Catching Your Breath: Managing COPD Exacerbations - Related Content
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Exacerbations of COPD are associated with a more rapid decline in lung function. Pharmacists can be instrumental in educating patients and can serve as a resource for multidisciplinary teams in the setting of COPD exacerbations.
Chronic obstructive pulmonary disease COPD is an inflammatory disease of the lung characterized by progressive airflow limitation that is not fully reversible. Emphysema is a destruction of the alveolar surfaces that results in the inability to perform efficient gas exchange.
Most patients with COPD have elements of both emphysema and chronic bronchitis. The term COPD is now used more frequently, since it encompasses both conditions. Approximately 12 million people in the United States have been diagnosed with COPD, and it is estimated that another 12 million are undiagnosed. COPD development is due to environmental exposures and various other factors. Cigarette smoking is the most common risk factor for COPD.
In recent years, studies have shown an increase in the prevalence of COPD among women; this increase is due to a rise in the number of women who smoke, changes in occupational trends, and possibly greater susceptibility.
Exacerbations of COPD cause a more rapid decline in lung function and result in increased hospital admissions and mortality, which are associated with a greater financial burden. People with known COPD average 1. This article will highlight the management of acute COPD exacerbations.
The GOLD Committee, which was formed in , is a multidisciplinary team of healthcare providers and scientists who are working to promote COPD awareness and provide strategies for effective patient care. This article will discuss some of the GOLD recommendations. This imbalance can cause hyperinflation, hypercapnia , or hypoxemia, depending upon the severity of the exacerbation.
Exacerbations may be precipitated by several factors. However, in more than one-third of exacerbations, the cause is not identified. The three cardinal symptoms of COPD exacerbation are increased dyspnea, cough, and purulent sputum production. An exacerbation is acute in nature and is associated with a change in symptoms that is beyond normal day-to-day variation. Patients experiencing exacerbations should receive a thorough medical assessment including medical history, exposure history, clinical signs of severity, comorbidities, and additional laboratory tests.
Laboratory assessments include comparison of pulse oximetry with the patient at rest and during activity if the patient can ambulate, chest radiographs, electrocardiogram, electrolytes, and whole blood count.
Spirometry is not recommended during exacerbations because the readings are inaccurate and the task is difficult for patients to perform. Management of exacerbations may occur in the inpatient or outpatient setting, depending upon the severity of the exacerbation and other patient-specific factors and circumstances. Hospitalization may be indicated for patients who experience frequent exacerbations, have significant comorbid conditions, or cannot be managed easily in the outpatient setting.
A worsening of clinical status, including the development of new physical signs or a pronounced increase in symptom intensity, also may warrant hospitalization. The goals of exacerbation therapy are to decrease symptoms to baseline and prevent subsequent exacerbations. Pharmacologic treatment of exacerbations involves bronchodilators, corticosteroids, and antibiotics. Short-Acting Bronchodilators: Short-acting beta 2 -agonists e.
In a meta-analysis examining improvement of airflow obstruction with use of short-acting bronchodilators, the change in forced expiratory volume in 1 second FEV 1 did not differ significantly between metered-dose inhalers MDIs and nebulizers. Methylxanthines theophylline and aminophylline are considered second-line IV therapy in patients having an insufficient response to short-acting bronchodilators.
Although inhaled long-acting beta-agonists, long-acting anticholinergics , and corticosteroids are the mainstay of COPD maintenance therapy, they are not appropriate for the treatment of COPD exacerbations. High doses of short-acting beta-agonists, short-acting anticholinergics , and systemic corticosteroids are better suited to decreasing acute respiratory symptoms, whereas long-acting agents are indicated for reducing day-to-day symptoms, preventing exacerbations, and limiting disease progression.
If these agents are used concomitantly during an exacerbation, the patient has a higher likelihood of experiencing adverse effects, since the medication classes are very similar. Corticosteroids: The benefits of systemic corticosteroid use as a component of COPD exacerbation treatment have been well established.
However, the optimal dosage and duration have yet to be determined. Systemic corticosteroids have been shown to shorten length of hospital stay, decrease recovery time, improve FEV 1 , and improve arterial hypoxemia. In the past, the GOLD guidelines suggested the use of prednisolone 30 to 40 mg daily for 10 to 14 days.
In addition, there were no significant differences in mortality, need for mechanical ventilation, short-term adverse effects, recovery of lung function, or improvement of disease-related symptoms. However, patients receiving the shorter course of corticosteroids had a significant reduction in corticosteroid exposure and a shortened length of hospital stay.
At this time, the GOLD guidelines note that nebulized budesonide may be used as an alternative to systemic corticosteroids. Antibiotics: Antibiotic use in the management of exacerbations remains controversial. Antibiotic resistance is an increasing problem worldwide. The choice of the antibiotic should be based on the local pattern of bacterial resistance. Studies support the use of antibiotics when the patient has signs of bacterial infection.
The recommended length of treatment is 5 to 10 days. Titrated oxygen is associated with less acidosis, a lower need for ventilation, and reduced mortality compared with the use of high-flow oxygen during exacerbations. Ventilatory Support: Some patients may require noninvasive nasal cannula or facial mask or invasive orotracheal tube or tracheostomy ventilatory support in order to maintain proper oxygenation.
Criteria for the use of noninvasive ventilation and invasive mechanical ventilation are given in TABLE 2. It may be appropriate to allow a trial of noninvasive methods prior to advancing support, as these modalities are associated with improvement in clinical signs, a decreased need for escalation to invasive mechanical ventilation, and reduced mortality. Although ventilatory support may seem necessary, it is important to take patient preferences into consideration and to be mindful of the risks.
There is not an established optimal length of hospitalization for patients with COPD exacerbations. Prior to discharge, patients should be clinically stable for a minimum of 12 to 24 hours and should need inhaled short-acting beta 2 -agonists no more than every 4 hours. A plan for effective home management and follow-up should be coordinated and clearly communicated to the patient and his or her caregivers and healthcare providers.
It is imperative that discharge planning include medication counseling to ensure patient and caregiver comprehension and proper medication use.
Despite efforts to prevent COPD exacerbations, the rate of readmission remains quite high, which has caught the attention of the Joint Commission and the Centers for Medicare and Medicaid Services in recent years. The frequency and severity of COPD exacerbations have been associated with poor prognosis and increased mortality. Pharmacists can counsel patients about how to prevent future COPD exacerbations, including disease education, smoking cessation, pneumococcal and annual influenza vaccinations, and proper inhaler technique for maintenance therapy.
Chronic obstructive pulmonary disease. National Institutes of Health. Fact sheet: chronic obstructive pulmonary disease COPD. Accessed February 21, World Health Organization. Chronic obstructive pulmonary disease fact sheet. Accessed February 20, Gender differences in COPD: are women more susceptible to smoking effects than men? COPD and gender differences: an update.
Transl Res. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. Respir Med. Prediction of the clinical course of chronic obstructive pulmonary disease, using the new GOLD classification: a study of the general population. Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations.
Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation.
Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support.
Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial.
Miravitlles M, Anzueto A. Antibiotics for acute and chronic respiratory infections in patients with chronic obstructive pulmonary disease. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. Gay PC. Complications of noninvasive ventilation in acute care.
Respir Care. Risk factors of hospitalization and readmission of patients with COPD exacerbation—systematic review. Readmissions for Chronic Obstructive Pulmonary Disease, Eisenhower C. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. Ann Pharmacother. Can the targeted use of a discharge pharmacist significantly decrease day readmissions? Hosp Pharm.
Sehatzadeh S. Influenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease COPD : an evidence-based review.
❾-50%}Systemic Corticosteroids for Acute Exacerbations of COPD | AAFP.Corticosteroid Taper Regimens in the Management of COPD Exacerbations | PracticeUpdate
Publication types Comparative Study Evaluation Study. Substances Adrenal Cortex Hormones. Antibiotics: Antibiotic use in the management of exacerbations remains controversial. Antibiotic resistance is an increasing problem worldwide. The choice of the antibiotic should be based on the local pattern of bacterial resistance.
Studies support the use of antibiotics when the patient has signs of bacterial infection. The recommended length of treatment is 5 to 10 days. Titrated oxygen is associated with less acidosis, a lower need for ventilation, and reduced mortality compared with the use of high-flow oxygen during exacerbations. Ventilatory Support: Some patients may require noninvasive nasal cannula or facial mask or invasive orotracheal tube or tracheostomy ventilatory support in order to maintain proper oxygenation.
Criteria for the use of noninvasive ventilation and invasive mechanical ventilation are given in TABLE 2. It may be appropriate to allow a trial of noninvasive methods prior to advancing support, as these modalities are associated with improvement in clinical signs, a decreased need for escalation to invasive mechanical ventilation, and reduced mortality.
Although ventilatory support may seem necessary, it is important to take patient preferences into consideration and to be mindful of the risks. There is not an established optimal length of hospitalization for patients with COPD exacerbations. Prior to discharge, patients should be clinically stable for a minimum of 12 to 24 hours and should need inhaled short-acting beta 2 -agonists no more than every 4 hours.
A plan for effective home management and follow-up should be coordinated and clearly communicated to the patient and his or her caregivers and healthcare providers. It is imperative that discharge planning include medication counseling to ensure patient and caregiver comprehension and proper medication use.
Despite efforts to prevent COPD exacerbations, the rate of readmission remains quite high, which has caught the attention of the Joint Commission and the Centers for Medicare and Medicaid Services in recent years.
The frequency and severity of COPD exacerbations have been associated with poor prognosis and increased mortality. Pharmacists can counsel patients about how to prevent future COPD exacerbations, including disease education, smoking cessation, pneumococcal and annual influenza vaccinations, and proper inhaler technique for maintenance therapy.
Chronic obstructive pulmonary disease. National Institutes of Health. Fact sheet: chronic obstructive pulmonary disease COPD. Accessed February 21, World Health Organization. Chronic obstructive pulmonary disease fact sheet. Accessed February 20, Gender differences in COPD: are women more susceptible to smoking effects than men? COPD and gender differences: an update. This Cochrane review updates an earlier meta-analysis with two new studies. Although systemic steroids are widely used for the treatment of acute COPD exacerbations, the authors stress that it is important to know the magnitude of their benefit and the extent of associated side effects.
The question of whether oral or intramuscular steroids are more effective was not addressed. Four of the studies in this analysis involved oral prednisone with an initial dose of 30 to 60 mg tapering over nine to 14 days; in a fifth study, high-dose oral prednisone 2.
In studies of intravenous methylprednisolone Solu-Medrol , a variety of dosing regimens were used, from a single mg dose to 72 hours of methylprednisolone followed by a day prednisone taper. Despite the differences between studies, the review authors were able to combine the results from seven studies of treatment failure and nine studies of mortality. Two studies looked at longer-term treatment failure as measured by hospital admission rates in the 30 days following treatment.
Search PracticeUpdate Cancel. This single-center retrospective cohort study evaluated patients who received high-dose methylprednisolone in the ICU and subsequently were prescribed either an extended or short course of oral corticosteroids to determine incidence of treatment failure.
The study demonstrated that patients who received a short taper did not experience an increased risk of treatment failure. Further prospective research is indicated in this area. This abstract is available on the publisher's site. Access this abstract now. Additional Info. National Library of Medicine.
Previous literature has suggested that a short course of corticosteroids is similarly effective as an extended course for managing an acute exacerbation of chronic obstructive pulmonary disease AECOPD. However, there are limited data regarding the optimal corticosteroid regimen in critically ill patients and the dosing strategies remain highly variable in this population.
This retrospective cohort study evaluated patients with AECOPD admitted to the intensive care unit within a 2-year period. The primary end point was treatment failure, defined as the need for intubation, reintubation, or noninvasive mechanical ventilation. Secondary end points included the duration of mechanical ventilation, hospital and intensive care unit length of stay, and adverse events. Of the patients who met the inclusion criteria, 94 received an extended taper and 57 received a short taper.
No differences in adverse events were observed. A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased corticosteroid exposure without increased risk of treatment failure. A prospective randomized trial is warranted.
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Please update your settings with a valid address before to continue using PracticeUpdate. Close Back. Sign in. Join now. Follow us on:. Search PracticeUpdate Cancel. This single-center retrospective cohort study evaluated patients who received high-dose methylprednisolone in the ICU and subsequently were prescribed either an extended or short course of oral corticosteroids to determine incidence of treatment failure.
The study demonstrated that patients who received a short taper did not experience an increased risk of treatment failure.
Further prospective research is indicated in this area. This abstract is available on the publisher's site. Access this abstract now. Additional Info.
National Library of Medicine. Become a PracticeUpdate member now. Further Reading. Respiratory Medicine Respiratory Medicine.
Conclusion: A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased. Four of the studies in this analysis involved oral prednisone with an initial dose of 30 to 60 mg tapering over nine to 14 days; in a fifth. A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased. In the past, the GOLD guidelines suggested the use of prednisolone 30 to 40 mg daily for 10 to 14 days. However, the most recent update. Outpatient treatment of acute COPD exacerbation with prednisone accelerates recovery sone in a tapering dose of 60 mg for 3 d, 40 mg for 3 d, and 20 mg. Exacerbations of COPD are associated with a more rapid decline in lung function. Influenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease COPD : an evidence-based review. Previous literature has suggested that a short course of corticosteroids is similarly effective as an extended course for managing an acute exacerbation of chronic obstructive pulmonary disease AECOPD. Transl Res. Hosp Pharm. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. In recent years, studies have shown an increase in the prevalence of COPD among women; this increase is due to a rise in the number of women who smoke, changes in occupational trends, and possibly greater susceptibility.Do oral or parenteral corticosteroids improve clinical outcomes in patients with an acute exacerbation of chronic obstructive pulmonary disease COPD? Systemic corticosteroids improve symptoms of acute COPD exacerbations at three days and reduce the likelihood of treatment failure.
There is no evidence that they reduce mortality or prevent recurrence at 30 days, but the existing studies may be too small to detect such a benefit. Adverse effects are common but generally are not serious.
This Cochrane review updates an earlier meta-analysis with two new studies. Although systemic steroids are widely used for the treatment of acute COPD exacerbations, the authors stress that it is important to know the magnitude of their benefit and the extent of associated side effects.
The question of whether oral or intramuscular steroids are more effective was not addressed. Four of the studies in this analysis involved oral prednisone with an initial dose of 30 to 60 mg tapering over nine to 14 days; in a fifth study, high-dose oral prednisone 2. In studies of intravenous methylprednisolone Solu-Medrol , a variety of dosing regimens were used, from a single mg dose to 72 hours of methylprednisolone followed by a day prednisone taper.
Despite the differences between studies, the review authors were able to combine the results from seven studies of treatment failure and nine studies of mortality.
Two studies looked at longer-term treatment failure as measured by hospital admission rates in the 30 days following treatment. Although researchers found no significant difference between steroid and placebo groups 11 versus 15 percent, respectively , these studies were too small for a clinically important difference to be evident, if one existed. Respiratory symptom scores at 72 hours were significantly more likely to be improved if patients received steroids.
However, adverse events were common; the number needed to harm was 7 for any adverse event. In addition to steroids, albuterol Ventolin should be used for bronchodilation because of its short onset of action. Ipratropium bromide Atrovent may be added. Antibiotics also should be considered for exacerbations that are not clearly triggered by viral infections.
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Clinical Question. Evidence-Based Answer. Practice Pointers. MARK H. These are summaries of reviews from the Cochrane Library.
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