C.T. Patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. N. Roche, J.M. Cordoba, E.L. Strandberg. The NHS protocol for management of COPD exacerbations in primary care states that bronchodilators and corticosteroids are the mainstay of exacerbation treatment. It is important to identify the underlying cause of an exacerbation as this will guide the therapeutic strategy. Wedzicha, D. Banerji, K.R. COPD, or chronic obstructive pulmonary disease, is a common form of lung disease.COPD causes inflammation in your lungs, which narrows your … When using theophylline, it is necessary to monitor blood levels, side effects and potential drug interactions.8,31. Int J Chron Obstruct Pulmon Dis, 10 (2015), pp. 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%. 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. Transition between inpatient hospital settings and community or care home settings for adults with social care needs 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 … 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. These medications are fast-acting, and they work by helping open the airway passages and reduce inflammation. Tsui, S.L. COPD: How can evidence from randomised controlled trials... Noninvasive ventilation during weaning from prolonged... Creative Commons Attribution 4.0 International License. Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Symptoms such as breathlessness, cough or sputum,7 oxygen saturation levels,7 new limitation of daily activities,6,7 clinical signs of severity such as use of accessory respiratory muscles,1,5 paradoxical chest wall movements,1,5 worsening or new onset central cyanosis,1,7 development of peripheral edema,1,7 hemodynamic instability,1 deteriorated mental status1,6,7 and comorbidities1 should all be assessed. The authors do not advise the use of COPD Assessment Test (CAT) score23 routinely in Portugal as it is not validated for the Portuguese population. Heterogeneity of chronic obstructive pulmonary disease exacerbations: a two-axes classification proposal. Describe a plan for implementing these physician's orders. 39-49. Referral to a Pulmonology Consultation if the patient is not already attending one is of the utmost importance. After an exacerbation is appropriately managed, a suitable discharge plan should be prepared. van Eeden. Moreover, the recent FLAME study,28 the first prospective study evaluating blood eosinophilia as a biomarker of therapeutic response, showed that indacaterol/glycopyrronium demonstrated a significant improvement in lung function compared with salmeterol/fluticasone for all the cutoffs analyzed.29 A recent post hoc analysis of the WISDOM study identified a subgroup of patients – patients with ≥2 exacerbations and ≥400cells/μL – that seem to be at increased risk of exacerbation when discontinued from ICS.30 In fact, and according to the most recent version of the GOLD document,1 symptomatic patients in the stable phase of COPD and a history of ≥2 moderate exacerbations, or 1 with hospital admission, in the past year, may benefit from an ICS on top of LABA/LAMA. 662-671. Ther Adv Respir Dis, 7 (2013), pp. Read more. Ohar. SF declares no conflicts of interest. Dual therapy strategies for COPD: the scientific rationale for LAMA + LABA. Albuterol 2.5 mg plus ipratropium 350 mcg nebulizer treatment STAT O2 to maintain Spo2 of 90% Arterial blood gases in am CBC and differential now Basic metabolic panel now CXR … 2257-2263. 379-388. Chapman, J. Vestbo, N. Roche, R.T. Ayers. Pulse oximetry should be performed on all patients.6 If a patient is referred to a hospital, arterial blood gases should be measured5,6,8,15,19–21 and a chest radiography should be done to exclude comorbidities and/or other pulmonary diseases.1,6,8,15,19 In these cases, it is also recommended that patients should have an ECG,1,6,19,20 whole blood count,1,6,8,20–22 and basic biochemical tests, including electrolyte concentrations,1,8,20,21 urea,8 glycemia1,20 and metabolic panel.6 Theophylline levels should be measured in patients on theophylline therapy at admission and blood cultures should be taken if the patient has fever.8 Culture of sputum samples is not recommended in routine practice, only if sputum is purulent,8 and the GOLD 2018 document recommends sputum culture and an antibiotic sensitivity test only if an infectious exacerbation does not respond to the empirical antibiotic treatment.1 Some authors mention eosinophilia blood count as an advisable procedure to guide COPD exacerbations therapy since it has been suggested that eosinophilic exacerbations may be more responsive to systemic steroids.1,15 Spirometry is not recommended during an exacerbation.1, If the exacerbation is severe and the patient hospitalized, brain natriuretic peptide and cardiac enzyme measurements levels should be considered, especially if the patient is not responding to conventional treatment.6 Also, pharyngeal swab or sputum should be tested for viruses and bacteria14,20,23 and serum C-reactive protein measured.14,20,24 Procalcitonin may guide antibiotic therapy since it has been suggested as a more specific marker for bacterial infections and that may be of value in deciding on antibiotics prescription.1 The Charlson comorbidity index,5,20,21,23 the modified Medical Research Council (mMRC) dyspnea scale,5,20,21,23 physical activity5 and general health5 should be assessed. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. Predictive model of hospital admission for COPD exacerbation. Chapman, C.F. Lun, M.S. Celik. Mirici et al. Niewoehner, T. Sandstrom, A.F. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. Leung, A.P. Several factors that can lead to a worsening of symptoms have been identified, and in 70% to 80% of COPD exacerbation cases, the precipitant factor is a respiratory tract infection,4 either viral4,9,14,15 or bacterial,4,9,15 but in about a-third of severe exacerbations of COPD a cause cannot be identified.1. Patients with COPD have airways which chronically grow a variety of organisms. Hanania. COPD causes significant morbidity and mortality, and is frequently placed in the top four leading causes of death worldwide . C. Llor, L. Bjerrum, A. Munck, M.P. Am J Respir Crit Care Med, 186 (2012), pp. 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. Types of COPD Exacerbation Treatment Offered at TrustPoint Rehab Hospital During the streamlined admissions process, the need for rehabilitative services will be assessed. in 2003, analyzed 44 patients with COPD exacerbation . Global Initiative for Chronic Obstructive Lung Disease. Procalcitonin vs C-reactive protein as predictive markers of response to antibiotic therapy in acute exacerbations of COPD. Eosinophilia, frequent exacerbations, and steroid response in chronic obstructive pulmonary disease. C. Esteban, I. Arostegui, S. Garcia-Gutierrez, N. Gonzalez, I. Lafuente, M. Bare. 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. Huang, K.C. 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). 1. You can't change the severity of your disease, but you can take steps to … Pulmonology (previously Revista Portuguesa de Pneumologia) is the official journal of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia/SPP). N. Roche, K.R. J.A. 767-774. A new follow-up consultation should be scheduled within the next 30–60 days. Exacerbations are acute complications of this disease which significantly affect its trajectory and often require emergency management in both the … Optimal treatment sequence in COPD: can a consensus be found?. reduce treatment failures, and shorten hospital length of stay of patients with. 167-176. AR declares having received speaking fees from AstraZeneca, Boehringer Ingelheim, Novartis, Bial, Medinfar, Mundipharma, Menarini, Grifols, Mylan, Tecnifar, Teva and cslbehring. Vollenweider, H. Jarrett, C.A. Continuing navigation will be considered as acceptance of this use. 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. 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. On day 1, all patients received 80 mg of IV methylprednisolone. 2. 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. The body is compensating for lack of oxygen and is overstressed. G.J. Very severe exacerbations require admission to an Intensive Care Unit (ICU)1 and have a very severe impact on physical activity. Blood eosinophils and response to maintenance COPD treatment: data from the FLAME trial. D.J. Systemic corticosteroids in acute exacerbation of COPD: a meta-analysis of controlled studies with emphasis on ICU patients. Patients sick enough to be in the ICU due to COPD should receive antibiotics (even if there is no infiltrate on the chest X-ray)(Vollenweider et al 2012). 131-137. Pharmacological treatment should be optimized. COPD exacerbations: management and hospital discharge. Cheng, V.L. In addition, obtaining a thorough, detailed and accurate history can help the provider anticipate likely outcomes and responses to prehospital treatmen… 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. When should acute exacerbations of COPD be treated with systemic corticosteroids and antibiotics in primary care: a systematic review of current COPD guidelines. In most cases, a COPD exacerbation has direct links to an infection in the lungs or the body. © 2018 Published by Elsevier España, S.L.U. J. Montserrat-Capdevila, P. Godoy, J.R. Marsal, F. Barbe. T.W. Clark, M.J. Medina, S. Batham, M.D. Predictors of outcomes in COPD exacerbation cases presenting to the emergency department. Criner, J. Bourbeau, R.L. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. 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. For all patients, the choice of antibiotic should be guided by the local bacterial resistance pattern,1,8 the microbiology story of the patient and his/her risk factors. 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?. 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. M. Guerrero, E. Crisafulli, A. Liapikou, A. Huerta, A. Gabarrus, A. Chetta. Most patients with exacerbation of chronic obstructive pulmonary disease (COPD) require oxygen supplementation during an exacerbation. Cydulka RK, Emerman CL. Rev Port Pneumol (2006), 22 (2016), pp. https://doi.org/10.1016/j.pulmoe.2018.06.006. H. Qureshi, A. Sharafkhaneh, N.A. By continuing you agree to the use of cookies. Thorax 2018;79:713–22. During a chronic obstructive pulmonary disease (COPD) exacerbation, a person experiences a sudden worsening of their symptoms. CRC declares speaking fees from Boehringer Ingelheim, Roche, Novartis, AstraZeneca, Pfizer vaccines, Teva, Menarini, Medinfar and Tecnifar, and participating in advisory boards of Boehringer Ingelheim, Roche, Novartis, GSK, AstraZeneca and Pfizer vaccines. Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD. The best treatment for an exacerbation … M. Bafadhel, S. McKenna, S. Terry, V. Mistry, C. Reid, P. Haldar. 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. This should generally include reclassification of the patient according to GOLD criteria, optimization of pharmacological therapy, management of comorbidities, patient (or caregiver) education on the correct use of medications, referral to a Pulmonology Outpatient Clinic, if they are not already attending one, and a smoking cessation and respiratory rehabilitation program. Shatoria Grant These findings are expected for COPD exacerbation but not appropriate. In this paper, we will focus on the pharmacological strategies for the management of COPD exacerbations, risk stratification and a hospital discharge plan proposal. Although the most effective duration of treatment is still to be defined,32 the recommended length of antibiotic therapy is usually 5–7 days (Evidence D)1 but treatment duration will depend on the antibiotic used. 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. 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. They may need to seek medical help at a hospital. Steurer-Stey, J. Garcia-Aymerich, M.A. Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review. 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. Sin, S.F. J.S. Funding for this paper was provided by Novartis Portugal. During the follow-up consultation (three months for moderate exacerbations and 4–6 weeks for severe exacerbations), spirometry and arterial blood gases should be measured. procedure or treatment must be made by the physician in light of the circumstances presented by the patient. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. M. Guimaraes, A. Bugalho, A.S. Oliveira, J. Moita, A. Marques. If the patient remains hypoxemic, long-term supplemental oxygen therapy may be required.1 Also, patients should be given clear instructions about when and how to stop their corticosteroid treatment.1,8 Concerning the need for individualized care, a Canadian study in which the patients were offered a post discharge phone call, a home visit and continued care concluded that although there was no reduction in 30- and 90-day readmission rates, a decrease in 90-day total mortality was seen. The infection is typically the result of a virus, but bacteria or other organisms can also be responsible.