Chest
Special ReportManagement of Acute Exacerbations of COPD: A Summary and Appraisal of Published Evidence
Section snippets
COPD
In the United States at present, > 16 million adults areafflicted with COPD, a slowly progressive condition that typicallybecomes symptomatic in the fifth and sixth decade of life. As the USpopulation ages, the prevalence of this disease is expected toclimb.2 COPD currently accounts for approximately 110,000 deaths per year, making it, after heart disease, cancer, and stroke, the fourth leading cause of death. Nonasthma COPD in the United States annually accounts for 16,367,000 office visits,
What Is an Acute Exacerbation of COPD?
In evaluating the published literature, and in developing practiceguidelines, we have attempted to adhere to a generally accepted anduseful concept of an acute exacerbation or flareof COPD. Unfortunately, many definitions exist, many authors employsubstantively different criteria, and many studies poorly describetheir inclusion criteria. As a generalization, however, most publisheddefinitions embrace some combination of the following three clinicalfindings: worsening of dyspnea; increase in
Identification of Topics for Literature Search
Topics to be covered in this article and in the practiceguideline were determined through a consensus process that involvedboth the ACP-ASIM/ACCP expert panel and the technical advisory panel ofthe Evidence-Based Practice Center at Duke University (Durham, NC). Thetopic list was generated to address the following three questions: (1)what information is available to aid clinicians in predicting theclinical course of a patient with an acute exacerbation?; (2) whatinformation is available about
Approach to the Patient With an Acute Exacerbation of COPD
In the following section, we discuss our recommendations andfindings for the following three domains of care for patients withacute exacerbations of COPD: risk stratification of patients(specifically, data on predictors of outpatient relapse) and predictorsof inpatient mortality; choice of diagnostic tests; and benefits andrisks of therapeutic interventions, including mucus clearancestrategies, bronchodilating agents, corticosteroids, antibiotics, oxygen, and noninvasive mechanical ventilation.
Prediction of Outpatient Relapse
Based on 10 studies that evaluated patients with acuteexacerbations of COPD in emergency departments (7 studies) and in theoutpatient setting (3 studies), we concluded that certaincharacteristics are associated with patients returning for moretreatment rather than with those experiencing gradual improvement(Table 7). The ability to identify patients at high risk for relapseshould improve decisions about hospital admissions and follow-upappointments. Several investigators have confirmed that
General Approach
Many assessment techniques frequently are used in evaluatingpatients with acute exacerbations of COPD. These include measuringroutine laboratory values, performing a physical examination, obtainingan ECG, assessing cardiac function, and instituting an empiric trial of diuretics. We found no published evidence that could help us todetermine the utility of these approaches. For another commonly usedassessment (arterial blood gas sampling), we found indirect evidence ina number of studies
Bronchodilating Agents
Based on 14 randomized studies, we concluded the following: thatshort-acting β-agonist-type and anticholinergic-type inhaledbronchodilators have comparable effects on spirometry and a greatereffect than all parenterally administered bronchodilators(ie, parenteral methylxanthines and sympathomimetics); thatthe toxicity profile of the methylxanthine agents makes thempotentially harmful; and that there may be an additional benefit insome patients when a second bronchodilating agent is administered
Research Priorities
In a disease held responsible for 5% of all deaths in the United States, enormous disability, and $18 billion dollars in annualhealth-care costs, the paucity of primary data on therapeuticsis startling. We found that in more than 40 years of research, fewerthan 1,100 patients had been enrolled in randomized, placebo-controlledtrials of antibiotics, fewer than 650 patients had been enrolled instudies of corticosteroids vs placebo (before the 1999 SCOPPE trial, the count was less than 400), and
ACKNOWLEDGMENT
We gratefully acknowledge the assistance of thecombined ACP-ASIM and ACCP expert panel, the Evidence-Based Center peerreview and technical advisory panels, and the efforts of Ruth E. Goslin, MAT, and Rebecca N. Gray, DPhil.
References (128)
- et al.
Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD
Chest
(1999) Epidemiology and treatment of chronic bronchitis and its exacerbations
Chest
(1995)- et al.
Determinants of immediate survival among chronic respiratory insufficiency patients admitted to an ICUs for acute respiratory failure: a prospective multicenter study; the French Task Group for Acute Respiratory Failure in Chronic Respiratory insufficiency
Chest
(1992) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996) - et al.
The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults
Chest
(1991) - et al.
Evaluation of high-yield criteria for chest radiography in acute exacerbation of chronic obstructive pulmonary disease
Ann Emerg Med
(1993) - et al.
Relationship between arterial blood gases and spirometry in acute exacerbations of chronic obstructive pulmonary disease
Ann Emerg Med
(1989) - et al.
Use of peak expiratory flow rate in emergency department evaluation of acute exacerbation of chronic obstructive pulmonary disease
Ann Emerg Med
(1996) - et al.
Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction
Lancet
(1989) - et al.
A comparison of the effects of ipratropium bromide and metaproterenol sulfate in acute exacerbations of COPD
Chest
(1990)
Effect of different albuterol dosing regimens in the treatment of acute exacerbation of chronic obstructive pulmonary disease
Ann Emerg Med
Intravenous aminophylline in the treatment of acute bronchospastic exacerbations of chronic obstructive pulmonary disease
Ann Emerg Med
Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to β-agonist therapy
Ann Emerg Med
Severe exacerbations of COPD and asthma: incremental benefit of adding ipratropium to usual therapy
Chest
Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room
Am J Med
Risk of toxicity in patients with elevated theophylline levels
Ann Emerg Med
Nebulizer vs spacer for bronchodilator delivery in patients hospitalized for acute exacerbations of COPD
Chest
Cost-benefit comparison of aerosol bronchodilator delivery methods in hospitalized patients
Chest
Comparison of a hand-held nebulizer with a metered dose inhaler-spacer combination in acute obstructive pulmonary disease
Chest
Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction
Chest
Early corticosteroid use in acute exacerbations of chronic airflow obstruction
Am J Emerg Med
A randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD
Chest
Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial
Lancet
Exacerbations of chronic bronchitis: treatment with oxytetracycline
Lancet
Antibiotic regimes in chronic bronchitis
Br J Dis Chest
Antibiotic regimens in moderately ill patients with purulent exacerbations of chronic bronchitis
Br J Dis Chest
Controlled oxygen administration in acute respiratory failure in chronic obstructive pulmonary disease: a reappraisal
Am J Med
Double-blind clinical trial of bromhexine as a mucolytic drug in chronic bronchitis
Lancet
Randomised controlled trial of nasal ventilation in acute ventilatory failure because of chronic obstructive airways disease
Lancet
Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease Report No. 19
Strategies in preserving lung health and preventing COPD and associated diseases
Chest
Statistical abstract of the United States 1997; US Department of Commerce, Bureau of the Census
Healthcare cost and utilization project: nationwide inpatient sample for 1997
Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute Workshop Summary; Bethesda, Maryland, August 29–31, 1995
JAMA
Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease
Ann Intern Med
Role of infection in chronic bronchitis
Am Rev Respir Dis
Chlamydia pneumoniae, strain TWAR, infection in patients with chronic obstructive pulmonary disease
Am Rev Respir Dis
Interactions between viruses and bacteria in patients with chronic bronchitis
J Infect Dis
An analysis of decisions by European general practitioners to admit to hospital patients with lower respiratory tract infections
Thorax
Air pollution and hospital admissions for the elderly in Detroit, Michigan
Am J Respir Crit Care Med
Outcomes following acute exacerbation of severe chronic obstructive lung disease: the SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)
Am J Respir Crit Care Med
Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease
Am J Respir Crit Care Med
Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease
Am J Respir Crit Care Med
The necessary length of hospital stay for chronic pulmonary disease
JAMA
Acute respiratory failure in chronic obstructive pulmonary disease: immediate and long-term prognosis
Arch Intern Med
Hospital and 1-year survival of patients admitted to ICUs with acute exacerbation of chronic obstructive pulmonary disease
JAMA
Effect of inspiratory flow rate on gas exchange during mechanical ventilation
Am Rev Respir Dis
Follow-up study of disability among elderly patients discharged from hospital with exacerbations of chronic bronchitis
Thorax
Predicting future functional status for seriously ill hospitalized adults: the SUPPORT prognostic model
Ann Intern Med
Does increased access to primary care reduce hospital readmissions?
N Engl J Med
Cited by (185)
Spanish COPD Guidelines (GesEPOC) 2021 Update Diagnosis and Treatment of COPD Exacerbation Syndrome
2022, Archivos de BronconeumologiaCOPD exacerbation
2017, Archivos de BronconeumologiaAppropriate investigations during an acute COPD exacerbation requiring hospitalization
2017, Revue des Maladies RespiratoiresPreventing Hospitalizations From Acute Exacerbations of Chronic Obstructive Pulmonary Disease
2017, American Journal of the Medical SciencesCitation Excerpt :The precipitant for many events is never identified, but most are thought to be viral or bacterial infections.9-11 Poor air quality, seasonal weather changes and comorbid illnesses such as chronic heart failure may also trigger exacerbations.12-14 Although often difficult to prevent, there are ways to identify patients at highest risk for AE-COPD and create proactive plans to limit attacks to some degree.
This article is based on research conducted by investigators at Memorial Sloan-Kettering Cancer Center, New York, NY, under contractwith the ACP–ASIM and the ACCP, and by investigators at Duke University, Durham, NC, under contract with the Agency for Healthcare Research and Quality (contract No. 290–97-0014).
This paper also appeared in Annals of Internal Medicine 2001; 134:600–620
The authors of this article are responsible for its contents, includingany clinical or treatment recommendations. No statement in this articleshould be construed as an official position of the Agency for Healthcare Research and Quality of the US Department of Health and Human Services.