Treatment Of Acute Exacerbation Of Chronic Obstructive Pulmonary Disease Research Articles

Do Guidelines Influence Emergency Department Staff Behaviours and Improve Patient Outcomes? Evaluation of a Multifaceted Intervention for the Implementation of Local Acute Exacerbations of Chronic Obstructive Pulmonary Disease Guidelines.

IntroductionPublished national guidelines on chronic obstructive pulmonary disease (COPD) highlight the importance of oxygen therapy, bronchodilators, corticosteroids, and appropriate antibiotics during acute exacerbations of COPD (AECOPD). We wished to assess how the implementation of local COPD guidelines affects emergency department (ED) staff awareness, knowledge, the use of such guidelines, and patient outcomes, including treatment failure and rates of return to the ED.MethodsThis study was conducted at a tertiary hospital ED. Local COPD guidelines were developed by a quality improvement group. Guidelines were posted in the department, and educational sessions were provided for staff. We conducted a retrospective chart review and looked at 1849 patient visits before and after COPD guideline implementation. All visits with a diagnosis of COPD or AECOPD were included in the study (for a total of 130 patient visits), and data were collected using a standardized abstraction tool. For non-admitted patients, we recorded 30-day return rates and treatment failures occurring within 30 days of presenting to the ED. Pre- and post-implementation outcomes were analyzed with Fisher’s exact tests. We also assessed ED staff awareness, knowledge, and use of COPD guidelines through surveys given out before implementation, and both one and 10 months after the implementation. We calculated proportions and 95% confidence intervals (CI) for our surveys. Pre- and post-implementation survey responses were compared with Fisher's exact tests.ResultsFor ED physicians, the survey response rate was 78%, 79%, and 58% at pre-implementation, one-month follow-up, and 10-month follow-up, respectively. Prior to implementation, 14.3% (95% CI 4.1%-35.5%) were aware and 0% (0%-18.2%) reported using guidelines. One month after implementation, 90.9% (71.0%-98.7%) were aware and 81.8% (60.9%-93.3%) reported using guidelines. At 10 months, 100% (76.1%-100%) were aware and 100% (82%-100%) reported using local guidelines. Similar trends were seen among nurses and respiratory therapists. To assess actual guideline use, 130 visits were evaluated (51 visits prior to implementation and 79 post-implementation). Prior to implementation, 57% (43%-70%) received bronchodilators, systemic steroids, and antibiotics appropriately. Following guideline implementation, 57% (46%-67%) received the respective treatments (p=1.0). For patient-related outcomes, 86 non-admission patient visits were evaluated (35 visits prior to implementation and 51 post-implementation). Prior to guideline implementation, 17% (8%-33%) failed their initial AECOPD treatment, compared to 10% (4%-21%) following guideline implementation (p=0.34). Prior to guideline implementation, 23% (12%-39%) returned to the ED within 30 days in the pre-implementation period while 14% (7%-26%) returned post-implementation (p=0.39).ConclusionOur introduction of local COPD guidelines was successful at increasing self-reported awareness, knowledge, and the use of best practice guidelines among ED staff. At the 10-month follow-up, increased awareness, knowledge, and use of COPD guidelines among ED staff was maintained. However, in practice, guideline adherence, treatment failure, and return rates did not improve significantly after the implementation of local guidelines.

Resolving Viral-Induced Secondary Bacterial Infection in COPD: A Concise Review

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and death world-wide, where chronic inflammation accelerates lung function decline. Pathological inflammation is worsened by chronic bacterial lung infections and susceptibility to recurrent acute exacerbations of COPD (AECOPD), typically caused by viral and/or bacterial respiratory pathogens. Despite ongoing efforts to reduce AECOPD rates with inhaled corticosteroids, COPD patients remain at heightened risk of developing serious lung infections/AECOPD, frequently leading to hospitalization and infection-dependent delirium. Here, we review emerging mechanisms into why COPD patients are susceptible to chronic bacterial infections and highlight dysregulated inflammation and production of reactive oxygen species (ROS) as central causes. This underlying chronic infection leaves COPD patients particularly vulnerable to acute viral infections, which further destabilize host immunity to bacteria. The pathogeneses of bacterial and viral exacerbations are significant as clinical symptoms are more severe and there is a marked increase in neutrophilic inflammation and tissue damage. AECOPD triggered by a bacterial and viral co-infection increases circulating levels of the systemic inflammatory marker, serum amyloid A (SAA). SAA is a functional agonist for formyl peptide receptor 2 (FPR2/ALX), where it promotes chemotaxis and survival of neutrophils. Excessive levels of SAA can antagonize the protective actions of FPR2/ALX that involve engagement of specialized pro-resolving mediators, such as resolvin-D1. We propose that the anti-microbial and anti-inflammatory actions of specialized pro-resolving mediators, such as resolvin-D1 should be harnessed for the treatment of AECOPD that are complicated by the co-pathogenesis of viruses and bacteria.

Monitoring Antioxidant Enzyme Activity during Exacerbations of Chronic Obstructive Pulmonary Disease

Superoxide dismutases (SODs) and catalase (CAT) have been implicated as major antioxidant enzymes of the human lungs. In this study, we investigated whether activities of these enzymes are altered in the airways of patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). SOD and CAT activities were measured in the sputum, exhaled breath condensate, and serum of 36 COPD patients experiencing a severe exacerbation. Measurements were performed using colorimetric assays in samples collected at the time of hospital admission and at the time of hospital discharge following treatment of AECOPD. For comparison, antioxidants were also assessed in 24 stable COPD patients and 23 healthy control subjects. SOD and CAT activities in sputum were significantly increased in patients with AECOPD compared to those with stable disease (SOD: 0.142 [0.053–0.81] vs. 0.038 [0.002–0.146] U/mL, p < 0.01; CAT: 48.7 [18.7–72.6] vs. 10.2 [2.9–40.6] nmol/min/mL, p < 0.05), while treatment of exacerbation led to a decrease in enzyme activities (SOD: 0.094 [0.046–0.45] U/mL, p < 0.05; CAT: 28.0 [7.3–60.4] nmol/min/mL, p < 0.005). No changes were observed in the serum (p > 0.05). Both SOD and CAT activities significantly correlated with sputum neutrophil and lymphocyte cell counts in patients with AECOPD. Moreover, SOD and CAT values correlated with each other and also with sputum malondialdehyde, an established marker for oxidative stress. Our data demonstrate that sputum antioxidant activity is elevated during COPD exacerbation and suggest that activation of SODs and CAT is an integral part of the human defense mechanism against the increased oxidant production associated with AECOPD.

Comparative Efficacy of Chinese Herbal Injections for Treating Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Bayesian Network Meta-Analysis of Randomized Controlled Trials.

Introduction Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) imposes a huge economic burden on healthcare systems worldwide. Chinese herbal injections (CHIs) are widely used to treat AECOPD. In this study, we examined the efficacy of CHIs in the treatment of AECOPD using a network meta-analysis (NMA). Methods Literature search was conducted from electronic databases of randomized controlled trials (RCTs) on CHIs plus Western medicine (WM) versus WM. WinBUGS 1.4.3 and STATA 12.0 were adopted to compute calculations and prepare graphs, respectively. Results We included 155 RCTs with 13,218 patients. The results revealed that Danhong injection (DH) + WM had the greatest therapeutic potential in terms of rate of clinical efficacy (RCE). In addition, in comprehensively improving RCE and FEV1%, and RCE and C-reactive protein, Huangqi injection (HQ) +WM was associated with preferable effects. Similarly, Xixinnao injection + WM, Reduning injection (RDN) +WM, and HQ+WM had a favorable effect on RCE and PaO2. The effect of RDN+WM was favorable in all outcomes except RCE. The safety of CHIs needs to be further assessed. Conclusions Based on this NMA, DH+WM, HQ+WM, and RDN+WM were potential optimal therapies in AECOPD and their safety should be strictly monitored.

Use of glucocorticoids in patients with COPD exacerbations in China: a retrospective observational study.

Background:Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common in patients with underlying moderate to severe COPD and are associated with increased health and economic burden. International and Chinese guidelines recommend using glucocorticoids for the management of AECOPD because glucocorticoid therapy has been shown to benefit clinical outcomes. However, only scant data are available for current status of glucocorticoid therapy in hospitalized AECOPD patients in China. The aim of the study was to identify current use of glucocorticoids for the treatment of AECOPD in China.Methods:This retrospective, multicenter, noninterventional study evaluated the treatment pattern of AECOPD in patients hospitalized from January 2014 to September 2014 at 43 sites (41 tertiary hospitals and two secondary hospitals) in China. The endpoints of the study were the percentage of patients receiving glucocorticoids by different routes of administration, doses and duration, mortality, and the mean length of hospitalization.Results:A total of 4569 patients (90.17%) received glucocorticoids for AECOPD treatment. A combination of nebulized and systemic route was most frequently used (40.51%), followed by using nebulized route alone (38.00%), systemic route alone (15.45%), and inhaled route other than nebulization (6.04%). Furthermore, the most commonly prescribed glucocorticoids of the nebulized, intravenous, inhaled (other than nebulized) and oral route was budesonide (69.4%), methylprednisolone sodium succinate (45.31%), fluticasone propionate (19.54%), and prednisone acetate (11.90%), respectively. The in-hospital mortality rate was 1.24% and the mean length of hospitalization was 12.22 ± 6.20 days (± SD).Conclusions:Our study was the first study of the treatment pattern of glucocorticoids in the management of hospitalized AECOPD patients in China. Data indicates that there is a gap in the implementation of international guidelines for the treatment of AECOPD in China. Further studies are warranted to clarify the appropriate glucocorticoids strategy for the management of AECOPD to determine the optimal route of administration, dose and duration, and resulting clinical outcomes.

General practitioner use of a C-reactive protein point-of-care test to help target antibiotic prescribing in patients with acute exacerbations of chronic obstructive pulmonary disease (the PACE study): study protocol for a randomised controlled trial

BackgroundMost patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed an antibiotic, which may not always be appropriate and may cause harm. C-reactive protein (CRP) is an acute-phase biomarker that can be rapidly measured at the point of care and may predict benefit from antibiotic treatment in AECOPD. It is not clear whether the addition of a CRP point-of-care test (POCT) to clinical assessment leads to a reduction in antibiotic consumption without having a negative impact on COPD health status.Methods/designThis is a multicentre, individually randomised controlled trial (RCT) aiming to include 650 participants with a diagnosis of AECOPD in primary care. Participants will be randomised to be managed according to usual care (control) or with the addition of a CRP POCT to guide antibiotic prescribing. Antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status (total score) measured by the Clinical COPD Questionnaire (CCQ) at 2 weeks post randomisation will be co-primary outcomes. Primary analysis (by intention-to-treat) will determine differences in antibiotic consumption for superiority and COPD health status for non-inferiority. Secondary outcomes include: COPD health status, CCQ domain scores, use of other COPD treatments (weeks 1, 2 and 4), EQ-5D utility scores (weeks 1, 2 and 4 and month 6), disease-specific, health-related quality of life (HRQoL) at 6 months, all-cause antibiotic consumption (antibiotic use for any condition) during first 4 weeks post randomisation, total antibiotic consumption (number of days during first 4 weeks of antibiotic consumed for AECOPD/any reason), antibiotic prescribing at the index consultation and during following 4 weeks, adverse effects over the first 4 weeks, incidence of pneumonia (weeks 4 and 6 months), health care resource use and cost comparison over the 6 months following randomisation. Prevalence and resistance profiles of bacteria will be assessed using throat and sputum samples collected at baseline and 4-week follow-up. A health economic evaluation and qualitative process evaluation will be carried out.DiscussionIf shown to be effective (i.e. leads to a reduction in antibiotic use with no worse COPD health status), the use of the CRP POCT could lead to better outcomes for patients with AECOPD and help reduce selective pressures driving the development of antimicrobial resistance. PACE will be one of the first studies to evaluate the cost-effectiveness of a POCT biomarker to guide clinical decision-making in primary care on patient-reported outcomes, antibiotic prescribing and antibiotic resistance for AECOPD.Trial registrationISRCTN registry, ID: ISRCTN24346473. Registered on 20 August 2014.

Selection of AECOPD-specific immunomodulatory biomarkers by integrating genomics and proteomics with clinical informatics.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) as a serious event has high mortality and medical costs. Systemic inflammation and immune response are the major factors influencing the outcome and quality of patient with AECOPD. On basis of identification and validation of AECOPD-specific inflammatory biomarkers, the present study aimed to identify AECOPD-specific immunomodulatory mediators by evaluating dynamic genomic and proteomic profiles of peripheral blood mononuclear cells (PBMCs) and plasma in patients with AECOPD on day 1, 3, and 10 after the hospital admission, to compare with healthy controls or patients with stable COPD. We found that genes and proteins of C1QC and C1RL were co-differentially up-expressed in patients with COPD or AECOPD, while haptoglobin (HP), ORM1, SERPING1, and C3 were identified as a panel of AECOPD-specific immunomodulatory mediators. We also found that inflammatory stimuli could up-regulate osteopontin (OPN)-associated HP expression through the PI3K signal pathway in A549 cells. Block of autocrine production of OPN by gene inhibition could reduce HP production from inflammation-induced lung epithelial cells. The complex network of AECOPD- or COPD-specific immunomodulatory mediators will benefit the development of precision or personalized medicine strategies for prevention and treatment of AECOPD.

Retrospective audit of antimicrobial prescribing practices for acute exacerbations of chronic obstructive pulmonary diseases in a large regional hospital.

Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity and mortality, and frequent exacerbations are associated with an increased risk of death, deterioration in lung function and reduced quality of life. Current Australian guidelines developed by the Lung Foundation of Australia (the COPD-X Plan) recommends the use of a short course of corticosteroids and oral antibiotics (amoxycillin or doxycycline) as part of the treatment of an AECOPD; however, it was noted that clinical practice at the study hospital had deviated from these guidelines. To evaluate the antibiotic prescribing practices in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients, and to compare the differences in clinical outcomes (primarily mean length of stay and the rate of unplanned readmissions) between patients who received broad- vs. narrow-spectrum antibiotics in a large regional hospital. Retrospective audit of medical records for patients admitted with uncomplicated AECOPD during January-September, 2014 in a 224 acute bed regional hospital in Victoria, Australia. Fifty-nine per cent of patients received broad-spectrum antibiotics (ceftriaxone), whereas only 10% of prescriptions were concordant with current Australian guideline recommendations. Patients receiving a broad-spectrum regimen were more likely to be older (74·9 vs. 69·9 years; P = 0·009), have a higher COPD severity score (i.e. BAP-65 score, 1·55 vs. 1·06; P = 0·002) and a higher CRP (59·2 vs. 25·5 mg/L; P = 0·003) on admission. The mean LOS was not significantly different between those who received ceftriaxone and those who did not (5·09 vs. 4·55 days; P = 0·47). There was no significant difference between the groups in rates of readmissions. The antibiotic prescribing patterns for AECOPD in rural and regional Australian hospitals have not previously been examined in the current literature. In the study hospital, the majority of patients received broad-spectrum antibiotics in the initial treatment of AECOPD. No differences in hospital length of stay, or rate of readmission for AECOPD were observed between those who received broad- and narrow-spectrum antibiotics.

A randomized, controlled multicentric study of inhaled budesonide and intravenous methylprednisolone in the treatment on acute exacerbation of chronic obstructive pulmonary disease

BackgroundAlmost all international guidelines recommend corticosteroids for management of exacerbations of chronic obstructive pulmonary disease (COPD), because it leads to improved outcomes of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Nevertheless, due to its side effects, there are still concerns regarding the use of systemic corticosteroid (SC). Inhaled corticosteroids (IC) can be used as an alternative to SC, while reducing the risk of occurrence of side effects. PurposeTo measure the clinical efficacy and side effects of nebulized budesonide and systemic methylprednisolone in AECOPD. MethodsValid data from 410 AECOPD patients in 10 hospitals was collected. Patients were randomly divided into 2 groups; budesonide group, treated with nebulized budesonide (2 mg 3 times/day); and methylprednisolone group, treated with intravenously injected methylprednisolone (40 mg/day). COPD assessment test (CAT), arterial blood gas analysis, hospitalization days, adverse effects, fasting blood glucose, serum creatinine, alanine aminotransferase levels, and blood drug were measured and analyzed in both groups. ResultsSymptoms, pulmonary function and arterial blood gas analysis were significantly improved after treatment in both groups (P < 0.05), with no significant differences between them (P > 0.05), while incidence of adverse events in the budesonide group was lower (P < 0.05). No significant differences in CAT score, days of admission, blood gas analysis results and physiological and biochemical indexes were found between the two groups. Patients treated with methylprednisolone showed a higher degree of PaO2 level improvement. ConclusionResults show that inhalation of budesonide (2 mg 3 times/day) and systemic methylprednisolone (40 mg/day) had similar clinical outcome in AECOPD. In conclusion, inhaled budesonide is an alternative to systemic corticosteroids in AECOPD treatment.

Prediction of key genes and miRNAs responsible for loss of muscle force in patients during an acute exacerbation of chronic obstructive pulmonary disease.

The present study aimed to identify genes and microRNAs (miRNAs or miRs) that were abnormally expressed in the vastus lateralis muscle of patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The gene expression profile of GSE10828 was downloaded from the Gene Expression Omnibus database, and this dataset was comprised of 4 samples from patients with AECOPD and 5 samples from patients with stable COPD. Differentially expressed genes (DEGs) were screened using the Limma package in R. A protein-protein interaction (PPI) network of DEGs was built based on the STRING database. Module analysis of the PPI network was performed using the ClusterONE plugin and functional analysis of DEGs was conducted using DAVID. Additionally, key miRNAs were enriched using gene set enrichment analysis (GSEA) software and a miR-gene regulatory network was constructed using Cytoscape software. In total, 166 up- and 129 downregulated DEGs associated with muscle weakness in AECOPD were screened. Among them, NCL, GOT1, TMOD1, TSPO, SOD2, NCL and PA2G4 were observed in the modules consisting of upregulated or downregulated genes. The upregulated DEGs in modules (including KLF6 and XRCC5) were enriched in GO terms associated with immune system development, whereas the downregulated DEGs were enriched in GO terms associated with cell death and muscle contraction. Additionally, 39 key AECOPD-related miRNAs were also predicted, including miR-1, miR-9 and miR-23a, miR-16 and miR-15a. In conclusion, DEGs (NCL, GOT1, SOD2, KLF6, XRCC5, TSPO and TMOD1) and miRNAs (such as miR-1, miR-9 and miR-23a) may be associated with the loss of muscle force in patients during an acute exacerbation of COPD which also may act as therapeutic targets in the treatment of AECOPD.

Early COPD Exacerbation Treatment with Combination of ICS and LABA for Patients Presenting with Mild-to-Moderate Worsening of Dyspnea

ABSTRACTThis is a proof of concept study that aims to establish feasibility and safety of a new strategy that includes an action plan for early treatment of acute exacerbations of COPD (AECOPD) with doubling dose of a combination of a long-acting beta2 agonist and an inhaled corticosteroid, and to explore its potential for avoiding the requirement of prednisone and its safety. Thirty-seven COPD outpatients with previous exacerbations were enrolled and followed-up for 12 months. The written action plan included a standing prescription to be used in the event of an AECOPD: Antibiotic, for 5 days (for purulent exacerbations) and doubling a combination of Salmeterol and Fluticasone Propionate for 10 days. The primary outcome was “treatment success” defined as “no need of prednisone within 30 days of the onset.” Twenty-seven patients experienced an AECOPD and doubled their combination dose. Among the 27 patients, there were 21 patients (78%) who did not require prednisone, and none of those had cardiovascular events, pneumonia, ER and hospital admissions. We have assessed that an early treatment of AECOPD with doubling the dose of a combination of Salmeterol and Fluticasone Propionate appears to be safe, well-tolerated and adhered to, and results in no requirement of systemic corticosteroid in a large proportion of patients presenting with mild-to-moderate worsening of dyspnea. This trial has the potential to change the approach of treatment of AECOPD and reduce the use of oral corticosteroids.

Acute exacerbations of chronic obstructive pulmonary disease: diagnosis, management, and prevention in critically ill patients.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate-to-severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid-acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU.

Correlation between decrease of CRP and resolution of airway inflammatory response, improvement of health status, and clinical outcomes during severe acute exacerbation of chronic obstructive pulmonary disease.

Circulating C-reactive protein (CRP) plays an important role in mediating extra-pulmonary complications of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the relationship between changes in high sensitivity (hs)-CRP levels and the resolution of airway inflammatory markers and clinical health status during the recovery period after an acute exacerbation of COPD (AECOPD). Consecutive patients hospitalized for AECOPD were recruited. Serum hs-CRP, airway inflammatory markers, and COPD Assessment Test (CAT) score were evaluated at admission prior to treatment and at days 4, 7, and 14. Adverse outcomes were recorded. The relationship between changes in airway inflammatory markers, CAT score, and hs-CRP during the recovery period was studied. A total of 135 patients were enrolled. Serum hs-CRP levels at admission of patients with adverse outcomes were marginally higher than those without an adverse outcome (7.6 [4.8, 16.7] vs. 6.6 [4.7, 9.3], p = 0.061). Compared with patients without cardiovascular complications, patients with cardiovascular complications had higher serum hs-CRP levels at admission (11.6 [6.7, 16.7] vs. 6.6 [4.4, 10.0], p = 0.001). Sputum neutrophils were positively correlated to hs-CRP at admission (r = 0.474, p < 0.001). A decreasing hs-CRP level was positively related to decreasing sputum neutrophils at day 4 and 7 (r = 0.455, p < 0.001; r = 0.504, p < 0.001, respectively). Significant correlations between decreasing hs-CRP and CAT at all time-points were noted. Hs-CRP may be useful in monitoring airway inflammation resolution and improvement of health status during AECOPD treatment.

The effect and prognosis of noninvasive positive pressure ventilation for the treatment of acute exacerbation of chronic obstructive pulmonary disease with pulmonary encephalopathy

Objective To explore the treatment effect and prognosis of BiPAP non-invasive ventilator of sequential mechanical ventilation for the treatment of acute exacerbation of chronic obstructive pulmonary disease(AECOPD)complicated with pulmonary encephalopathy,and to provide the basis for clinical therapy. Methods According to the digital table,62 AECOPD patients with pulmonary encephalopathy were selected and randomly divided into the two groups.And 30 cases in the control group received routine treatment,and 32 cases in the observation group received BiPAP non-invasive ventilator sequential ventilation.The partial pressure of oxygen(PaO2),partial pressure of carbon dioxide(PaCO2)and oxygen saturation(SaO2)before and after treatment,the changes of heart rate,respiratory rate and average arterial pressure of the two groups and the improvement time were observed. Results PaO2 and SaO2 of the two groups after treatment were higher than those before treatment(t= 12.30,10.37,11.42,13.71,all P<0.05).PaO2 and SaO2 of the observation group after treatment were(77.14±4.16)mm Hg and(90.37±2.04)%, which were higher than the control group after the treatment(72.96±3.22)mm Hg and(85.80±1.96)%(t= 6.58,7.14,all P<0.05).PaCO2 of the two groups after treatment was lower than that before treatment(t= 9.25,10.22,all P<0.05).PaCO2 of the observation group after treatment was(50.12±2.86)mm Hg,which was lower than that before treatment(54.27±3.01)mm Hg(t= 6.29,P< 0.05).The heart rate,respiratory rate and mean arterial pressure of the control group and the observation group after treatment were lower than before treatment(t= 10.11,9.43,8.66,11.28,8.56,9.15,all P< 0.05).The heart rate,respiratory rate and mean arterial pressure of the observation group after treatment were(76.52±4.35)times/min,(20.35±1.08)times/min and(83.26±3.07)mm Hg,which were lower than those of the control group after treatment(t= 6.44,5.82,6.70,all P< 0.05).The blood gas improvement time,ventilation time and hospitalization time of the observation group were(4.06±1.17)d,(4.53±0.90)d and(16.18±2.20) d, which were lower than the control group(t= 6.13, 7.05, 5.97, all P< 0.0 5). Conclusion The BiPAP non-invasive ventilator sequential ventilation for the treatment of AECOPD with pulmonary encephalopathy has good treatment effect,which can improve the difficult ventilation of patients,avoid hypoxia and CO2 retention,shorten treatment time. Key words: Ventilators,mechanical; Pulmonary disease,chronic obstructive; Brain diseases

Pharmacoeconomic analysis of therapy of acute exacerbation of chronic obstructive pulmonary disease in a large Krasnoyarsk hospital

The aim of this study was to evaluate cost structure and rationality of pharmacotherapy of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in a pulmonology department of a multiprofile Krasnoyarsk hospital in 2014. Methods. This was a retrospective 1-year study evaluating pharmacotherapy of AECOPD according to electronic medical reports. Medication therapy and frequency of administration of certain drugs were evaluated using frequency analysis. Rationality of medication therapy and treatment expenses were analyzed with ABC/VEN analysis. Results. One hundred and thirty one electronic medical reports were analyzed. Frequency analysis showed that all patients received the combined bronchodilator Berodual and the expectorant bromhexine. Moreover, 81.7% of patients received antibiotics, 75.6% received systemic steroids and 41.2% received inhaled corticosteroids. This is consistent with current scientific trends and recent recommendations. ABC/VEN-analysis showed a rational pharmacotherapy expenditure of funds in patients with AECOPD. The main expenses were associated with vital drugs (58.2%) followed by pharmacotherapy of comorbidity (41.8%) which was administered to 87.8% of the patients. Anticoagulants had the highest cost (22.5% of the total pharmacotherapy of AECOPD). Second-line drugs were not used in the treatment of AECOPD. Conclusion. The main portion of cost of AECOPD pharmacotherapy was related to pathogenic treatment followed by treatment for comorbidity and prevention as the former greatly effects severity and outcomes of COPD.

Compare the efficacy of inhaled budesonide and systemic methylprednisolone on systemic inflammation of AECOPD

BackgroundCorticosteroids have been shown to improve the outcome of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, whether inhaled corticosteroids (IC) alone have similar effects with systemic corticosteroid (SCS) is still unclear. ObjectivesTo compare the efficacy of inhaled budesonide and systemic methylprednisolone on systemic inflammation of AECOPD. Methods30 AECOPD patients were randomly divided into two group. Budesonide group (15 cases) were treated with inhaled budesonide (3 mg Bid); methylprednisolone group (15 cases) were treated with systemic methylprednisolone (methylprednisolone acetate injectable suspension 40 mg Qd for three days and then methylprednisolone tablets 8 mg Bid). Observe symptoms, lung function, blood gas analysis and adverse effects of the patients in two groups. Peripheral blood samples were collected before and after treatment for 1 day, 4 days and 7 days. Interleukin-8 (IL-8) and TNF-α levels were determined by an enzyme linked immunosorbent assay (ELISA). Hs-CRP levels were detected by automatic biochemical analyzer. Western blotting was used to determine histone deacetylase 2 (HDAC2) protein expression. Measurements and main resultsSymptoms, pulmonary function and blood gas analysis were significantly improved after treatment in the two groups (P < 0.05) and no significant differences between the two groups (P > 0.05). There were no significant differences of IL-8, TNF-α and hs-CRP levels in the two groups (P > 0.05). Besides, the levels of HDAC2 protein expression before treatment were significantly lower comparing to that after treatment for 4 and 7 days. Incidence of adverse events (heart rate, blood pressure, glycemic, sleep condition, gastrointestinal symptoms) in budesonide group was lower than methylprednisolone group (P < 0.05). ConclusionsInhaled budesonide and systemic methylprednisolone have the same effects on systemic inflammation of AECOPD. Inhaled corticosteroid alone could instead systemic corticosteroid in AECOPD treatment.

Bacterial Infection, Airway and Systemic Inflammation and Clinical Outcomes before and after Treatment of AECOPD, a Longitudinal and Cross-sectional Study

Bacterial infection is a major cause of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), which are associated with significantly increased airway and systemic inflammation. However, the relationship among bacteriology, the resolution of inflammation and clinical outcomes is largely unknown. In this study, we recruited consecutive patients hospitalized for AECOPD with purulent sputum. We measured the airway and systemic inflammation levels, the COPD assessment test (CAT) score and adverse outcomes between patients with and without potentially pathogenic microorganisms (PPM). Among sputum samples collected from the 135 episodes of AECOPD, 42 (31.1%) were PPM-positive at admission. Compared with those in the PPM-negative group, more patients in the PPM-positive group had ≥2 exacerbations in previous year and Anthonisen type I at admission and higher drop in sputum neutrophil, serum hs-CRP and CAT value from exacerbation to the subsequent baseline. No significant differences in the adverse outcomes between the two groups were observed. Among the 38 PPM-positive patients who survived and were discharged from hospital, 19 remained PPM-positive (bacterial persistence group) and 19 PPM-negative (bacterial clearance group). Both inflammation indices and CAT score decreased compared to admission in the two groups, regardless of the bacteriology at discharge. Our data suggest uncultivated bacteria and/or virus might also play important roles in causing inflammation and AECOPD.

Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease.

BackgroundChronic obstructive pulmonary disease (COPD) is a chronic and progressive disease that affects an estimated 10% of the world’s population over the age of 40 years. Worldwide, COPD ranks in the top ten for causes of disability and death. Given the significant impact of this disease, it is important to note that acute exacerbations of COPD (AECOPD) are by far the most costly and devastating aspect of disease management. Systemic steroids have long been a standard for the treatment of AECOPD; however, the optimal strategy for dosing and administration of these medications continues to be debated.ObjectiveTo review the use of corticosteroids in the treatment of acute exacerbations of COPD.Materials and methodsLiterature was identified through PubMed Medline (1950–February 2014) and Embase (1950–February 2014) utilizing the search terms corticosteroids, COPD, chronic bronchitis, emphysema, and exacerbation. All reference citations from identified publications were reviewed for possible inclusion. All identified randomized, placebo-controlled trials, meta-analyses, and systematic reviews evaluating the efficacy of systemic corticosteroids in the treatment of AECOPD were reviewed and summarized.ResultsThe administration of corticosteroids in the treatment of AECOPD was assessed. In comparison to placebo, systemic corticosteroids improve airflow, decrease the rate of treatment failure and risk of relapse, and may improve symptoms and decrease the length of hospital stay. Therefore, corticosteroids are recommended by all major guidelines in the treatment of AECOPD. Existing literature suggests that low-dose oral corticosteroids are as efficacious as high-dose, intravenous corticosteroid regimens, while minimizing adverse effects. Recent data suggest that shorter durations of corticosteroid therapy are as efficacious as the traditional treatment durations currently recommended by guidelines.ConclusionSystemic corticosteroids are efficacious in the treatment of AECOPD and considered a standard of care for patients experiencing an AECOPD. Therefore, systemic corticosteroids should be administered to all patients experiencing AECOPD severe enough to seek emergent medical care. The lowest effective dose and shortest duration of therapy should be considered.

Expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the People's Republic of China.

Chronic obstructive pulmonary disease (COPD) is a common disease that severely threatens human health. Acute exacerbation of COPD (AECOPD) is a major cause of disease progression and death, and causes huge medical expenditures. This consensus statement represents a description of clinical features of AECOPD in the People’s Republic of China and a set of recommendations. It is intended to provide clinical guidelines for community physicians, pulmonologists and other health care providers for the prevention, diagnosis, and treatment of AECOPD.

Effect of non-invasive bi-level positive airway pressure ventilation combined with naloxone in the treatment of AECOPD complicated with pulmonary encephalopathy: a meta-analysis

Objective To review the effect of non-invasive bi-level positive airway pressure ventilation combined with naloxone in the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with pulmonary encephalopathy (PE). Methods Related published studies involving BiPAP combined with naloxone in the treatment of AECOPD complicated with PE were recruited and identified from Pubmed, ISI Web of knowledge, CBM Disc, CNKI, Wanfang Data, and randomized controlled trails(RCTs) primarily collected were screened according to inclusive criteria and exclusive criteria.Valid data were extracted after quality evaluation for meta-analysis utilizing RevMan 5.2. Results A total of 10 Chinese RCTs were enrolled, including 697 patients (353 patients in experimental group while 343 patients in control group). The results of meta-analysis indicated that BiPAP combined with naloxone improved PaO2(WMD=4.10, 95%CI(2.83, 5.38), P<0.00001), PH value(WMD=0.04, 95%CI(0.02, 0.05), P<0.00001) and clinical efficiency rate(OR=3.58, 95% CI((2.22, 5.76), P<0.00001), and reduced PaCO2(WMD=-5.78, 95%CI(-6.87, 4.69), P<0.00001), re-endotracheal intubation rate (OR=0.19, 95%CI(0.11, 0.35), P<0.00001), but failed to decrease mortality(OR=0.38, 95%CI(0.11, 1.34), P=0.13) of patients with AECOPD complicated with PE. Conclusions BiPAP combined with naloxone play a protective role in enhancing arterial blood gas indexes, improving clinical efficiency rate and limiting re-endotracheal intubation rate.However, the mortality of patients cannot be reduced. Key words: BiPAP; Naloxone; AECOPD; Pulmonary encephalopathy; Meta-analysis