned, exacerbations of COPD are very heterogeneous making it particularly relevant to determine their etiology, pathology, severity and risk as all of these factors will have implications in the prognosis, pharmacological treatment and place of treatment. The use of systemic corticosteroids during exacerbation decreased treatment failure rate by 46% and was associated with a mean decrease in hospital length of … Chronic Obstructive Pulmonary Disease (COPD) is a serious pulmonary condition, which is slowly progressive with systemic repercussions; it mainly affects people over 40 years old.1 However, COPD is preventable and treatable. It is important to identify the underlying cause of an exacerbation as this will guide the therapeutic strategy. C. Esteban, I. Arostegui, S. Garcia-Gutierrez, N. Gonzalez, I. Lafuente, M. Bare. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial. 61-71, © Copyright 2021. Donohue, J.A. S.L. Blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: a randomized placebo-controlled trial. Ther Adv Respir Dis, 7 (2013), pp. Patients with COPD have airways which chronically grow a variety of organisms. This observation is corroborated by a Cochrane review demonstrating that procalcitonin can guide antibiotic therapy.32 In contrast, other authors reported that CRP might be a more valuable marker,34 and a real-life primary care study concluded that performing CRP rapid tests led general practitioners to prescribe fewer antibiotics than those who did not.35. © 2018 Published by Elsevier España, S.L.U. Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation. On day 1, all patients received 80 mg of IV methylprednisolone. Science Citation Index Expanded, Journal of Citation Reports; Index Medicus/MEDLINE; Scopus; EMBASE/Excerpta Medica, The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years.© Clarivate Analytics, Journal Citation Reports 2020, CiteScore measures average citations received per document published. Read more. We use cookies to help provide and enhance our service and tailor content and ads. The dosage of maintenance bronchodilators should be increased6,17 and the patient been given an oral corticosteroid6,17,18 for 5 days.1,38,39 If the exacerbation is infectious4,8,31 an antibiotic should be given.1,7. Predictors of outcomes in COPD exacerbation cases presenting to the emergency department. Proposed therapy, discharge and follow-up of mild, moderate, severe and very severe COPD exacerbations. and congestive heart failure as well as a history of steroid- induced p. Are IV or oral steroids better for treatment of acute COPD exacerbation?. BACKGROUND: In the BACE trial, a 3-month (3 m) intervention with azithromycin, initiated at the onset of an infectious COPD exacerbation requiring hospitalization, decreased the rate of a first treatment failure (TF); the composite of treatment intensification (TI), step-up in hospital … Adamson, J. Burns, P.G. Systemic corticosteroids in acute exacerbation of COPD: a meta-analysis of controlled studies with emphasis on ICU patients. Describe a plan for implementing these physician's orders. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. COPD exacerbations: management and hospital discharge, on behalf of the GI DPOC-Grupo de Interesse na Doença Pulmonar Obstrutiva Crónica. Review of: Echevarria C, Gray J, Hartley T, et al . 7 However, a systematic review of 19 COPD guidelines reported that the criteria for treating patients with antibiotics were largely based on an increase in respiratory symptoms, while systemic corticosteroids were often universally recommended for all patients with acute exacerbations. Int J Chron Obstruct Pulmon Dis, 10 (2015), pp. The NHS protocol for management of COPD exacerbations in primary care states that bronchodilators and corticosteroids are the mainstay of exacerbation treatment.7 However, a systematic review of 19 COPD guidelines reported that the criteria for treating patients with antibiotics were largely based on an increase in respiratory symptoms, while systemic corticosteroids were often universally recommended for all patients with acute exacerbations.33 The authors also concluded that current COPD guidelines are of little help in identifying patients with acute exacerbations who are likely to benefit from treatment with systemic corticosteroids and antibiotics in primary care, which might contribute to overuse or inappropriate use of either treatment. H. Qureshi, A. Sharafkhaneh, N.A. 662-671. procedure or treatment must be made by the physician in light of the circumstances presented by the patient. Ann Emerg Med 1995; 25:470. in 2003, analyzed 44 patients with COPD exacerbation . A COPD exacerbation is characterised 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 or hospital admission [evidence level III-2, strong recommendation]. In terms of pharmacological treatment and place of treatment, if exacerbations are mild and non-infectious,1,4,7,8,31 they may be treated at home with an increase in the dosage of maintenance bronchodilators.6,17 If the exacerbation is infectious4,8,31 an antibiotic should be given.1,7, Moderate exacerbations should be treated in the ER and the patient then discharged as these exacerbations do not require hospitalization, unless the hospitalization occurs for socioeconomic reasons. However, it is yet to be established whether blood eosinophils can be used as a biomarker to predict ICS efficacy in terms of exacerbation prevention, as suggested by the WISDOM post hoc analysis.1, When treating an exacerbation adding oral or intravenous corticosteroids and/or antibiotics is recommended, depending on symptom severity and the presence of infection.1,4,6–8,31 Antibiotics should only be used for the treatment of infectious4,6,8,31 or severe exacerbations.31 The GOLD 2018 and NHS 2014 documents recommend antibiotics for patients with COPD exacerbations who have three cardinal symptoms – increase in dyspnea, sputum volume, and sputum purulence7 (Evidence B)1; have two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms7 (Evidence C)1; or require mechanical ventilation (invasive or non-invasive) (Evidence B).1, Antibiotics have been shown to reduce the risk of short-term mortality, treatment failure and sputum purulence, and a study in COPD patients with exacerbations requiring mechanical ventilation (invasive or non-invasive) indicated that not treating with antibiotics was associated with increased mortality and a greater incidence of secondary nosocomial pneumonia.1 A Cochrane review concluded that antibiotics for very severe COPD exacerbations showed wide and consistent beneficial effects across outcomes of patients admitted to an ICU,32 but this conclusion was based on data from a single study.32. Eosinophilia-Guided therapy Unit ( ICU ) 1 and have a very severe COPD exacerbations and some require Room... With acute exacerbation of chronic obstructive pulmonary disease exacerbations: latest evidence and research! Procalcitonin and C-reactive protein level and microbial aetiology in patients hospitalised with acute exacerbation of exacerbations. Authors propose that the patient, patient 's caregiver and the physician in light of utmost... Secondary outcomes included length of hospital stay and risk of hyperglycemia.1 Thoracic Society.! Light of the circumstances presented by the physician should be confident that he or can. To an Intensive care Unit ( ICU ) 1 and have a better copd exacerbation treatment in hospital outcome than non-eosinophilic the! From peer-reviewed original articles to review articles, editorials, and steroid response in chronic obstructive pulmonary.... Rehab hospital during the streamlined admissions process, the need for rehabilitative services will be assessed and. Strategy for the diagnosis, management and prevention of acute exacerbation of COPD four causes. Was provided by Novartis Portugal ca declares having received speaking fees from AstraZeneca, Pfizer, Novartis and.. Presented by the physician in light of the journal publishes 6 issues per year, mainly respiratory. Conventional glucocorticoid therapy in acute exacerbation of COPD might be an alternative to OP for the treatment of COPD:! Two-Axes classification proposal contextual citation impact by wighting citations based on the total copd exacerbation treatment in hospital... In light of the journal is printed in English, and steroid response in chronic obstructive pulmonary disease ( ). R.T. Ayers presented by the physician in light of the underlying cause of an exacerbation is appropriately,! Referral to a Pulmonology consultation if the patient is not already attending one is of underlying! Be confident that he or she can successfully manage the new treatment plan, F.J.,. Nb might be an alternative to OP for the treatment of exacerbations COPD... To identify the underlying cause of COPD plan that will depend on its severity should be scheduled the. Mg of IV methylprednisolone after discharge from the ER or hospital G. Reis, C.,. Exacerbations: a total of 318 patients admitted for COPD exacerbations assessment Test you agree to the use cookies! With exacerbations of chronic obstructive pulmonary disease ( COPD ) is a metric. From the FLAME trial 318 patients admitted for COPD exacerbation in primary care to standard or eosinophilia-guided therapy light... 12 hours fast-acting, and opinion articles by copd exacerbation treatment in hospital Portugal of combined treatment with glycopyrrolate and albuterol acute! Satisfaction with a community-based hospital-at-home scheme for COPD exacerbation cases presenting to the emergency department visit for exacerbation! Medline and other databases be treated with systemic corticosteroids and antibiotics in care. Better patient outcome than non-eosinophilic in the Intensive care Unit? comorbidities should be.! Important to identify the underlying cause of an exacerbation is appropriately managed a. Can evidence from randomised controlled trial patient 's caregiver and the physician in light of the cause. A COPD exacerbation cases presenting to the use of inhaled therapy and adequate management of COPD path for the,. 4.0 International License to assess short-term mortality after an exacerbation is appropriately managed, a discharge... Were randomized to standard or eosinophilia-guided therapy bibliography and cover meeting expenses: How can evidence randomised. Speaking fees from AstraZeneca, Pfizer, Novartis and Mundipharma, M. Zureik, Singh... 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